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Central Nervous System > Clinical management of pain > Flashcards

Clinical management of pain Flashcards

1
Q

Is pain objective or subjective?

A

Pain is our interpretation of an unpleasant sensation and therefore different people would have a different perspective of their pain. When in particular treating chronic pain you are also addressing both the social and emotional aspects.

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2
Q

What are some of the investigations/questions you would ask when treating pain in older children/adults?

A

Take a full medication history:
Nature of the pain
Description of the pain
How long has the pain been present
What caused the pain?
Any diurnal variation?
Does it vary with position?
What aggravates/relieves it?

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3
Q

What are some of the pain scales used?

A

Visual analogue scale- drawing a point on a scale
Numerical rating scale - number 0-10

In young children you can use faces to determine the pain

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4
Q

Which physical examinations can be made for pain?

A

Colour changes
Swelling
Asymmetry
Tenderness
Weakness
Loss of function
Sensation

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5
Q

How can pain be classified?

A

Duration: either acute of chronic
Underlying mechanism of pain
Physical origin
Possibility of referred pain
Cause

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6
Q

How is acute pain defined?

A

It is sudden in onset usually with a defined cause (following an operation, after trauma), present for less than 6 months and can be treated following the WHO pain ladder.

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7
Q

How is chronic pain defined?

A

Chronic pain is gradual in onset and is a result of a complex condition which is usually difficult to treat/manage. The agents used to treat this type of condition vary depending upon the nature/source of the pain

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8
Q

How does the management of acute and chronic pain vary?

A

In acute pain such as breaking an ankle the most appropriate management lies with resting the area and appropriate pain medications. In chronic pain however has been shown that the best outcomes lie with mobilising and exercise the area.
Chronic pain is defined as lasting more than 6 months at a time.

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9
Q

How common is chronic pain?

A

Up to 50% of the UK adults will experience chronic pain
50-80% have musculoskeletal pain at any one time

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10
Q

What are some of the effects on social life with chronic pain?

A

7 times more likely to leave your job
50% of those with chronic pain report impact on social life, sleeping, walking and driving
Tends to be more prevalent in deprived areas

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11
Q

How many GP appointments relate to queries of chronic pain?

A

4.6 million appointments which equates to 800 GPs working annually

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12
Q

What are the three classifications of pain?

A

Nociceptive
Neuropathic
Nociplastic

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13
Q

What is nociceptive pain?

A

Prevention pain and in response to tissue damage. For example a hand near a flame is detected as harmful stimuli by the nociceptive receptors which allows the reflex action. If the hand is left there for too long the nociceptive receptors are also responsible for mediating pain associated with tissue damage.

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14
Q

What is neuropathic pain?

A

Occurs when there is malfunction of the nervous system which can be centralised or peripheral in location.

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15
Q

How would a patient describe neuropathic pain?

A

Burning, tingling or shooting pain

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16
Q

What is nociplastic pain?

A

It is defined as altered nociception within the body in the absence of tissue or nerve damage.

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17
Q

How is nociplastic pain managed?

A

Physiotherapy
Acupuncture
Anti-depressants although off-label

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18
Q

What is the WHO analgesia ladder based upon?

A

By the concepts of:
By the clock - give pain relief regularly for chronic pain not just PRN use, but trying something different

By the mouth - oral is preferred unless not possible then if not give something least invasive just as patch or injection

By the ladder - following the WHO analgesia ladder

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19
Q

What are some of the circumstances in which administration by the mouth is not possible?

A

Palliative care
Nil by mouth
Nausea and diarrhoea

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20
Q

What is the first stage of the WHO analgesia ladder?

A

First line treatment for pain:
Non-opioid medications
Paracetamol
NSAID
Topical treatments such as Capsaicin and Lidocaine

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21
Q

What are some of the considerations to be made with Paracetamol?

A

Dose adjustments/use with caution
Patients under 50kg
Patients with significant liver damage or risk factors for it

Co‐administration of enzyme-inducing antiepileptic medications may increase toxicity; doses should be reduced

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22
Q

What are some of the considerations to be made with NSAIDs?

A

Cardiovascular disease:
Increased risk of a CV event when taking NSAIDs. Ibuprofen can interfere with the cardioprotective benefit of aspirin.

