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Specialities > Anaesthetics: Essential Pain Management > Flashcards

Anaesthetics: Essential Pain Management Flashcards

1
Q

What is pain?

A

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

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2
Q

What are the physical benefits for the patient if we treat pain?

A
  • Improved sleep, better appetite
  • Fewer medical complications (e.g. heart attack, pneumonia)
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3
Q

What are the psychological benefits for the patient if we treat pain?

A
  • Reduced suffering
  • Less depression, anxiety
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4
Q

What are the benefits for the family if we treat pain?

A
  • Improved functioning as a family member (e.g. as a father or mother)
  • Able to keep working
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5
Q

What are the benefits for society if we treat pain?

A
  • Lower health costs (e.g. hospital stay)
  • Able to contribute to the community
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6
Q

How can pain be classified?

A
  • Duration
    • Acute
    • Chronic Cause
  • Cancer / Non-cancer
  • Mechanism
    • Nociceptive
    • Neuropathic
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7
Q

Describe nociceptive pain

A
  • Sharp +/- dull
  • Well localised
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8
Q

When does nociceptive pain occur?

A

When there is obvious tissue injury or illness

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9
Q

What is the function of nociceptive pain?

A

It has a protective function and is also referred to as inflammatory pain

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10
Q

When does neuropathic pain occur?

A

When there is nervous system damage or abnormality

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11
Q

Describe neuropathic pain

A
  • Burning, shooting +/- paraesthesia
  • Not well localised
  • Does not have a protective function
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12
Q

What are the 4 steps in the physiology of pain?

A
  • Periphery
  • Spinal cord
  • Brain
  • Modulation
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13
Q

What physiology occurs in the periphery during the pain response?

A
  • Tissue injury
  • Release of chemicals e.g. prostaglandins, substance P
  • Stimulation of pain receptors (nociceptors)
  • Signal travels in Aδ or C nerve to spinal cord
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14
Q

What physiology occurs in the spinal cord during the pain response?

A
  • Dorsal horn is the first relay station
  • Aδ or C nerve synapses with second nerve
  • Second nerve travels up contralateral side of spinal cord
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15
Q

What physiology occurs in the brain during the pain response?

A
  • Thalamus is the second relay station
  • Connections to many parts of the brain including cortex, limbic system and brainstem
  • Pain perception occurs in the cortex
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16
Q

What physiology occurs during modulation in the pain response?

A
  • Descending pathway from brain to dorsal horn
  • Usually decreases pain signal
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17
Q

What is the gate theory?

A

Stimulation by non-noxious input is able to suppress pain by closing the ‘gate’ to painful input preventing pain sensation from travelling to the cortex

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18
Q

Give examples of neuropathic pain

A
  • Nerve trauma, diabetic pain (damage)
  • Fibromyalgia, chronic tension headache (dysfunction)
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19
Q

What is the pathology behind neuropathic pain?

A
  • Increased receptor numbers
  • Abnormal sensitisation of nerves (peripheral and central)
  • Chemical changes in the dorsal horn
  • Loss of normal inhibitory modulation
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20
Q

What non-drug treatments can be used to act at the periphery?

A
  • Rest
  • Ice
  • Compression
  • Elevation
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21
Q

What drugs can be used to act at the periphery?

A
  • NSAIDs
  • Local anaesthetics
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22
Q

What non-drug treatments can be used to act at the spinal cord?

A
  • Acupuncture
  • Massage
  • TENS
23
Q

What drugs can be used to act at the spinal cord?

A
  • Local anaesthetics
  • Opioids
  • Ketamine
24
Q

What non-drug treatment can be used to act at the brain?

A

Psychological therapies

25
Q

What drugs can be used to act on the brain?

A
  • Paracetamol
  • Opioids
  • Amitriptyline
26
Q

What route of drug delivery is preferred?

A

Oral

27
Q

What are the advantages of paracetamol?

A
  • Cheap, safe
  • Can be given orally, rectally or intravenously
28
Q

What is the disadvantage of paracetamol?

A

Liver damage in overdose

29
Q

What is paracetamol good for?

A

Mild pain (by itself) or moderate to severe pain (with other drugs)

30
Q

Give examples of NSAIDs

A
  • Aspirin
  • Ibuprofen
  • Diclofenac
31
Q

What are the advantages of NSAIDs?

A
  • Cheap
  • Generally safe
32
Q

What is the disadvantage of NSAIDs?

A
  • GI and renal side effects
  • Can cause exacerbation of asthma
33
Q

What are NSAIDs good for?

A

Nociceptive pain

34
Q

What are the advantages of codeine?

A
  • Cheap
  • Safe
35
Q

What is codeine good for?

A

Mild to moderate acute nociceptive pain

36
Q

What are the disadvantages of codeine?

A
  • Can cause constipation, drowsiness
  • Not good for chronic pain - addictive
37
Q

What are the advantages of morphine?

A
  • Cheap, generally safe
  • Can be given IV, IM, SC
  • Effective if given regularly
38
Q

What is morphine good for?

A
  • Moderate to severe nociceptive pain (i.e. post-op pain)
  • Chronic cancer pain
39
Q

What are the disadvantages of morphine?

A
  • Constipation
  • Respiratory depression in high dose
  • Misunderstandings about addiction
  • Controlled drug
40
Q

How does the oral dose of morphine differ from the IV/IM/SC dose?

A

Oral dose is 2-3 times that of IV/IM/SC dose

41
Q

What is amitriptyline?

A

Tricyclic antidepressant

42
Q

How does amitriptyline work?

A

Increases descending inhibitory signals

43
Q

What are the advantages of amitriptyline?

A
  • Cheap, safe in low dose
  • Good for neuropathic pain
  • Also treats depression and poor sleep
44
Q

What are the disadvantages of amitriptyline?

A

Anti-cholinergic side effects (i.e. glaucoma, urinary retention)

45
Q

Give examples of anticonvulsants that can be used for pain.

A
  • Gabapentin (neurotonin)
  • Carbamazepine (tegretol)
  • Sodium valproate (epilim)
46
Q

Why are anticonvulsants also known as membrane stabilisers?

A

They reduce abnormal firing of nerves

47
Q

What type of pain are anticonvulsants good for?

A

Neuropathic pain

48
Q

What are the steps in the WHO pain ladder?

A
  • Step 1 -Paracetamol +/- NSAIDs
  • Step 2 Paracetamol (+/- NSAIDs) + Codeine/alternative
  • Step 3 Paracetamol (+/-NSAID) + Morphine
49
Q

How should the pain ladder be used as pain resolves?

A
  • Move from top to middle of WHO ladder
  • Continue bottom rung drugs at all times
  • Lastly stop NSAIDs, then paracetamol as more adverse side effects with NSAIDs
50
Q

What is the RAT approach to pain?

A
  • Recognise
  • Assess
  • Treat
51
Q

How do you assess pain severity?

A
  • Verbal scale (mild, mod, severe)
  • Numerical rating scale
  • Visual analogue scale
  • Faces scale
52
Q

What other factors can influence the severity of a patient’s pain?

A

Physical factors

  • Other illnesses

Psychological and social factors

  • Anger, anxiety, depression
  • Lack of social support
53
Q

What drugs are used in neuropathic pain?

A
  • Amitriptyline (tricyclic antidepressant)
  • Gabapentin (anticonvulsant)
  • Duloxetine (selective serotonin noradrenaline reuptake inhibitor - SNRI)

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