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Pharm > E2 > Flashcards

E2 Flashcards

1
Q

Define pain

A

Complex physical, emotional & physiologic condition to tissue injury.

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2
Q

What is pain threshold?

A

Level of pain required to transmit pain impulses

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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
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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
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5
Q

What are some excitatory SC modulators?

A 
Glutamate
Calcitonin
Aspartate
Neuropeptide Y
Substance P
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6
Q

What is allodynia?

A

-Perception of pain sensations in response to normally NONpainful stimuli

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7
Q

What causes visceral pain?

A

Ischemia, stretching ligamentous attachments

Spasms, distention

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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

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9
Q

Define sedative-hypnotic

A

A drug that reversibly depresses the activity of the CNS

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10
Q

Methohexital dose and onset

A

1.5 mg/kg IV

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11
Q

What are CV responses to pain?

A

HTN, Tachycardia, myocardial irritability, increased SVR

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12
Q

Define general anesthesia.

A

State of drug-induced unconsciousness

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13
Q

Distinction of chronic pain

A
  • Unpleasant emotional experience, affective qualities

- Anxiety, depression, cognitive deficits, emotional distress

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14
Q

What are the catabolic hormones that increase with pain?

A

Catecholamines
Cortisol
Glucagon

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15
Q

Where are pain receptors and channels located?

A
  • Dorsal root ganglion

- Peripheral nerve terminals

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16
Q

What emotional responses occur with pain?

A

Anxiety
Depression
Sleep disturbances

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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
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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
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19
Q

What interventions could block pain at transduction?

A

Peripheral nerve blocks

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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

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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
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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
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23
Q

What is neuropathic pain?

A

Persists after tissue has healed

Can lead to allodynia or hyperalgesia

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24
Q

What is the motivational-affective response to pain?

A
  • Attention & arousal
  • Somatic & autonomic reflexes
  • Endocrine response
  • Emotional response
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25
Q

What GI responses occur with pain?

A 
Enhanced SNS tone
Increased sphincter tone
Decreased motility
Hypersecretion of acid
N/V
Abdominal distention
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26
Q

What are some effects of mu1 agonism?

A 
Analgesia
Euphoria
Low abuse potential
Miosis
Bradycardia
Hypothermia
Urinary retention
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27
Q

What are some MAO-i’s & TCAs that meperidine should not be administered with?

A

MAO-i’s:
-nardil, parnate
TCA:
-Amytriptiline

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28
Q

2 Components of/responses to pain

A

Sensory-discriminative

Motivational-affective

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29
Q

What are the anabolic hormones that decrease with pain?

A

Insulin

Testosterone

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30
Q

Thiopental dose

and onset

A

4 mg/kg

30 sec

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31
Q

What are 2 primary peptide peripheral chemical pain mediators?

A

Bradykinin (1st released)

Substance P

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32
Q

What characteristics define stage 2 of anesthesia?

A
  • Exaggerated responses, excitement
  • CV instability
  • dysconjugate ocular movements
  • LARYNGOSPASMS
  • Emesis
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33
Q

What is nociception?

A
  • 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
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34
Q

How is pain unique in the neonate?

A
  • Pain perception at 23 weeks gestation

- Lower pain threshold & exaggerated response

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35
Q

Types of noxious stimuli that elicit pain

A

Thermal
Mechanic
Pressure
Electrical

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36
Q

Etomidate dose for induction & onset

A

0.2-0.4 mg/kg

Onset = 1 min IV

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37
Q

What are the descending inhibitory neurotransmitters?

A

Endorphins
Enkephalins
Serotonin

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38
Q

What immune responses occur with pain?

A
  • Stress related leukocytosis

- Suppression = Depressed reticuloendothelial system leading to increased infection

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39
Q

What is transduction?

A
  • Afferent response
  • Nerve endings receive noxious stimuli
  • -heat ,pressure, electrical
  • Altered chemistry at nerve endings sends AP
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40
Q

Define hypnotic

A

a drug that induces hypnosis or sleep

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41
Q

What populations are at risk for neuropathic pain?

A

Cancer patients d/t chemo & radiation

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42
Q

What occurs during stage 3 anesthesia?

A
  • Absence of response to surgical incision
  • Depression in all elements of nervous system function
  • 4 planes of general anesthesia
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43
Q

What is a complication of chest wall movement when someone is in pain?

A

Promotes atelectasis & intrapulmonary shunting

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44
Q

What interventions could block pain during modulations?

A

IV pain medications

45
Q

Where does the CNS pain response start?

A

At the spinal cord

46
Q

What is hyperalgesia?