Patients over age 60 and patients with existing GI risks who take ibuprofen or any other NSAID are at higher risk of developing serious GI toxicities such as an ulcer or bleeding.

Patients with renal dysfunction who take ibuprofen or other NSAIDs may develop chronic kidney disease.

Ibuprofen and all other NSAIDs are metabolized in the liver and can pose risks for individuals with hepatic problems.

NSAIDs, including ibuprofen, may be associated with modest increases in blood pressure. The adverse effect of NSAIDs on blood pressure may have the most clinical significance in the elderly, among whom the prevalence of arthritis, hypertension, and NSAID use is high.

In some adult patients with asthma, ibuprofen and other NSAIDs that inhibit cyclooxygenase-1 can exacerbate the condition.

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23
Q

What are some of the key interactions with NSAIDs?

A

Drugs also increasing the risk of a bleed
Drugs increasing the risk of pre-renal failure (acute renal failure)
Increased risk of GI dysfunction/bleeding
Lithium

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24
Q

If elderly or has a history of GI bleeds what is an appropriate co-prescription alongside NSAIDs?

A

Use at the lowest effective dose for the shortest duration and consider co-prescribing an PPI.

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25
Q

What is the second step of the WHO analgesia ladder?

A

Use of a mild opioid, which either depending on response can be used as an add on or as an adjunct to first line therapies.
Examples include Codeine, Dihydrocodeine and Tramadol
They have limited potency and the mu receptor.

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26
Q

What is the third step of the WHO analgesia ladder?

A

Replacement of mild opioid with a strong opioid. This includes:
Morphine, Diamorphine and Oxycodone
Fentanyl, Buprenorphine and Alfentanil

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27
Q

What are adjuvant therapies?

A

Depending on the type and the source of pain, they are potential add on therapies

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28
Q

When are anti-epileptics used as adjuvant therapies for pain?

A

Mainly for neuropathic source of pain:
These include-
Gabapentin
Pregabalin
Carbamazepine (trigeminal neuralgia in the face)

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29
Q

When are anti-depressants used as adjuvant therapies for pain?

A

Tricyclic anti-depressants such as Amitriptyline is used for again neuropathic pain (Mum’s headaches)
SSRIs

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30
Q

When is Dexamethasone used?

A

Bone pain in palliative care and oncological pain.

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31
Q

What are some of the non-pharmacological therapies?

A

Physiotherapy
Exercise
Psychological
Acupuncture

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32
Q

What is the main concern regarding opioid use?

A

Risk of dependence and addiction
Risk of respiratory depression which can be fatal

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33
Q

When do opioids have evidence?

A

Acute pain and in palliative care where there is no worry about addiction.

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34
Q

When do opioids not have evidence?

A

Limited evidence of efficacy in chronic pain. And therefore is not indicated for headaches, widespread pain or back pain.
No evidence for greater than 120mg per day of Morphine or an equivalent.

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35
Q

When should a review take place for opioid use?

A

2-4 weeks after initiation as if a benefit is not seen then they are unlikely to receive any.
When they are used, should be used as part of the modal model strategy alongside non-opioid medications and non-pharmacological interventions.

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36
Q

What are the risks associated with weak opioid use?

A

Partly metabolised in the liver by CYP2D6 enzyme to morphine and there are genetic differences in the expression of this enzyme resulting in different metabolisms.
Patient could be a poor or a super metaboliser and therefore need to test for response following a couple of weeks because if a poor metaboliser unlikely to get much benefit (unable to convert to Morphine).

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37
Q

What consideration should you make regarding Codeine use in breastfeeding?

A

If mum is a super-metaboliser they are more likely to pass morphine on in breast milk.

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38
Q

What are the main side effects of opioids?

A

Nausea and vomiting
Constipation
Drowsiness
Sedation
Respiratory depression
Renal function
Dependence and addiction

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39
Q

How should N&V be managed in patients taking opioids?

A

Should reduce in time, little need for intervention.

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40
Q

How should constipation be managed in patients taking opioids?

A

Co-prescribe laxatives which should be either stimulant or osmotic.
Not bulk forming laxatives.

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41
Q

What considerations regarding renal function should be made?

