E2 Flashcards
(109 cards)
1
Q
Define pain
A
Complex physical, emotional & physiologic condition to tissue injury.
2
Q
What is pain threshold?
A
Level of pain required to transmit pain impulses
3
Q
If pts have cardiac history, what type of CV responses may they have.
A
- Myocardial irritability
- In compromised LV fxn
- -decreased CO
- -MI
4
Q
What is modulation?
A
- Process of altering the pain transmission and interpreting it
- Inhibitory and excitatory process in PSNS & CNS
- -May recruit the descending effector responses
5
Q
What are some excitatory SC modulators?
A
Glutamate Calcitonin Aspartate Neuropeptide Y Substance P
6
Q
What is allodynia?
A
-Perception of pain sensations in response to normally NONpainful stimuli
7
Q
What causes visceral pain?
A
Ischemia, stretching ligamentous attachments
Spasms, distention
8
Q
Alfentanil induction, alone induction, maintenance and onset.
A
Induction = 15-30 mcg/kg IV
Alone induction = 150-300 mcg/kg
Maintenance = 25-150 mcg/kg/hr w/ gas
Onset = 1.4 min
9
Q
Define sedative-hypnotic
A
A drug that reversibly depresses the activity of the CNS
10
Q
Methohexital dose and onset
A
1.5 mg/kg IV
11
Q
What are CV responses to pain?
A
HTN, Tachycardia, myocardial irritability, increased SVR
12
Q
Define general anesthesia.
A
State of drug-induced unconsciousness
13
Q
Distinction of chronic pain
A
- Unpleasant emotional experience, affective qualities
- Anxiety, depression, cognitive deficits, emotional distress
14
Q
What are the catabolic hormones that increase with pain?
A
Catecholamines
Cortisol
Glucagon
15
Q
Where are pain receptors and channels located?
A
- Dorsal root ganglion
- Peripheral nerve terminals
16
Q
What emotional responses occur with pain?
A
Anxiety
Depression
Sleep disturbances
17
Q
What is gate control theory of pain?
A
- Located in dorsal horn
- Gate opens = pain projected to supraspinal regions
- Gate closed = pain is not transmitted due to inhibitory impulses
18
Q
What are characteristics of complex regional pain syndromes?
A
Spontaneous pain, allodynia, hyperalgesia, edema,
- autonomic abnormalities
- active and passive movement disorders
- trophic changes of skin & tissue
19
Q
What interventions could block pain at transduction?
A
Peripheral nerve blocks
20
Q
What is the limbic cortex and thalamus role in pain? Where are they located?
A
They interpret stimuli = perception of motivational-affective pain components
Limbic cortex location = cerebral cortex
Thalamus = below 3rd ventricle
21
Q
What are some peripheral chemical mediators?
A
- PEPTIDES (Substance P, bradykinin [1st released])
- Eicosanoids
- LIPIDS (PGs, TXA, leukotrienes)
- Neutrophins
- Cytokines
- Chemokines
- ECF proteases & protons
22
Q
What are pulmonary responses to pain?
A
- Increased total body O2 consumption & CO@ production
- Increased minute ventilation and work of breathing
- Splinting
- Decreased chest wall movement
- Impaired coughing
23
Q
What is neuropathic pain?
A
Persists after tissue has healed
Can lead to allodynia or hyperalgesia
24
Q
What is the motivational-affective response to pain?
A
- Attention & arousal
- Somatic & autonomic reflexes
- Endocrine response
- Emotional response
25
What GI responses occur with pain?
```
Enhanced SNS tone
Increased sphincter tone
Decreased motility
Hypersecretion of acid
N/V
Abdominal distention
```
26
What are some effects of mu1 agonism?
```
Analgesia
Euphoria
Low abuse potential
Miosis
Bradycardia
Hypothermia
Urinary retention
```
27
What are some MAO-i's & TCAs that meperidine should not be administered with?
MAO-i's:
-nardil, parnate
TCA:
-Amytriptiline
28
2 Components of/responses to pain
Sensory-discriminative
| Motivational-affective
29
What are the anabolic hormones that decrease with pain?
