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Y3 - anaesthetic s > essential pain management > Flashcards

essential pain management Flashcards

1
Q

what is pain

A

unpleasant sensory and emotional experience associated with/resembling that associated with actual or potential tissue damage or described in terms of such damage

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2
Q

6 key notes - looking after patients with pain

A
  • pain is a personal experience influenced by biological, psychological and social factors
  • pain and nociception are different phenomena
  • individuals learn the concept of pain through life experiences
  • a person’s report of pain should be respected
  • pain serves an adaptive role but may have adverse effects on function and psychological wellbeing
  • verbal description is only one of several behaviours to express pain
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3
Q

how many people live with persistent pain

A

1 in 4

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4
Q

why is pain important to treat

A

persistent pain is common
basic human right
66% of people attending A&E seeking help w/ pain had made ~ 3 visits to HCP in proceeding weeks

pain results in poor QOL as bad as other neurological diseases

low back pain is the number 1 disease for yrs lost to disability worldwide

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5
Q

physical benefits of treating pain for the patient

A

improved sleep
better appetite
fewer medical complications e.g. MI, pneumonia

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6
Q

psychological benefits of treating pain for the patient

A

reduced suffering

less depression, anxiety

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7
Q

benefits of treating pain for the family

A

improved functioning as a family member e.g. as a parent

able to keep working

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8
Q

benefits of treating pain for society

A

lower health costs e.g. shorter hospital stay

able to contribute to the community

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9
Q

3 ways to classify pain

A

duration - acute, chronic, acute on chronic
cause - cancer, non-cancer
mechanism - nociceptive, neuropathic

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10
Q

what is acute pain

A

pain of recent onset and probable limited duration

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11
Q

what is chronic pain

A

pain lasting >3mths
pain lasting after normal healing
often no identifiable cause

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12
Q

what is cancer pain

A

progressive

can be a mixture of acute and chronic

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13
Q

what is non-cancer pain

A

many different causes

acute or chronic

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14
Q

what is nociceptive pain

A

obvious tissue injury or illness
aka physiological or inflammatory pain
protective function
description: sharp +/- dull, well localised

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15
Q

what is neuropathic pain

A

nervous system damage or abnormality
tissue injury may not be obvious
doesn’t have a protective function

description:

  • burning, shooting +/- numbness, pins and needles
  • not well localised
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16
Q

what are the 4 steps in pain physiology

A

periphery
spinal cord
brain
modulation

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17
Q

4 steps in pain physiology - periphery

A

tissue injury
release of chemicals e.g. prostaglandins, substance P
stimulation of pain receptors - nociceptors
signal travels in Adelta or C nerve to spinal cord - dorsal ganglia

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18
Q

4 steps in pain physiology - spinal cord

A

dorsal horn is the first relay station for pain
Adelta or C nerve synapses with 2nd nerve (usually in the spinothalamic tract)
2nd nerve travels up opposite side of spinal cord into the thalamus

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19
Q

4 steps in pain physiology - brain

A

thalamus is the 2nd relay station
connections to many parts of the brain - cortex, limbic system, brainstem
pain perception occurs in the cortex

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20
Q

what is the result of the pathway from the cortex to the thalamus

A

produce an expectation of pain

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21
Q

4 steps in pain physiology - modulation

A

descending pathway from brain to dorsal horn

usually decreases pain signal

done through many different types of neurotransmitters

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22
Q

what is the result of a very active descending pathway in pain modulation

A

less pain experience than those who have a less good descending inhibition

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23
Q

what is the gate theory of pain

A

by rubbing/massaging/application of heat etc stimulates the large peripheral Abeta fibres

this stimulates an inihibitory neurone

this switches off the nociceptive afferent signal from going into the dorsal horn

modulation pathway occurs at the periphery and at certain levels within the brain and spinal cord to modulate the pain pathway

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24
Q

what causes neuropathic pain

A

abnormal processing of pain signal
nervous system damage or dysfunction

needs to be treated differently

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25
Q

examples of neuropathic pain

A

nerve trauma, diabetic pain (damage)

fibromyalgia, chronic tension headache (dysfunction)

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26
Q

pathological mechanisms of neuropathic pain

A

increased receptor numbers - enhances pain signal and keeps it going for longer
abnormal sensitisation of nerves (peripheral, central) - pain signal is exaggerated all through the pathway
chemical changes in the dorsal horn - enhanced pain signal
loss of normal inhibitory modulation

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27
Q

drug classification for treating pain

A

simple analgesics:
paracetamol (acetaminophen)
NSAIDs - diclofenac, ibuprofen

opioids:
weak - codeine, dihydrocodeine, tramadol
strong - morphine, oxycodone, fentanyl

other

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28
Q

which opiates have the potential for addiction

A

both weak and strong

29
Q

other analgesics

A

tramadol - mixed opiate and 5HT/NA reuptake inhibitor
antidepressants - amitriptyline, duloxetine
anticonvulsants - gabapentin
ketamine - NMDA receptor antagonist
local anaesthetics
topical agents - capsaicin

30
Q

treatments for pain - periphery

A

non-drug - rest, ice, elevation
NSAIDs - reduce amount of prostagland
local anaesthetic

31
Q

treatments for pain - spinal cord

A

non-drug - acupuncture, massage, TENS
local anaesthetics - epidural, nerve block
opioids - epidural, intrathecal, into CSF
ketamine - modulates pain signal in descending pathway

32
Q

treatments for pain - brain

A

non-drug - psychological

drug - paracetamol, opioids, amitriptyline, clonidine

33
Q

advantages of paracetamol

A

cheap
safe
route: oral, rectal, IV
good for: mild pain by itself, mod-severe pain with other drugs