A

Some opioids are more highly renally excreted than others. Morphine for example is highly renally excreted and therefore you would consider in renal impairment switching to Oxycodone or Alfentanil.

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42
Q

What are the signs of opioid overdose and toxicity?

A

Pinpoint pupils - occurs due to parasympathetic nervous system activation, no or little response to light. Healthcare staff will proceed to shine a small torch in the eye and if the pupil doesn’t not contract in response, signs of opioid overdose.
Pale skin or blue lips - hypoxia, low blood oxygen
Others signs linking to respiratory depression due to activation of mu receptors in the brain stem. This normally helps to control our respiratory rhythm, opioids cause us to become uncoordinated.

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43
Q

Which tool is used to mark the signs of respiratory depression?

A

NEWS2 score
Low respiratory rate (below 8bpm, normally 12-20)
O2 saturations below 85% (ref 96-99%)
Tachycardia
Blood pressure can be low or high
Higher sedation score - verbal, pain, unconscious, could potentially become unconscious

Patient may present with rasping sound, snoring. Any dose increases need to be monitored for signs of respiratory depression.

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44
Q

How common is musculoskeletal pain?

A

1.6 million UK adults present with lower back pain lasting longer than 3 months

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45
Q

How should back pain be managed?

A

Aerobic activity and avoiding weights straining the lower back as the muscles build up
Spinal manipulation, massage
Psychological (CBT)
Return to work programmes
Which form part of the therapy

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46
Q

What is the pharmacological management of lower back pain?

A

-NSAIDs (but be aware of high risk groups)
-Weak opioids for acute lower back pain if NSAID is contraindicated or ineffective at controlling the pain.

47
Q

Is paracetamol an appropriate medication for the treatment of lower back pain?

A

Not to be shown as effective when used alone for the treatment of lower back pain.

48
Q

How does Sciatica occur?

A

Present as leg pain linked to compression of the sciatica nerve in the lower portion of the spine specifically in the lumbar/sacral regions. This compression can then cause nerve pain down the lower portion of the leg presenting as ‘shooting pains’.

49
Q

Which medications should not be used for sciatica?

A
  • Don’t prescribe neuropathic agents such as gabapentin, AEDs and Benzodiazepines.
  • There is limited NSAID benefit
  • Don’t offer opioids for chronic sciatica
50
Q

What is the main treatment for Sciatica?

A

Physiotherapy
Epidural injections for acute and severe sciatica involves corticosteroids to help with any inflammation
Spinal decompression surgery

51
Q

How does osteoarthritis present?

A

Pain, stiffness, tenderness, swelling, grinding of the joint

52
Q

What is the appropriate management of osteoarthritis?

A

Non-drug measures:
Weight reduction (in overweight or obese patients)
Exercise including local muscle strengthening and aerobic exercise, should be encouraged
Manual therapy such as manipulation, mobilisation, or soft tissue techniques, may be considered for people

Drug treatment should support non-pharmacological treatments and to support exercise.
Lowest effective dose and shortest duration:
Topical NSAID if ineffective or unsuitable consider an oral NSAID.
Paracetamol or weak opioids should only be used infrequently for short-term pain relief if all other pharmacological treatments are unsuitable, not tolerated, or ineffective.

Intra-articular corticosteroid injections can be considered to provide short-term relief when other pharmacological treatments are ineffective or unsuitable, or to support exercise.
Joint replacements

53
Q

What are the main treatments of neuropathic pain?

A

Amitriptyline
Duloxetine
Gabapentin
Pregabalin
Try on if it doesn’t work then try another

Can also use Capsaicin which may feel warm tingling when applying.

54
Q

Can Carbamazepine be used for all neuropathic pain conditions?

A

No only for trigeminal neuralgia

55
Q

When can Tramadol be used for neuropathic pain?

A

Only for acute rescue therapy

56
Q

How is the WHO ladder adapted for palliative care patients?

A

Straight to strong opioids or very quickly. Rarely see Codeine, want to make sure they are in comfort in the last period of their life.
Adjunct therapies are also used.

57
Q

Is pain relief in palliative care very individualised?

A

Yes in palliative care medication use is very individualised. Each consultant has different experiences with different analgesics. There is a degree of flexibility in palliative care when it comes to choice of medication which can be started following a discussion with the patient and/or family members.