Insulin
| Testosterone
30
Thiopental dose
| and onset
4 mg/kg
| 30 sec
31
What are 2 primary peptide peripheral chemical pain mediators?
Bradykinin (1st released)
| Substance P
32
What characteristics define stage 2 of anesthesia?
- Exaggerated responses, excitement
- CV instability
- dysconjugate ocular movements
- LARYNGOSPASMS
- Emesis
33
What is nociception?
- Experience of pain w/ a series of complex neurophysiologic processes
- Medications target causes of pain in the CNS & PSNS systems by acting on
- -transduction
- -transmission
- -interpretation
- -modulation
34
How is pain unique in the neonate?
- Pain perception at 23 weeks gestation
| - Lower pain threshold & exaggerated response
35
Types of noxious stimuli that elicit pain
Thermal
Mechanic
Pressure
Electrical
36
Etomidate dose for induction & onset
0.2-0.4 mg/kg
| Onset = 1 min IV
37
What are the descending inhibitory neurotransmitters?
Endorphins
Enkephalins
Serotonin
38
What immune responses occur with pain?
- Stress related leukocytosis
| - Suppression = Depressed reticuloendothelial system leading to increased infection
39
What is transduction?
- Afferent response
- Nerve endings receive noxious stimuli
- -heat ,pressure, electrical
- Altered chemistry at nerve endings sends AP
40
Define hypnotic
a drug that induces hypnosis or sleep
41
What populations are at risk for neuropathic pain?
Cancer patients d/t chemo & radiation
42
What occurs during stage 3 anesthesia?
- Absence of response to surgical incision
- Depression in all elements of nervous system function
- 4 planes of general anesthesia
43
What is a complication of chest wall movement when someone is in pain?
Promotes atelectasis & intrapulmonary shunting
44
What interventions could block pain during modulations?
IV pain medications
45
Where does the CNS pain response start?
At the spinal cord
46
What is hyperalgesia?
- INCREASE pain sensations to normal painful stimuli
- LEFT shift of pain rating curve
- May consider low pain threshold
47
What occurs during stage 1 of anesthesia?
- Stage 1 = analgesia
- Initiation of anesthetic to loss of consciousness
- The lightest level of anesthesia
- Sensory and mental depression
48
Ketamine dose for induction, analgesia, postop sedation, neuraxial analgesia and onset.
Induction = 1-2 mg/kg IV, 4-8 mg/kg IM
Analgesia = 0.2-0.5 mg/kg
Postop sedation = 1-2 mg/kg/hr
Neuraxial = 30 mgs
Onset = 1 min IV, 5 min IM
49
What aspects of pain are transmitted via spinohypothalamic path and which laminae?
- Autonomic, neuroendocrine, emotional aspects
| - Laminae = I, V, VII, X
50
Where are afferent C-fibers relayed?
```
Lamina I (marginal layer)
Lamina II (substantia gelatinosa)
```
51
Where are myelinated fibers relayed?
Laminae I, IV-VII & ventral horn
52
Why does O2 consumption & CO2 production increase in pain?
- Because it is a heightened sympathetic response increasing cardiac work, and perfusion to sites of pain.
- This leads to increased needs for O2 and increased metabolism
53
What are the characteristics of plane 4 of Stage 3 anesthesia?
Thoracic immobility
| diminished diaphragmatic movement
54
What is the neurophysiologic process of nociception?
Transduction
Transmission
Modulation
Perception
55
At what point is pain considered chronic
- >3 to 6 months
| - persists beyond tissue healing
56
How is nociception handled in the forebrain somatosensory cortex?
-Interprets location & intensity
57
What is stage 4 anesthesia?
Stage 4 = Medullary paralysis
- Associated w/ cessation of spontaneous respirations and medullary cardiac reflexes
- ALL reflexes are absent
- Flaccid paralysis
- Marked hypotension w/ weak, irregular pulse
- Leads to death
58
What is complex regional pain syndrome?
A variety of painful conditions following injury in a region of impairment of sensory, motor, and autonomic systems
59
What is the endocrine response to pain?