A
  • INCREASE pain sensations to normal painful stimuli
  • LEFT shift of pain rating curve
  • May consider low pain threshold
47
Q

What occurs during stage 1 of anesthesia?

A
  • Stage 1 = analgesia
  • Initiation of anesthetic to loss of consciousness
  • The lightest level of anesthesia
  • Sensory and mental depression
48
Q

Ketamine dose for induction, analgesia, postop sedation, neuraxial analgesia and onset.

A

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
Q

What aspects of pain are transmitted via spinohypothalamic path and which laminae?

A
  • Autonomic, neuroendocrine, emotional aspects

- Laminae = I, V, VII, X

50
Q

Where are afferent C-fibers relayed?

A 
Lamina I (marginal layer)
Lamina II (substantia gelatinosa)
51
Q

Where are myelinated fibers relayed?

A

Laminae I, IV-VII & ventral horn

52
Q

Why does O2 consumption & CO2 production increase in pain?

A
  • 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
Q

What are the characteristics of plane 4 of Stage 3 anesthesia?

A

Thoracic immobility

diminished diaphragmatic movement

54
Q

What is the neurophysiologic process of nociception?

A

Transduction
Transmission
Modulation
Perception

55
Q

At what point is pain considered chronic

A
  • > 3 to 6 months

- persists beyond tissue healing

56
Q

How is nociception handled in the forebrain somatosensory cortex?

A

-Interprets location & intensity

57
Q

What is stage 4 anesthesia?

A

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
Q

What is complex regional pain syndrome?

A

A variety of painful conditions following injury in a region of impairment of sensory, motor, and autonomic systems

59
Q

What is the endocrine response to pain?

A

Increased catabolic hormones

Decreased anabolic hormones

60
Q

Fentanyl dose for analgesia, induction, adjunct, anesthetic, intrathecal, mucosal, dermal and onset

A 
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
Q

What are some inhibitory SC modulators?

A 
GABA (primary NT)
Glycine
enkephalins
Norepi
Dopamine
62
Q

Propofol for induction, sedation, maintenance, PONV, antipruitic doses and onset

A 
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
Q

What are the 4 stages of anesthesia?

A
  1. Analgesia
  2. Delirium
  3. Surgical Anesthesia
  4. Medullary Paralysis
64
Q

Define anxiolytic

A

A drug that reduces anxiety and has sedation as a side effect

65
Q

What are CNS neuromodulators?

A 
Substance P
Glutamate
CGRP
NMDA
AMPA
Cytokines
66
Q

Significance of spinobulbar path and laminae

A
  • Behavior towards pain

- Laminae = I, V, VII

67
Q

Which lamina are utilized in pain relay through the spinal dorsal horn?

A

Lamina I
Lamina II
Lamina IV - VII
Lamina III & IV

68
Q

What are the 4 ascending/afferent pathways for nociception transmission?

A

Spinothalamic (primary path)
Spinomedullary
Spinobulbar
Spinohypothalamic

69
Q

What is the societal impact of pain and what percent of population are affected by chronic, low back or musculoskeletal pain.

A
  • 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
Q

What are some effects of mu2 agonism?

A

Analgesia
depressed ventilation
physical dependence
marked contipation

71
Q

What characteristics define stage 1 of anesthesia

A
  • able to open their eyes on command
  • breathe normally
  • maintain protective reflexes
  • tolerate mild stimuli
72
Q

What are the characteristics of plane 1 of Stage 3 anesthesia?

A
  • Deep respirations
  • Coordinated thoracic/diaphragmatic muscular activity
  • pupillary constriction
73
Q

Where does the descending inhibitory tract originate and what is it’s efferent path?

A
  • Originates = periaqueductal gray (PAG)
  • Travels through rostral ventral medulla (RVM)
  • Via dorsalateral funiculus
  • Synapses in SC at the dorsal horn
74
Q

Meperidine dosing and onset

A 
Analgesia = 50-100 mg
Shivering = 12.5-30 mg

Onset = sim to morphine?

75
Q

What interventions could block pain transmission?

A

Spinal or epidural

76
Q

What complications can the enhanced SNS response lead to in the GI system related to pain?

A

Ileus
Urinary retention
Stress ulceration
Aspiration

77
Q

What occurs in peripheral area of modulation?

A

Tissue injury releases nociception mediators (substance P, glutamate)

  • Damaged cells, mast cell etc release more pain modulating mediators
  • -facilitates increase in pain
78
Q

Where are the spuraspinal emotional and motivational aspects of modulation occurring?

A
  • Anterior cingulate cortex

- Insular cortex

79
Q

How does chronic pain differ from acute pain?