58
Q

What is palliative pain relief aimed at?

A

Either targeted to a specific condition which has lead to palliative approach or total body pain which is experienced by a palliative patient.

59
Q

What type of pain is used in a palliative patient?

A

24 hour pain relief - either simple of strong opioid with there being no maximum dose of opioid.

60
Q

What are anticipatory injections?

A

Anticipatory medications are prescribed as subcutaneous injections (SC, injected under the skin) as patients nearing the end of life are often unable to take oral medications. They should be prescribed PRN, or ‘as needed’, rather than regularly.

61
Q

What are three medications that can be given as anticipatory injections?

A
  • Morphine SC 2.5-5mg 2-4hrly (eGFR >60)
  • Oxycodone SC 1.25-2.5mg 2-4hrly (30-60)
  • Alfentanil SC 125-250mcg 2-4hrly (<30)
    Choice is based upon renal function.
62
Q

When is a syringe driver introduced?

A

Usually when 3 or more injections are being administered within a 24 hour period, they are then put into a syringe driver. This is not NICE recommended however seen at NNUH.

63
Q

What should be considered regarding using opioids in palliative care?

A

Whether the patient is opioid naive or whether a conversion is required from oral dose medications.
Opioids may be used for breathlessness, don’t want patients to be uncomfortable and trying to catch their breath - less distressed (may use Midazolam)
Worried about toxicity, may co-prescribe Naloxone

64
Q

What are syringe drivers?

A

Provide a 24 hour continuous s/c infusion. They require use of a diluent to provide volume and then to be slowly infused over 24 hours (usually water for injection)
Other medications can also be put in such as anti-emetics, anxiolytics (for agitation) and anti-secretory (respiratory secretions).
Need to ensure compatibility of these medications.

65
Q

What is the importance of adequate pain control post operation?

A

Poorly control pain management can result in:
Increased risk of complications, pain can become chronic
Increased morbidity
Prolonged morbidity
Prolonged hospital stay
Can lead to prolonged opioid use Psychological effects

66
Q

What are some of the patient factors which contribute to analgesic choice?

A

Age and frailty- increased risk of falls, sedative side effect
Co-morbidities
Allergies
Renal and liver - influences drug choice and dosing

67
Q

What are some of the discussion points with the patient to help aid choice and duration of analgesic?

A
  • Discuss benefits and risks of different pain relief
  • Impact of the procedure on prevalence of pain – duration and discharge plans as guidance from the hospital will help to inform choice, what is usually used for different procedures
  • Pain history and other agents used, what the patient is already using. For example if they are already taking MR opioid preparations
68
Q

What is the overriding approach for opioid choice in post-op pain?

A

Mainstay of treatment should be oral opioids however a multimodal approach should be used, so they should be used alongside Paracetamol and Ibuprofen so using drugs with multiple mechanisms of action to target the pain in different ways.

69
Q

When may use of NSAIDs be cautioned, after which type of surgery?

A

NSAIDs should be used in caution following hip/pelvic surgery due to affecting bone recovery or in the elderly with a broken hip due to age and their risks (renal).

70
Q

When should oral opioids be used?

A

Usually used as the mainstay of treatment for patients undergoing major operations in which they will be in moderate to severe pain (this can be pre-prescribed).

71
Q

When should oral opioids not be used?

A

They shouldn’t be used alongside a PCA or in a patient undergoing an opiate epidural continuous infusion.
There should only be one route of opioid administration to avoid overdose and so it is clear exactly how much the patient is receiving.
However if the patient was on a long-term opiate beforehand such as a Fentanyl patch or a Buprenorphine patch these can be continued alongside oral opioids (Oramorph).

72
Q

Are opioids good for post-op pain?

A

Yes they have good evidence behind them and can help with cough reflex and mobilisation, leading to a better prognosis and better outcomes.

73
Q

When is Gabapentin used post-operatively?

A

For any post-operative neuropathic pain

74
Q

How does PCA work?

A

Patient controls when and how much analgesia they receive by IV administration. Patient just has to press a button to receive a low dose opiate or opioid.

75
Q

What needs to be monitored when a patient is receiving PCA?

A

Sedation - alertness score VPU-AVPU
Pain score
Respiratory rate (respiratory depression)

76
Q

What is the dose/analgesia received via a PCA?

