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Priniclpes Of Anesthesia > exam 3- chronic pain > Flashcards

exam 3- chronic pain Flashcards

1
Q

Chronic pain definition

A

Uninterrupted persistent pain lasting for 3 months or more

Determination of source is not always clear

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2
Q

Things that go along with chronic pain

A

povrty, despair, suicide, divorce, interferes with ADLs, economic impact

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3
Q

Chronic pain classification

A

malignant or non malignant

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4
Q

Chronic pain treatment goal

A

improve ADLs, enhance function, multidisciplinary approach to treatment

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5
Q

Pathophysiology of chronic pain (4 steps)

A
  1. Afferent signals amplified
  2. descending modulation from dorsal horn pathway is decreased
  3. prolonged stimulation, inflammation and nerve injury can sensitize pain transmission fibers
  4. Death of inhibitory cells and/or cause structural neuroplastic changes
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6
Q

Central mechanisms of chronic pain (2)

A
  1. chronic inflammation
  2. hyper excitability of second order neurons in the dorsal horn
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7
Q

Primary neurotransmitter released by primary afferent in the dorsal horn

A

glutamate

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8
Q

Glutamate role in chronic pain

A

excites receptors, causing influx of calcium into cell –>increases second messengers such as protein kinase and phospholipase

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9
Q

Glutamate activates (2)

A
  1. NMDA receptor (among others)
  2. Substance P and CGRP to bind
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10
Q

Activation of secondary messengers from glutamate binding:

A

Up - regulation and hyperexcitability

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11
Q

Up-regulation and hyper excitability of NMDA receptors causes

A

Long term neuronal plasticity and eventually gene transcription changes = sensitization and chronic pain states

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12
Q

What is wind up

A

abnormal response and chronic pain sensation

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13
Q

What causes wind up

A

Repetitive stimulation from chronic inflammation or nerve damage

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14
Q

2 phases of windup:

A
  1. hyperalgesia (less and less stim required to initiate pain
  2. FIbers that don’t normally carry painful stimulation are recruited and start transmitting pain
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15
Q

Chronic pain can lead to

A

psychological dysfunction

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16
Q

Prevention of chronic pain and wind up

A

Treat underlying conditions

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17
Q

In windup, synchronous volleys of affarents produce

A

long lasting synaptic potentials

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18
Q

Windup is the repetitive activation of ______ which______

A

C-fibers, which increases magnitude of evoked responses

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19
Q

Windup leads to

A

central sensitization

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20
Q

Central sensitization is

A

enhanced excitability of dorsal horn neurons

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21
Q

Central sensitization contributes to

A

hyperalgesia

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22
Q

Types of chronic pain (4)

A
  1. neuropathic pain
  2. nociceptive pain
  3. somatic pain
  4. visceral pain
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23
Q

Neuropathic pain definition and manifestations

example

A

pain radiates from a damaged nerve along dermatome

manifestations: intense burning sensation, allodynia. (exaggerated pain repsonse)

ex. shingles

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24
Q

Complex regional pain syndrome s/sx

A

spontaneous pain, hyperalgesia, allodynia, trophic, sudomotor, vasomotor abnormalities, active/passive movement disorders

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25
Q

Complex regional pain syndrome treatment (3)

A

Sympathetic block,
meds,
spinal cord stimulator

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26
Q

Complex regional pain syndrome meds

A

gabapentin, ketamine infusion, memantine

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27
Q

Complex regional pain syndrome type 1 (including pathophys)

A

Reflex sympathetic dystrophy

cause: trauma, surgery, neck injury, female

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28
Q

Complex regional pain syndrome type II (including pathophys)

A

Causalgia
cause: nerve injury (i.e. nerve cut in surgery)

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29
Q

Somatic pain originates in

A

arms, legs, face, muscles, tendons, extrinsic areas of body

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30
Q

Somatic pain is triggered by

A

acute injury or chronic disease (cut, bruise, arthritis, joint injury)

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31
Q

Visceral pain and presentation

A

internal organs

recepted as referred pain

Presentation: N/V, jitteriness

32
Q

Inflammatory nuerochemical substances and reason

A

Bradykinin, histamine, substance P

Serves to protect and prevent further damage

33
Q

Chronic post-surgical pain risk factors:

