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Year Three - Specialities > Anaesthetics - Essential Pain Management > Flashcards

Anaesthetics - Essential Pain Management Flashcards

1
Q

What is pain?

A

An unpleasant sensory and emotional experience associated with actual or potential tissue damage

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2
Q

What is nociception?

A

The physiologic process by which noxious stimulation is communicated through the peripheral and central nervous system

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3
Q

What are the two ways in which pain can be classified?

A

Duration

Mechanism

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4
Q

What are the two subtypes of pain duration?

A

Acute

Chronic

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5
Q

What is acute pain?

A

It is defined as pain which typically lasts less than three months

It always occurs in the presence of noxious stimuli, to provide a protective function.

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6
Q

What is chronic pain?

A

It is defined as pain which typically lasts longer than three months

It doesn’t always occur in the presence of noxious stimuli, and therefore doesn’t usually serve a purpose

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7
Q

What are the three subtypes of pain mechanism?

A

Nociceptive Pain

Neuropathic Pain

Nociplastic Pain

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8
Q

What is nociceptive pain?

A

It is a sensory experience that occurs when nociceptors respond to tissue damage, providing a protective function

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9
Q

Is nociceptive pain localised?

A

Yes

It is typically localised to the site of injury

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10
Q

Is nociceptive pain acute or chronic?

A

In most cases, this pain is acute and resolves when the damaged tissue heals

However, it can be chronic in nature.

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11
Q

Does nociceptive pain respond well to conventional analgesics?

A

Yes

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12
Q

What is neuropathic pain?

A

It is a sensory experience that occurs when there is abnormal processing of pain signals in the somato-sensory nervous system

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13
Q

Is neuropathic pain localised?

A

No

It will occur in the neurological territory of the affected structure

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14
Q

How do patients tend to describe neuropathic pain?

A

A burning and shooting type pain

It can be associated with paraestoesia and numbness

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15
Q

Is neuropathic pain acute or chronic?

A

In most cases, this pain is a chronic condition

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16
Q

What are four chronic conditions associated with neuropathic pain?

A

Nerve trauma

Diabetes

Fibromyalgia

Chronic tension headaches

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17
Q

Does neuropathic pain respond well to conventional analgesics?

A

No

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18
Q

What is nociplastic pain?

A

It is a sensory experience that arises from altered nociception, despite no clear evidence of actual or threatened tissue damage or a disease/lesion in the somatosensory system

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19
Q

What are the four steps of the nociception pathway?

A

Periphery

Spinal cord

Thalamus

Modulation

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20
Q

What are nociceptors?

A

They are specialised receptors in the periphery which are activated when thermal, chemical or mechanical stimuli reaches a threshold within noxious range

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21
Q

Describe step one of the nociception pathway

A

Once tissue injury has occurred, there is a release of chemicals from the affected cells

These chemicals stimulate nociceptors, resulting in the transmission of this information to the spinal cord via first order neurones

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22
Q

What are two chemicals which are released when tissue injury occurs?

A

Prostaglandins

Substance P

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23
Q

What are nociceptors made up of?

A

The free nerve endings of Aδ and AC fibres

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24
Q

What are first order neurones?

A

They are Aδ and AC nerve fibres, who have their cell body located in the dorsal root ganglion and their dendrites projecting into the spinal cord

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25
Q

What are the two features of Aδ nerve fibres?

A

Lightly myelinated

Medium diameter

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26
Q

What type of pain is Aδ nerve fibres responsible for?

A

Fast, cold, sharp pain

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27
Q

What are the two features of AC nerve fibres?

A

Unmyelinated

Small diameter fibres

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28
Q

What type of pain is AC nerve fibres responsible for?

A

Slow, hot, dull pain

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29
Q

Describe step two of the nociception pathway

A

In the spinal cord, the first order neurones synapse immediately to the second order neurone in the dorsal horn of the spinal cord

The second order neurones processes and conveys the transmitted impulses to the thalamus of the brain

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30
Q

What is the first relay station of the nociception pathway?

A

The dorsal horn of the spinal cord

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31
Q

What two tracts are used by second order neurones to directly synapse to the thalamus?