Increased catabolic hormones
| Decreased anabolic hormones
60
Fentanyl dose for analgesia, induction, adjunct, anesthetic, intrathecal, mucosal, dermal and onset
```
Analgesia = 1-2 mcg/kg
Induction = 1.5-3 mcg/kg
Adjunct = 2-20 mcg/kg
Solo anesthesia = 50-1500 mcg/kg
Intrathecal = 25 mcg
Mucosal = 5-20 mcg/kg
Dermal = 75-100 mcg
```
Onset = rapid
61
What are some inhibitory SC modulators?
```
GABA (primary NT)
Glycine
enkephalins
Norepi
Dopamine
```
62
Propofol for induction, sedation, maintenance, PONV, antipruitic doses and onset
```
induction = 1.5-2.5 mg/kg
Sedation = 25-100 mcg/kg/min
maintenance = 100-300 mcg/kg//min
PONV = 10-15 mg/IV
Antipruritic = 10 mg
```
ONSET =LOC in 30 sec
63
What are the 4 stages of anesthesia?
1. Analgesia
2. Delirium
3. Surgical Anesthesia
4. Medullary Paralysis
64
Define anxiolytic
A drug that reduces anxiety and has sedation as a side effect
65
What are CNS neuromodulators?
```
Substance P
Glutamate
CGRP
NMDA
AMPA
Cytokines
```
66
Significance of spinobulbar path and laminae
- Behavior towards pain
| - Laminae = I, V, VII
67
Which lamina are utilized in pain relay through the spinal dorsal horn?
Lamina I
Lamina II
Lamina IV - VII
Lamina III & IV
68
What are the 4 ascending/afferent pathways for nociception transmission?
Spinothalamic (primary path)
Spinomedullary
Spinobulbar
Spinohypothalamic
69
What is the societal impact of pain and what percent of population are affected by chronic, low back or musculoskeletal pain.
- Most common reason people see providers
- $40 billion spent per year on pain
- 40% of adults have chronic pain
- 8--37% of adults experience back pain
- 40 million people have MS pain conditions
70
What are some effects of mu2 agonism?
Analgesia
depressed ventilation
physical dependence
marked contipation
71
What characteristics define stage 1 of anesthesia
- able to open their eyes on command
- breathe normally
- maintain protective reflexes
- tolerate mild stimuli
72
What are the characteristics of plane 1 of Stage 3 anesthesia?
- Deep respirations
- Coordinated thoracic/diaphragmatic muscular activity
- pupillary constriction
73
Where does the descending inhibitory tract originate and what is it's efferent path?
- Originates = periaqueductal gray (PAG)
- Travels through rostral ventral medulla (RVM)
- Via dorsalateral funiculus
- Synapses in SC at the dorsal horn
74
Meperidine dosing and onset
```
Analgesia = 50-100 mg
Shivering = 12.5-30 mg
```
Onset = sim to morphine?
75
What interventions could block pain transmission?
Spinal or epidural
76
What complications can the enhanced SNS response lead to in the GI system related to pain?
Ileus
Urinary retention
Stress ulceration
Aspiration
77
What occurs in peripheral area of modulation?
Tissue injury releases nociception mediators (substance P, glutamate)
- Damaged cells, mast cell etc release more pain modulating mediators
- -facilitates increase in pain
78
Where are the spuraspinal emotional and motivational aspects of modulation occurring?
- Anterior cingulate cortex
| - Insular cortex
79
How does chronic pain differ from acute pain?
- Acute pain resolves as tissue heals
- Chronic pain remains d/t inflammation that does not resolve
- -leads to over sensitization
80
Which induction drug is best for unstable CV due to it's decreased CV effects?
Etomidate
81
Hyrdomorphine analgesia dose.
0.5 mg
82
Define sedation
a drug that induces a state of calm or sleep
83
What treatments are used for neuropathic pain?
Symptomatic
| Opioids, gabapentin, amitriptyline, cannabis
84
What characterizes primary hyperalgesia
- DECREASED pain threshold
- increased response to suprathreshold stimuli
- Spontaneous pain
- Expansion of receptive field
85
What negative effects occur as a result of the endocrine response to pain?