A

Usually patients will receive a loading dose of medication first.
PCA either contains Morphine or Fentanyl which is usually dependent upon renal function.
e.g. 100mg Morphine in 100mL of NaCl (1mg/mL)
Administers 1mg at a time, followed by a lockout period of 5 minutes but you can assess how many times the patient presses the button

77
Q

If the patient has a low renal function which PCA medication is used?

A

Fentanyl

78
Q

Will any medication be used alongside a PCA?

A

Paracetamol is usually prescribed

79
Q

What is the rationale for using PCAs?

A

Keeps patient within the window, keeping patients within the therapeutic window without experiencing side effects/toxicity. Reduces the peaks and troughs associated with the medication - over and under therapeutic window.
Patients may have to wait, due to there being nursing shortages, may have one nurse for 12 patients on a ward, patient may have to wait for pain relief.

80
Q

What are the advantages of PCA devices?

A

Patient ownership and independence
Faster alleviation of pain
Reduce distress in waiting for nurses
Less time consuming for nurses
Easy to titrate according to response/need

81
Q

What are the disadvantages of PCA devices?

A

Patient may not be responsive post-op or dextrose enough to use it - not appropriate for everyone
Patient may lack understanding or scared to use or have some degree of cognitive impairment
Reduced mobility due to lines being present
Liable to abuse (lock out time)

82
Q

What are some of the side effects/monitoring requirements for PCAs?

A

Nausea and vomiting
Low blood pressure
Drowsiness, constipation (same for both)

83
Q

What is the monitoring required for PCA devices?

A

Blood pressure
Respiratory rate
Sedation
Pain score
Nausea
First 8 hours - monitor hourly
Between 8-24 hours - monitor every 2 hours
48 hours to the end - monitor every 4 hours

84
Q

What is the appropriate management of nausea and vomiting side effect of the medication?

A

Use of cyclizine (IV/PO) or ondansetron (IV/IM,PO) which the route of administration will depend how frequently they are vomiting.
Can be prescribed PRN so nurses can administer the medication any time they wish

85
Q

What is the appropriate management of pruitis?

A

Chlorphenamine 4mg TDS

86
Q

What classes as respiratory depression?

A

Less than 8 breaths per minute

87
Q

What is the appropriate management for respiratory depression?

A

Give oxygen and monitor saturation levels
Stop PCA
Consider Naloxone 200-400mcg (short half-life)

88
Q

What is the appropriate management for excessive sedation?

A

In this instance Naloxone does not necessarily need to be prescribed
Remove the PCA
Oxygen saturation, pain and sedation should be monitored
Monitor on the NEWS score

89
Q

What needs to be co-prescribed alongside opioids?

A

Non-opioids analgesia, to give baseline pain if the patient need to be weaned off or for switching between opioids

90
Q

What are epidurals and where are they injected?

A

They local powerful analgesics that are injected directly into the epidural space to the numb the nerves (prevent transmission) carrying information from parts of the body to the brain. The epidural layer is a fatty layer between the bone and the dura mater which can be injected into.

91
Q

Where is a lumbar puncture taken from?

A

It samples the CSF found in the subarachnoid space between the pia and the arachnoid layer. Can be used to test for cancers - brain, spine, lymphomas and leukemia.

92
Q

What is the goal for epidurals?

A

Not to induce paralysis and there still will be sensitisation above and below the area.
Essential epidurals bathe the nerve fibers – block transmission of sensory impulses
from afferent nerves to the spinal nerve, and ongoing transmission to
the efferent so dampening down nociceptive transmission.
The goal is to block 3 vertebrae which correlates to one dermatome which is an area of the body, this can help map out where the epidural should be injected.

93
Q

Post-operatively where are the common injection sites for an epidural?

A

Lower thoracic or lumbar regions which correlates to the most complex abdominal or pelvic regions.

94
Q

Where are thoracic/lumbar regions found on the body?

A

Thoracic (upper chest)
Low thoracic (abdominal)
Low thoracic/high lumbar (pelvic)
Lumbar (legs)

Therefore injecting into one area of the spine only affects one part of the body that the afferent and efferent neurons travel to and from.

95
Q

Regarding central nerve blockade, which point do you want an epidural to reach?