A

Lateral spinothalamic tracts

Ventral spinothalamic tracts

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32
Q

Why is pain from the right-hand side of the body actually processed in the left side of the brain?

A

In order to enter the spinothalamic tract, the second order neurones cross the spinal cord to the opposite side

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33
Q

What three tracts are used by second order neurones to indirectly synapse to the thalamus?

A

Spinoreticular tract

Spinomescephalic tract

Spinohypothalamic tract

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34
Q

What does it mean when second order neurones indirectly synapse to the thalamus?

A

This means that they initially synapse to the higher centres of the brain before the thalamus

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35
Q

What is the course of the spinorecticular tract?

A

It passes through the medulla to reach the thalamus

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36
Q

What is the course of the spinomescephalic tract?

A

It passes through the brainstem to reach the thalamus

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37
Q

What is the course of spinohypothalamic tract?

A

It passes through the hypothalamus to reach the thalamus

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38
Q

Describe step three of the nociception pathway

A

The thalamus receives input from the spinal cord via the lateral and ventral spinothalamic tracts

It feeds the messages to various centres in the brain, specifically the cortex, limbic system and brainstem

39
Q

What is the second relay station of the nociception pathway?

A

Thalamus

40
Q

Where does pain perception occur?

A

The cortex of the brain

41
Q

Describe step four of the nociception pathway

A

The feedback impulses from the brain centres are processed in the periaqueductal grey matter (PAG) of the midbrain

Depending on the input, the midbrain will decide whether to amplify or dampen the incoming signal from the periphery

This is known as pain modulation

42
Q

What pain modulation tends to occur?

A

The pain signal is dampened

43
Q

How are pain signals dampened?

A

In order to do this, neurones within the periaqueductal grey matter will pass through the nucleus raphe magnus of the medulla to synapse onto a second neurone

The second neurone is a serotonergic, nor-adrenergic neurone and will travel down to the dorsal horn of the spinal cord where the incoming first order neurones of the ascending pathway are located

They have an inhibitory effect on these cells, therefore decreasing the signal of pain

44
Q

What is the ‘Gate Theory of Pain’?

A

It states that non-painful stimuli close the ‘nerve gates’ to painful stimuli, thus preventing pain sensation from traveling to the central nervous system

It therefore describes how non-painful sensations can override and reduce painful sensations

45
Q

How is the ‘Gate Theory of Pain’ applied in clinical practice?

A

It involves a distractive stimulus (rubbing, massaging or heat application) being applied to the affected area

This stimulus stimulates the peripheral Aα and Aß nerve fibers, which inhibits the nociceptive signal in the dorsal horn of the spinal cord

46
Q

What are simple analgesics?

A

It describes a class of drugs, designed to relieve pain, however, are less potent and safer than opioids

47
Q

What are the two simple analgesics?

A

Paracetamol

NSAIDs

48
Q

What type of pain does paracetamol treat?

A

Mild pain

It is used in combination with other drugs to treat moderate-severe pain

49
Q

What is the side effect of paracetamol?

A

Liver damage

50
Q

Name three NSAIDs

A

Aspirin

Ibuprofen

Diclofenac

51
Q

What type of pain do NSAIDs treat?

A

Nociceptive pain

52
Q

What other drug is usually administered with NSAIDs?

A

Paracetamol

53
Q

What are the four side effects associated with NSAIDs?

A

Gastric ulceration

Renal impairment

Asthma sensitivity

Haemorrhage

54
Q

What is the mechanism of NSAIDs?

A

They work by inhibiting the synthesis of the chemical prostaglandins

This reduces the potential inflammatory response causing pain

55
Q

What is a contraindication of NSAIDs? Why?

A

Pain secondary to trauma

This is because they increase the risk of bleeding

56
Q

What are opiate analgesics?

A

They are drugs containing active ingredients that are naturally derived from Opium

57
Q

What is the mechanism of opiates?

A

They work by inhibiting neurotransmitter release from the primary afferent terminals in the spinal cord and activation of descending inhibitory controls in the midbrain

58
Q

What are three weak opiates?

