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Anaesthetics > Essential Pain Management > Flashcards

Essential Pain Management Flashcards

1
Q

What is pain?

A

Pain = unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage

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2
Q

What are the benefits of treating pain?

A
  • Patient
    • Physical
      • Improved sleep
      • Better appetite
      • Fewer medical complications such as heart attack
    • Psychologically
      • Reduced suffering
      • Less depression and anxiety
  • Family
    • Improved functioning as family member
    • Able to keep working
  • Society
    • Lower health costs
    • Contribute to community
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3
Q

How can pain be classified?

A
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4
Q

Describe acute and chronic pain?

A
  • Acute
    • Pain of recent onset and limited duration
  • Chronic
    • Pain lasting > 3 months
    • Pain lasting after normal healing
    • Often no identifiable cause
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5
Q

Describe cancer and non-cancer pain?

A
  • Cancer pain
    • Progressive
    • May be mixture of acute and chronic
  • Non-cancer pain
    • Many different causes
    • Acute or chronic
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6
Q

What is nociceptive pain?

A
  • Obvious tissue injury or illness
  • Also called physiological or inflammatory pain
  • Protective function
  • Description
    • Sharp +/- dull
    • Well localised
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7
Q

What is nociceptive pain also called?

A
  • Also called physiological or inflammatory pain
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8
Q

What function does nociceptive pain have?

A
  • Protective function
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9
Q

What would the patient complain of with nociceptive pain?

A
  • Sharp +/- dull
  • Well localised
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10
Q

What is neuropathic pain?

A
  • Nervous system damage or abnormality
  • Tissue injury may not be obvious
  • Does not have protective function
  • Description
    • Burning, shooting +/- numbness, pins and needles
    • Not well localised
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11
Q

How would a patient describe neuropathic pain?

A
  • Burning, shooting +/- numbness, pins and needles
  • Not well localised
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12
Q

Describe the 4 steps in pain physiology resulting in the experience of pain?

A
  • Periphery injury
    • Tissue injury causes release of chemicals such as prostaglandins, substance P
    • Stimulation of pain receptors (nociceptors)
    • Signals travel in Aδ or C nerve to spinal cord
  • Signals into spinal cord through dorsal route ganglion
    • Dorsal horn is first relay station
    • Aδ or C nerve synapses with second nerve
    • Travels up opposite side of spinal cord (usually spinothalamic tract) into thalamus
  • Ascending pathway to brain (thalamus) through dorsal horn
    • Thalamus is second relay station
    • Connections to many different parts of brain – cortex, limbic system and brainstem (connections go both ways)
    • Pain perception occurs in cortex
  • Modulation is descending pathway through dorsal horn to turn of pain
    • Descending pathway from brain to dorsal horn to decrease pain signal
    • Done using many different types of neurotransmitters
    • Most important way of modulation is known as “gate theory of pain”
      • Rubbing, massaging or application of heat stimulates large Aa/AB fibres that activates inhibitory neuron that switches off nociceptive afferent signal from going into dorsal horn
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13
Q

What is released in tissue injury, where does it act and what does this cause?

A
  • Tissue injury causes release of chemicals such as prostaglandins, substance P
  • Stimulation of pain receptors (nociceptors)
  • Signals travel in Aδ or C nerve to spinal cord
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14
Q

In what class of nerve fibres does pain travel?

A
  • Signals travel in Aδ or C nerve to spinal cord
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15
Q

What is the first relay station of pain?

A

Dorsal horn

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16
Q

Does pain signal travel up contra or ipsilateral side of spinal cord?

A

Contralateral (usually in spinothalamic tract)

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17
Q

In what spinal tract does pain normally travel up the spinal cord?

A

Spinothalamic tract

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18
Q

What is the second relay station of pain?

A

Thalamus

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19
Q

After the thalamus where does pain perception travel? Where does pain perception occur?

A
  • Connections to many different parts of brain – cortex, limbic system and brainstem (connections go both ways)
  • Pain perception occurs in cortex
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20
Q

What is modulation?

A
  • Descending pathway from brain to dorsal horn to decrease pain signal
  • Done using many different types of neurotransmitters
  • Most important way of modulation is known as “gate theory of pain”
    • Rubbing, massaging or application of heat stimulates large Aa/AB fibres that activates inhibitory neuron that switches off nociceptive afferent signal from going into dorsal horn
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21
Q

Describe gate theory of pain?

A
  • Rubbing, massaging or application of heat stimulates large Aa/AB fibres that activates inhibitory neuron that switches off nociceptive afferent signal from going into dorsal horn
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22
Q

What does neuropathic pain occur due to?

A
  • Due to nervous system damage or dysfunction
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23
Q

What are examples of neuropathic pain?