34
Q

disadvantages of paracetamol

A

liver damage in overdose

35
Q

examples of NSAIDS

A

aspirin
ibuprofen
diclofenac

36
Q

advantages of NSAIDs

A

cheap
generally safe
good for nociceptive pain - best given regularly with paracetamol (synergism)

37
Q

disadvantages of NSAIDs

A

GI side effects
renal side effects - reduced blood flow
bronchospasm in some patients with asthma

38
Q

advantages of codeine

A

cheap
safe
good for mild-moderate acute nociceptive pain
- best given regularly w/ paracetamol

39
Q

disadvantages of codeine

A

constipation

not good for neuropathic pain

40
Q

how does tramadol work

A

weak opioid effect

plus inhibitor of serotonin and noradrenaline reuptake

41
Q

advantages of tramadol

A

less respiratory depression
can be used w/ opioids and simple analgesics
less constipating than opioids

42
Q

disadvantages of tramadol

A

N+V
can be poorly tolerated by some pts, esp at bigger doses
controlled drug

42
Q

disadvantages of tramadol

A

N+V
can be poorly tolerated by some pts, esp at bigger doses
controlled drug

43
Q

advantages of morphine

A

cheap
generally safe
route: oral, IV, IM, SC, PR, intrathecally
effective if given regularly

good for: mod-severe nociceptive pain (e.g. post-op), cancer pain

not advised for neuropathic pain

44
Q

disadvantages of morphine

A

constipation
respiratory depression in high doses
addiction and avoidance due to fear of addiction
controlled drug

oral dose needs to be increased if changing from IV/IM or SC routes as 3rd pass metabolism reduces the amount of morphine available

45
Q

how does amitriptyline work

A

tricyclic antidepressant

increases descending inhibitory signals

46
Q

advantages of amitriptyline

A

cheap
safe in low dose
good for neuropathic pain
also treats depression, poor sleep

47
Q

disadvantages of amitriptyline

A

anti-cholinergic side effects e.g. dry mouth, glaucoma, urinary retention
long term use might be linked with cognitive decline and dementia

48
Q

examples of anti convulsant drugs

A

carbamazepine
sodium valproate
gabapentin

also called membrane stabilisers

49
Q

how do anti-convulsants work

A

reduce abnormal firing of nerves

good for neuropathic pain

49
Q

how do anti-convulsants work

A

reduce abnormal firing of nerves

good for neuropathic pain

50
Q

how do anti-convulsants work

A

reduce abnormal firing of nerves

good for neuropathic pain

51
Q

gabapentin and addiction

A

pretty addictive
cocaine like effect

only start w/ good evidence for neuropathic pain

52
Q

choosing route of delivery

A

patient may be NBM
if prescribing IM/SC consider how much the patient might require and if that is acceptable
S/C cannula might be more tolerable

oral route preferred where possible

53
Q

types of delivery routes

A 
oral 
rectal
sublingual 
subcutaneous 
transdermal 
IM
IV - boluses, possibly patient controlled systems or nurse administered
intrathecal/epidural
54
Q

delivery routes for LA

A 
epidural (+/- opiates)
intrathecal (+/- opiates)
wound  catheters
nerve plexus catheters
lidocaine patches for some neuropathic pain conditions
55
Q

how do we assess pain

A 
verbal rating score
numerical rating score
visual analogue scale 
smiling faces 
abbey pain scale (for confused patients)
functional assessments
56
Q

non-drug treatments for pain

A

physical:
- rest, ice, elevation
- surgery
- accupuncture, massage, physio

psychological:
- explanation
- reassurance
- counselling

57
Q

choosing drug treatments for pain

A

acute pain: WHO pain ladder

neuropathic pain: alternative analgesics +/or psychological and non-drug treatments; not responsive to WHO ladder drugs

58
Q

WHO analgesic ladder

A 
step 1 (mild-mod pain): 
- non-opioids: aspirin, NSAIDs or paracetamol

step 2 (mod-sev pain):

  • mild opioids: e.g. codeine
  • w/ or w/o non-opioids

step 3 (severe pain):

  • strong opioids: e.g. morphine
  • w/ or w/o non-opioids
59
Q

Link pain assessment to prescribing for acute nociceptive pain

A

mild pain - start at bottom of pain ladder
moderate pain - bottom of ladder plus middle rung
severe pain - bottom of ladder plus top, miss out the middle

it is okay to start at the top of the ladder for severe/unbearable pain

60
Q

what to do as pain resolves

A

move from top to middle of ladder
continue bottom rung at all times
lastly, stop NSAIDs first then paracetamol (NSAIDs have more side effects)

clear instructions must be given regarding reduction of all opiates

61
Q

RAT approach to pain management

A

Recognise
Assess - severity, type, other factors
Treat - non-drug and drug

62
Q

recognising pain

A

does the patient have pain?

  • ask
  • look - frowning, moving easily, sweating
  • functional ability e.g. move easily, cough, deep breath etc

do other people know the patient has pain

  • other health workers
  • family
63
Q

Assessment of pain - severity

A

what is the pain score

  • at rest
  • with movement

how is the pain affecting the patient
- can the patient move, cough,
can the patient work

64
Q

assessment of pain - type

A

take a pain hx

nociceptive or neuropathic

look for neuropathic features:
burning or shooting pain
phantom limb pain
other features - pins and needles, numbness

65
Q

assessment - are there any other factors

A
  • things that might make the patient more susceptible to pain or more difficult to treat w/ analgesia
  • physical factors - other illness etc
  • psychological and social factors - anger, anxiety, depression; lack of social support; prev drug use/addictive personality
66
Q

what to do after RAT

A

reassess the patient

is the treatment working
are other treatments needed

Y3 - anaesthetic s (5 decks)

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