A

Codeine

Tramadol

Dihydrocodeine

59
Q

What type of pain does codeine treat?

A

Mild to moderate acute nociceptive pain

60
Q

What is the side effect associated with codeine?

A

Constipation

61
Q

What is the mechanism of tramadol?

A

In addition to the opiate effect, it produces inhibitory effects on serotonin and noradrenaline reuptake

62
Q

What two drugs can be administered with tramadol?

A

Opioids

Simple analgesics

63
Q

What are the two side effects associated with tramadol?

A

Nausea

Vomiting

64
Q

What are the advantages of tramadol in comparison to alternative opioids?

A

The effects of constipation and respiratory depression are limited

65
Q

What are three strong opiates?

A

Morphine

Oxycodone

Fentanyl

66
Q

What type of pain does morphine treat?

A

Moderate to severe nociceptive pain

67
Q

What are the four side effects associated with morphine?

A

Constipation

Nausea

Respiratory depression

Addiction

68
Q

What drug is used to manage pain in cancer patients?

A

Morphine

69
Q

What changes do we make to morphine doses when changing the administration from intravenous, intramuscular and subcutaneous routes to oral? Why?

A

Increased

This is because third pass metabolism reduces the amount of morphine available

70
Q

Name a tricyclic antidepressant (TCA)

A

Amitriptyline

71
Q

What is the mechanism of TCAs?

A

They increase descending inhibitory signals

72
Q

What are four side effects associated with TCAs?

A

Glaucoma

Urinary retention

Cognitive decline

Dementia

73
Q

Name three anticonvulsants

A

Carbamazepine

Sodium valproate

Gabapentin

74
Q

What is the mechanism of anticonvulsants?

A

They suppress excessive rapid firing of nerves

75
Q

What type of drug is ketamine?

A

NDMA receptor antagonist

76
Q

What is the mechanism of ketamine?

A

They modulate pain signals in the descending pathways

77
Q

What is the purpose of the WHO analgesic ladder?

A

It provides a strategy for titrating analgesia, starting with simple analgesics and working upwards to strong opioids

78
Q

What is the first step of the WHO analgesic ladder?

A

Simple analgesics

79
Q

What is the second step of the WHO analgesic ladder?

A

Simple analgesics

AND

Weak opiates

80
Q

What is the third step of the WHO analgesic ladder?

A

Simple analgesics

AND

Strong opiates

81
Q

How do we apply the WHO analgesic ladder to pain recovery?

A

It is important to move down the ladder, and wean down the analgesia to a simpler regime

82
Q

What simple analgesic is stopped first? Why?

A

NSAIDs

This is due to the adverse effects associated with NSAIDs.

83
Q

Which type of pain is nonresponsive to the WHO analgesic ladder?

A

Neuropathic pain

84
Q

How do we manage neuropathic pain?

A

Alternative analgesics

Non-pharmacological treatments

85
Q

What are three alternative analgesics used to treat neuropathic pain?

A

Amitriptyline

Gabapentin

Duloxetine

86
Q

What is the first line analgesic used to manage neuropathic pain?

A

Amitriptyline

87
Q

What are the two second line analgesics used to manage neuropathic pain?

A

Gabapentin

Duloxetine

88
Q

What are three non-pharmacological treatments of pain?

A

Acupuncture

Massage

TENS

89
Q

What is the mechanism of non-pharmacological treatments for pain?

A

They close the ‘nerve gates’ in the spinal cord

90
Q

How is pain assessed subjectively?

A

It involves asking the patient to grade their pain on a scale of mild, moderate or severe

This is usually based on a numerical rating score ranging from one to ten

91
Q

How is pain assessed objectively?

A

It involves monitoring for the clinical features of pain

92
Q

What are the five clinical features of pain?

A

Tachycardia

Tachypnoea

Hypertension

Sweating

Flushing

In those less able to communicate their pain, an unwillingness to mobilise or agitation may be present

93
Q

What is the first line analgesic used to manage neuropathic pain?

A

Amitriptyline

Year Three - Specialities (15 decks)

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