Negative nitrogen balance
Carbohydrate intolerance
Increased renin, aldosterone, ang (INC BP)
86
Peripheral locations of nociceptors.
```
Skin
Muscle
Joints
Viscera
Vasculature
```
87
Morphine onset and peak.
```
Onset = 15-30 min IV/IM
Peak = 45-90 min
```
88
What are hematologic responses that occur with pain?
Platelet adhesiveness increases
Decreased fibrinolysis
Hypercoagulability
89
What are characteristics of stage 3 anesthesia?
- Stage 3 = Surgical anesthesia
- Hypnosis
- Analgesia
- Muscle relaxation
- Sympatholysis
- Amnesia
90
Which laminae have NKI receptors w/ substance P
Laminae III & IV
91
What is the the sensory-discriminative component to pain?
Ascending paths of the spinothalamic & trigeminothalamic tracts to the cerebral cortex
- Sensory procession to discrimination & perception
- -quality of pain
- -location of pain
- -intensity of pain
92
What is primary hyperalgesia?
At original site of injury/insult
93
Remifentanil induction dose and onset.
Induction =
Onset = 1.1 min
94
Sufentanil dose for analgesia and induction and the onset.
```
Analgesia = 0.1 - 0.4 mcg/kg
Induction = 18.9 mcg/kg
```
Onset = 6.2 min
95
What are medications to consider using for post-op shivering?
Meperidine
Physostigmine
Clonidine/Dextromepereidine
Butyrophinol
96
What are the characteristics of plane 3 of Stage 3 anesthesia?
-Continued diaphragmatic movement
-Diminished thoracic movement
further pupillary dilation
97
How do the descending inhibitory NTs affect pain?
- In the SC
- Hyperpolarize Ad & C fibers
- DECREASES substance P
- Opens K+ channels
- Inhibition of Ca++ channels
- Prevents relay of stimulus
98
Codeine analgesia and cough suppression dosing.
Analgesia = 60 mgs PO or IM
| Cough suppression = 15 mgs
99
What is transmission?
- Afferent response
- Conduction of AP to CNS (spine/supraspinal)
- -Via dorsal horn to thalamus
- Terminates at cingulate, insular and somatosensory cortices
100
What is perception?
- Thalamus acting as relay station for incoming signals
- sends signals to primary somatosensory cortex for interpretation
- Somato Cortex discriminates sensory stimuli
101
What are some pain transmitting neuron types and characteristics?
* C-Fibers: unmyelinated, slow pain impulses
- -burning, heat, pressure
*A-fibers: myelinated, large, fast pain impulses
--Type I fibers = Ab & Ad
+heat, mechanical, chemical
--Type II fibers = Ad fibers
+heat
102
What is the dorsal horn's role in pain transmission?
- Relay center for nociception
- Ascending afferent pathways
- Sends pain impulse to brain (thalamus)
103
What is visceral pain
Diffuse and POORLY LOCALIZED pain
| Referred to somatic sites (muscle, skin)
104
What occurs during stage 2 of anesthesia
- Stage 2 = Delirium
- loss of consciousness TO onset of automatic rhythmicity of vital signs
- Pass through rapidly
- Exaggerated response to stimulation
105
What are some peripheral nerve pain receptors and ion channels?
```
Purinergic
Metabotropic
Glutamatergic
Tachykinin
Neurotropic
Ion channels
```
106
Where does supraspinal modulation of nociception occur?
- FOREBRAIN SI & SII (primary site)
- Anterior cingulate cortex
- Insular cortex
- Prefrontal cortex
- Thalamus
- Cerebellum (bulbar level)
107
What is secondary hyperalgesia?
Uninjured skin surrounding primary site of injury
- Sensitization of central neuronal circuits
- Due to edema, inflammation
108
Type of pain transmitted via spinothalamic pathway via which laminae
- Pain, temperature, itch
- Laminae = I, VII, VIII
- C & A fibers
109
What are the characteristics of plane 2 of Stage 3 anesthesia?
- Diminished respiration
| - Fixed midline and dilated pupils