A
  • Fibromyalgia, chronic tension headache (dysfunction)
24
Q

Describe the pathological mechanisms that can cause neuropathic pain?

A
  • Increased receptor numbers
  • Abnormal sensitisation of nerves
    • Peripheral
    • Central
  • Chemical changes in dorsal horn
  • Loss of normal inhibitory modulation
25
Q

What are the different drug classifications for pain management?

A
  • Simple analgesics
    • Paracetamol (acetaminophen)
      • Good for mild pain (by itself) or moderate-severe pain (with other drugs)
      • Advantages – cheap, safe, many administration routes
      • Disadvantage – liver damage in OD
    • Non-steroidal anti-inflammatory drugs
      • Such as iclofenac, ibuprofen, aspirin
      • Good for nociceptive pain, best with paracetamol (synergism)
      • Advantages – cheap, generally safe
      • Disadvantages – GI side effects, reduced renal blood flow, bronchospasm in some patients with asthma
  • Opioids
    • Weak
      • Codeine
        • Good for mild-moderate acute nociceptive pain, best with regular paracetamol
        • Advantages – cheap, safe
        • Disadvantages – constipation, not good for neuropathic pain
      • Dihydrocodeine
      • Tramadol
        • Weak opioids effect plus inhibitor of serotonin and noradrenaline reuptake (modulation)
        • Advantages – less respiratory depression, can be used with opioids and simple analgesics, less constipation than opioids
        • Disadvantages – nausea and vomiting, controlled drug
    • Strong
      • Morphine
        • Good for mod-severe nociceptive pain and cancer pain, not adviced for neuropathic pain
        • Advantages – cheap, safe, many routes of administration
        • Disadvantages – constipation, respiratory depression in high doses, addition and avoidance due to fear of addiction, controlled drug
      • Oxycodone
      • Fentanyl
    • Both weak and strong have potential for addiction
  • Other
    • Tramadol
      • Mixed opiate and 5HT/NA reuptake inhibitor
    • Antidepressants
      • Amitriptyline
        • Tricyclic antidepressant (TCA)
        • Increases descending inhibitory signals
        • Good for neuropathic pain, also treats depression and poor sleep
        • Advantages – cheap, safe in low doses
        • Disadvantages – anti-cholinergic side effects (glaucoma, urinary retention), long term use might be linked with cognitive decline and dementia
      • Duloxetine
    • Anticonvulsants (also called membrane stabilisers)
      • Good for neuropathic pain
      • Carbamazepine
      • Sodium valproate
      • Gabapentin
    • Ketamine
      • NMDA receptor antagonist
    • Local anaesthetics
    • Topical agents
      • Such as capsaicin
26
Q

What are examples of simple analgesics?

A
  • Paracetamol (acetaminophen)
    • Good for mild pain (by itself) or moderate-severe pain (with other drugs)
    • Advantages – cheap, safe, many administration routes
    • Disadvantage – liver damage in OD
  • Non-steroidal anti-inflammatory drugs
    • Such as iclofenac, ibuprofen, aspirin
    • Good for nociceptive pain, best with paracetamol (synergism)
    • Advantages – cheap, generally safe
    • Disadvantages – GI side effects, reduced renal blood flow, bronchospasm in some patients with asthma
27
Q

For paracetomol:

  • indications
  • advantages
  • disadvantages
A
  • Good for mild pain (by itself) or moderate-severe pain (with other drugs)
  • Advantages – cheap, safe, many administration routes
  • Disadvantage – liver damage in OD
28
Q

For NSAIDs:

  • drugs
  • indications
  • advantages
  • disadvantages
A
  • Such as iclofenac, ibuprofen, aspirin
  • Good for nociceptive pain, best with paracetamol (synergism)
  • Advantages – cheap, generally safe
  • Disadvantages – GI side effects, reduced renal blood flow, bronchospasm in some patients with asthma
29
Q

What are the 2 different classes of opiods?

A
  • Weak
    • Codeine
      • Good for mild-moderate acute nociceptive pain, best with regular paracetamol
      • Advantages – cheap, safe
      • Disadvantages – constipation, not good for neuropathic pain
    • Dihydrocodeine
    • Tramadol
      • Weak opioids effect plus inhibitor of serotonin and noradrenaline reuptake (modulation)
      • Advantages – less respiratory depression, can be used with opioids and simple analgesics, less constipation than opioids
      • Disadvantages – nausea and vomiting, controlled drug
  • Strong
    • Morphine
      • Good for mod-severe nociceptive pain and cancer pain, not adviced for neuropathic pain
      • Advantages – cheap, safe, many routes of administration
      • Disadvantages – constipation, respiratory depression in high doses, addition and avoidance due to fear of addiction, controlled drug
    • Oxycodone
    • Fentanyl
  • Both weak and strong have potential for addiction
30
Q

What are examples of weak opiods?