A
  • Acute pain resolves as tissue heals
  • Chronic pain remains d/t inflammation that does not resolve
  • -leads to over sensitization
80
Q

Which induction drug is best for unstable CV due to it’s decreased CV effects?

A

Etomidate

81
Q

Hyrdomorphine analgesia dose.

A

0.5 mg

82
Q

Define sedation

A

a drug that induces a state of calm or sleep

83
Q

What treatments are used for neuropathic pain?

A

Symptomatic

Opioids, gabapentin, amitriptyline, cannabis

84
Q

What characterizes primary hyperalgesia

A
  • DECREASED pain threshold
  • increased response to suprathreshold stimuli
  • Spontaneous pain
  • Expansion of receptive field
85
Q

What negative effects occur as a result of the endocrine response to pain?

A

Negative nitrogen balance
Carbohydrate intolerance
Increased renin, aldosterone, ang (INC BP)

86
Q

Peripheral locations of nociceptors.

A 
Skin
Muscle
Joints
Viscera
Vasculature
87
Q

Morphine onset and peak.

A 
Onset = 15-30 min IV/IM
Peak = 45-90 min
88
Q

What are hematologic responses that occur with pain?

A

Platelet adhesiveness increases
Decreased fibrinolysis
Hypercoagulability

89
Q

What are characteristics of stage 3 anesthesia?

A
  • Stage 3 = Surgical anesthesia
  • Hypnosis
  • Analgesia
  • Muscle relaxation
  • Sympatholysis
  • Amnesia
90
Q

Which laminae have NKI receptors w/ substance P

A

Laminae III & IV

91
Q

What is the the sensory-discriminative component to pain?

A

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
Q

What is primary hyperalgesia?

A

At original site of injury/insult

93
Q

Remifentanil induction dose and onset.

A

Induction =

Onset = 1.1 min

94
Q

Sufentanil dose for analgesia and induction and the onset.

A 
Analgesia = 0.1 - 0.4 mcg/kg
Induction = 18.9 mcg/kg

Onset = 6.2 min

95
Q

What are medications to consider using for post-op shivering?

A

Meperidine
Physostigmine
Clonidine/Dextromepereidine
Butyrophinol

96
Q

What are the characteristics of plane 3 of Stage 3 anesthesia?

A

-Continued diaphragmatic movement
-Diminished thoracic movement
further pupillary dilation

97
Q

How do the descending inhibitory NTs affect pain?

A
  • In the SC
  • Hyperpolarize Ad & C fibers
  • DECREASES substance P
  • Opens K+ channels
  • Inhibition of Ca++ channels
  • Prevents relay of stimulus
98
Q

Codeine analgesia and cough suppression dosing.

A

Analgesia = 60 mgs PO or IM

Cough suppression = 15 mgs

99
Q

What is transmission?

A
  • Afferent response
  • Conduction of AP to CNS (spine/supraspinal)
  • -Via dorsal horn to thalamus
  • Terminates at cingulate, insular and somatosensory cortices
100
Q

What is perception?

A
  • Thalamus acting as relay station for incoming signals
  • sends signals to primary somatosensory cortex for interpretation
  • Somato Cortex discriminates sensory stimuli
101
Q

What are some pain transmitting neuron types and characteristics?

A
  • 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
Q

What is the dorsal horn’s role in pain transmission?

A
  • Relay center for nociception
  • Ascending afferent pathways
  • Sends pain impulse to brain (thalamus)
103
Q

What is visceral pain

A

Diffuse and POORLY LOCALIZED pain

Referred to somatic sites (muscle, skin)

104
Q

What occurs during stage 2 of anesthesia

A
  • Stage 2 = Delirium
  • loss of consciousness TO onset of automatic rhythmicity of vital signs
  • Pass through rapidly
  • Exaggerated response to stimulation
105
Q

What are some peripheral nerve pain receptors and ion channels?

A 
Purinergic
Metabotropic
Glutamatergic
Tachykinin
Neurotropic
Ion channels
106
Q

Where does supraspinal modulation of nociception occur?

A
  • FOREBRAIN SI & SII (primary site)
  • Anterior cingulate cortex
  • Insular cortex
  • Prefrontal cortex
  • Thalamus
  • Cerebellum (bulbar level)
107
Q

What is secondary hyperalgesia?

A

Uninjured skin surrounding primary site of injury

  • Sensitization of central neuronal circuits
  • Due to edema, inflammation
108
Q

Type of pain transmitted via spinothalamic pathway via which laminae

A
  • Pain, temperature, itch
  • Laminae = I, VII, VIII
  • C & A fibers
109
Q

What are the characteristics of plane 2 of Stage 3 anesthesia?

A
  • Diminished respiration

- Fixed midline and dilated pupils

Pharm (4 decks)

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