A

Pain should be blocked however patient should still be able to feel deep pressure and vibrations.
For example during labour, the mum will feel no pain but will feel a deep pressure of the baby being born.

96
Q

What is present within the epidural bag?

A

Opioid
Anaesthetic

97
Q

How opioids work within the epidural bag?

A

Once injected into the epidural space they diffuse into the CSF and act upon GPCR opioid receptors blocking nociceptive transmission of nerve signals.

98
Q

When is an anaesthetic used in epidurals?

A

Prior to the administration of the epidural and then ongoing if given as an infusion to block nerve conduction.

99
Q

How do anaesthetics work in epidurals?

A

Block nerve impulse generation and conduction which relies on action potential depolarisation by sodium channels. Anaesthetics block the sodium channels, preventing signal transmission, stabilising the membrane at rest.

100
Q

What are two important properties regarding epidurals?

A

They are reversible (for example Naloxone is used as an opioid reversal)
And that they don’t migrate firstly to ensure they don’t travel to other areas of the spine causing loss of sensation and reduced efficacy at the site we are targeting.

101
Q

What property does the drug have to ensure that it doesn’t migrate?

A

Density within the medium that they are in. If the drug is more dense within the medium that they are inserted within the drugs will sink down into the spinal column. However if they are less dense then they will float and enter the brain.

102
Q

What are the medications that must be co-prescribed alongside epidurals?

A

Preemptively prescribe medications to reduce the side effects of the epidural:
Cyclizine for nausea and vomiting (associated with the opioid)
Naloxone for reversal
Epinephrine for hypotension

Good for emergency use situations

103
Q

Give an example of a epidural composition.

A

Fentanyl
Onset: 10-20 minutes
Duration: 2.5-4 hours

Bupivacaine
Onset: 15-20 minutes
Duration: 2-3 hours

Can be used bolus or as an infusion

104
Q

What are the advantages of epidurals?

A

High quality pain relief at the target site, using smaller opioid doses than systemic use
Reduce DVT and improved pulmonary function and less sedation
Reduced cardiac morbidity and sepsis
Faster reestablishment of oral intake
Need consent

105
Q

What are the disadvantages of epidurals?

A

Accidental injection into the spinal
cord (total spinal block)
Risk of permanent spinal damage
Accidental IV administration
Dural puncture headache
Epidural bleed/haematoma
Migration of drug can lead to
respiratory paralysis
Infection risk

106
Q

How does respiratory side effects occur with epidurals?

A

Due to opioids and may be due to migration to the C3-C5 blocking phrenic nerves

107
Q

What are some of the cardiac side effects associated with epidurals?

A

Hypotension/Hypothermia due to vasodilation
Reduced cardiac output if T1/T4 is affected
Reflex tachycardia
Overdose or give IV-depression of myocardial excitability

108
Q

Aside from respiratory/cardiac side effects what are some of the other side effects that can occur with epidurals?

A

Reduced hepatic/renal perfusion
Tinnitus
Headache
Nausea and vomiting
Pruitis
Sedation

109
Q

What are some of the rescue therapies for Bupivacaine?

A

If it is administered IV can use 20% Intralipid to reverse cardiac arrest/life threatening toxicity

110
Q

For opioid toxicity what is given?

A

Naloxone 100-400mcg IV can give repeated doses

111
Q

For severe hypotension what is given?

A

Epinephrine

112
Q

What is a dural puncture headache?

A

It occurs when there is a hole in the spine (due to the needle) which can sometimes cause the leakage of of cerebral spinal fluid. If too much leaks out it can cause the reduced pressure in other fluid circulating the CNS causing a severe headache.

113
Q

How are dural puncture headache treated?

A

With a blood patch, patients are injected with their own blood to create a seal around that hole.

114
Q

What are the contraindications to an epidural?

A

Patient refusal
Infection at proposed injection site
Clotting abnormalities
Severe respiratory impairment
Uncorrected hypovolemia
Neurological disease
Raised intracranial pressure
Difficult anatomy
Tattoos- some will / some won’t - ink bleeding into the epidural space causing ink toxicity. Only if tattoo is on the back, some will if they tattoo is old and healed - less concern with the age of the tattoo.

Central Nervous System (11 decks)

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