A
  • Weak
    • Codeine
      • Good for mild-moderate acute nociceptive pain, best with regular paracetamol
      • Advantages – cheap, safe
      • Disadvantages – constipation, not good for neuropathic pain
    • Dihydrocodeine
    • Tramadol
      • Weak opioids effect plus inhibitor of serotonin and noradrenaline reuptake (modulation)
      • Advantages – less respiratory depression, can be used with opioids and simple analgesics, less constipation than opioids
      • Disadvantages – nausea and vomiting, controlled drug
  • Strong
    • Morphine
      • Good for mod-severe nociceptive pain and cancer pain, not adviced for neuropathic pain
      • Advantages – cheap, safe, many routes of administration
      • Disadvantages – constipation, respiratory depression in high doses, addition and avoidance due to fear of addiction, controlled drug
    • Oxycodone
    • Fentanyl
  • Both weak and strong have potential for addiction
31
Q

What are examples of strong opiods?

A
  • Weak
    • Codeine
      • Good for mild-moderate acute nociceptive pain, best with regular paracetamol
      • Advantages – cheap, safe
      • Disadvantages – constipation, not good for neuropathic pain
    • Dihydrocodeine
    • Tramadol
      • Weak opioids effect plus inhibitor of serotonin and noradrenaline reuptake (modulation)
      • Advantages – less respiratory depression, can be used with opioids and simple analgesics, less constipation than opioids
      • Disadvantages – nausea and vomiting, controlled drug
  • Strong
    • Morphine
      • Good for mod-severe nociceptive pain and cancer pain, not adviced for neuropathic pain
      • Advantages – cheap, safe, many routes of administration
      • Disadvantages – constipation, respiratory depression in high doses, addition and avoidance due to fear of addiction, controlled drug
    • Oxycodone
    • Fentanyl
  • Both weak and strong have potential for addiction
32
Q

For codeine:

  • indications
  • advantages
  • disadvantages
A
  • Good for mild-moderate acute nociceptive pain, best with regular paracetamol
  • Advantages – cheap, safe
  • Disadvantages – constipation, not good for neuropathic pain
33
Q

For tramadol:

  • mode of action
  • advantages
  • disadvantages
A
  • Weak opioids effect plus inhibitor of serotonin and noradrenaline reuptake (modulation)
  • Advantages – less respiratory depression, can be used with opioids and simple analgesics, less constipation than opioids
  • Disadvantages – nausea and vomiting, controlled drug
34
Q

For morphine:

  • indications
  • advantages
  • disadvantages
A
  • Good for mod-severe nociceptive pain and cancer pain, not adviced for neuropathic pain
  • Advantages – cheap, safe, many routes of administration
  • Disadvantages – constipation, respiratory depression in high doses, addition and avoidance due to fear of addiction, controlled drug
35
Q

What are examples of pain management drugs that not simple analgesics of opiods?

A
  • Tramadol
    • Mixed opiate and 5HT/NA reuptake inhibitor
  • Antidepressants
    • Amitriptyline
      • Tricyclic antidepressant (TCA)
      • Increases descending inhibitory signals
      • Good for neuropathic pain, also treats depression and poor sleep
      • Advantages – cheap, safe in low doses
      • Disadvantages – anti-cholinergic side effects (glaucoma, urinary retention), long term use might be linked with cognitive decline and dementia
    • Duloxetine
  • Anticonvulsants (also called membrane stabilisers)
    • Good for neuropathic pain
    • Carbamazepine
    • Sodium valproate
    • Gabapentin
  • Ketamine
    • NMDA receptor antagonist
  • Local anaesthetics
  • Topical agents
    • Such as capsaicin
36
Q

What class of drug is tramadol?

A
  • Mixed opiate and 5HT/NA reuptake inhibitor
37
Q

What are different antidepressants?

A
  • Amitriptyline
    • Tricyclic antidepressant (TCA)
    • Increases descending inhibitory signals
    • Good for neuropathic pain, also treats depression and poor sleep
    • Advantages – cheap, safe in low doses
    • Disadvantages – anti-cholinergic side effects (glaucoma, urinary retention), long term use might be linked with cognitive decline and dementia
  • Duloxetine
38
Q

What class of drug is amitriptyline?

A
  • Tricyclic antidepressant (TCA)
39
Q

For amitriptyline:

  • mode of action
  • indications
  • advantages
  • disadvantages
A
  • Increases descending inhibitory signals
  • Good for neuropathic pain, also treats depression and poor sleep
  • Advantages – cheap, safe in low doses
  • Disadvantages – anti-cholinergic side effects (glaucoma, urinary retention), long term use might be linked with cognitive decline and dementia
40
Q

What are anticonvulsants also called?

A

Membrane stabilisers

41
Q

For anticonvulsants:

  • indication
  • drugs
A
  • Good for neuropathic pain
  • Drugs
    • Carbamazepine
    • Sodium valproate
    • Gabapentin
42
Q

What is the mode of action of ketamine?

A
  • NMDA receptor antagonist
43
Q

What is an example of a topical agent used for pain management?

A

Capsaicin

44
Q

What pain treatments target the periphery?

A
  • Non-drug treatments like rest, ice, elevation
  • NSAIDs to reduce prostaglandin and inflammatory soup
  • Local anaesthetics
45
Q

What pain treatments target the spinal cord?

A
  • Non-drug treatments such as acupuncture, massage, TENS
  • Local anaesthetics – epidural delivery or nerve blockade
  • Opioids
  • Ketamine
46
Q

What pain treatments target the brain?

A
  • Non drug treatments, psychological
  • Drug treatments – paracetamol, opioids, amitriptyline, clonidine
47
Q

What are examples of routes of administration?

A
  • Oral
  • Rectal
  • Sublingual
  • Subcutaneous
  • Transdermal
  • Intramuscular
  • Intravenous – boluses, patient controlled systems or nurse administered
  • Intrathecal/epidural
48
Q

What are different delivery routes for local anaesthetics?

A
  • Epidural (+/- opiates)
  • Intrathecal (+/- opiates)
  • Wound catheters
  • Nerve plexus catheters
  • Local infiltration of wounds
  • Lidocaine patches for some neuropathic pain conditions
49
Q

What can pain be assessed by?

A
  • Verbal rating score (mild, moderate, severe, unbearable)
  • Numerical rating score (smaller scales are better like 0-4 than 0-10)
  • Visual analogue scale
  • Smiling faces scale
  • Abbey pain scale (for confused patients)
  • Functional assessments
50
Q

Describe the treatment of pain?

A
  • Non-pharmacological
    • Physical
      • Rest, ice, elevation
      • Surgery
      • Acupuncture, massage, physiotherapy
    • Psychological
      • Explanation
      • Reassurance
      • Counselling
  • Pharmacological
    • Acute pain – WHO pain ladder
    • Neuropathic pain – alternative analgesics, not responsive to WHO ladder drugs
51
Q

What are examples of non-pharmacological treatments for pain?

A
  • Physical
    • Rest, ice, elevation
    • Surgery
    • Acupuncture, massage, physiotherapy
  • Psychological
    • Explanation
    • Reassurance
    • Counselling
52
Q

What is the pharmacological treatment for acute and neuropathic pain?

A
  • Acute pain – WHO pain ladder
  • Neuropathic pain – alternative analgesics, not responsive to WHO ladder drugs
53
Q

Describe the WHO pain ladder?

A
  • Mild pain
    • Start at bottom of pain ladder
  • Moderate pain
    • Bottom plus middle rung
  • Severe
    • Bottom plus
  • REMEMBER – it is okay to start at top of ladder for severe/unbearable pain
  • As pain resolves
    • Move from top to middle, continuing bottom rungs drugs at all times
    • Lastly stop NSAIDs first then paracetamol as more adverse effects with NSAIDs
54
Q

What drugs are in steps 1, 2 and 3 of the WHO pain ladder?

A
55
Q

Describe the ‘RAT’ approach to pain management?

A
  • Recognise
    • Ask and look for signs
  • Assess
    • Severity – pain score at rest and with movement, how is pain affecting patient
    • Type – nociceptive or neuropathic, look for features of neuropathic like burning/shooting pain and phantom limb pain, other features like pins and needles or numbess
    • Other factors – physical and psychological factors to make patients more susceptible to pain or more difficult to treat
  • Treat
    • Non-pharmacological
      • RIE (rest, ice, elevation)
      • Nursing care
      • Surgery, acupuncture, message, TENS
      • Psychological – explanation and reassurance
    • Pharmacological
      • WHO pain ladder, see above
        • Not always useful, use other drugs early
  • After RAT, reassess the patient to see if treatment is working and if any other treatment is needed
56
Q

When assessing pain, as part of the ‘RAT’ approach, what should be considered?

A
  • Severity – pain score at rest and with movement, how is pain affecting patient
  • Type – nociceptive or neuropathic, look for features of neuropathic like burning/shooting pain and phantom limb pain, other features like pins and needles or numbess
  • Other factors – physical and psychological factors to make patients more susceptible to pain or more difficult to treat

Anaesthetics (6 decks)

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