A
  1. preoperative pain
  2. comorbidities/autoimmmune
  3. secondary gain
34
Q

Chronic postsurgical pain treatment goal

A

reduce central sensitization

35
Q

Methods to reduce central sensitization in postsurgical chronic pain

A

Pre-op treat (meds and block)

meds: NSAIDS/ketamine

36
Q

Post op control of chronic postsurical pain (3)

A
  1. Antidepressants
  2. PO pain meds: ST opioids, anticonvulsants, topical agents, NMDA antagonists
  3. Topical agents
37
Q

Chronic postsurgical pain nature

A

neuropathic without identifiable nerve injury. Still possible nerve compression/damage

38
Q

Common Chronic postsurgical pain surery:

A

Thoracotamy or thoracic penetration of some sort)

39
Q

Pharmaceuticals MOA in chronic pain (2)

A
  1. assist in returning body to normal function (reduce cycle)
  2. Treat pain perception only w/o reducing dysfunctional cycle of chronic pain
40
Q

NSAIDS MOA

A

COX blocking–>reduces release of PGs

41
Q

Best to reduce inflammation

A

COX-2 is better than nonselective COX inhibitor

42
Q

Aspirin

A

nonselective COX inhibitor

43
Q

Aspirin side effect

A

prolonged platelet aggregation

44
Q

Multimodal treatment options for chronic pain (8)

A
  1. Meds
  2. Rehab
  3. Psychology
  4. Interventional pain management
  5. implantable therapies
  6. Complementary/alternative treatments
  7. Nutrition counseling
  8. Vocational Counseling
45
Q

Opioids act in the

A

CNS, not periphery (not effective in chronic pain’s main source of pain)

can be used for short term releif

46
Q

Opioid induced hyperalgesia

A

Sensitization to painful stimuli d/t opioid exposure (hyperalgesia)

May be same or different pain from original pain

47
Q

Chronic opioid therapy and preoperative pain management (3)

A
  1. Know doses, don’t d/c or if you must, give adjunct
  2. Consider intrathecal or epidural infusion and continue perioperatively
  3. benzos
48
Q

Methadone use

A

1.Preemptive analgesia for acute pain management
2. opioid addiction txmt

*need EKG - prolonged QT

49
Q

Suboxone use

A

get off chronic opioids - prevents w/d and raving

50
Q

Suboxone MOA

A

Blocks other opioids from binding

51
Q

Suboxone caution

A

NEVER give versed or benzos: can throw them back into addiction

52
Q

Chronic opioid therapy patients - perioperative pain management (5)

A
  1. Increase dose
  2. avoid opioid antagonist or agonist-antagonist (w/d)
  3. Nonopioid analgesic adjuncts (ketamine, clonidine, dex)
  4. Magnesium 2-3 g
  5. regional/local
53
Q

Gabapentin (antivonvulsant) in chronic pain - MOA

A

blocks alpha 2 delta of Ca+ channels in CNS, prevents excitatory neurotransmitter release

overall decrease in neuronal excitation

54
Q

Perioperative pain management in COT (4)

A
  1. Regional
  2. IV PCA (feeling of control)
    3.pain specialist
    4.Monitory for respiratory depression
55
Q

Ketamine MOA

A

blocks NMDA = treatment and prevention of chronic pain

56
Q

Pros of ketamine perioperatively

A
  1. lowers opioid requirement (even at low dose 0.25-0.5 mg/kg)
57
Q

Ketamine should be used at a _____ because _____

A

low dose (0.5 mg/kg or less), because it minimizes N/V, hallucinations.

58
Q

Cylobenzaprine (flexeril) result

A

Relief of muscle spasm

59
Q

Cyclobenzaprine (flexeril) is chemically related to

A

amtriptyline (antidepressant)

60
Q

NSAID topical agents pros (2)

A
  1. absorption better than PO
  2. Continuous deliver may. help reestablish a noral pathway
61
Q

Sleep is important for

A

healing and cell regeneration

promote sleep in chronic pain!KAn

62
Q

Issue with sleep aid meds

A

interrupt rapid eye movement, disrupting quality of sleep

63
Q

Antidepressant and chronic pain MOA

A

Block reuptake of serotonin and NE = increase their availability

Improved mood = increased compliance, decreased opioid use

64
Q

in chronic pain, Tricyclic antidepressants used for (3)

A

1.postherpetic neuralgia
2. HAs
3. fibromyalgia

65
Q

SNRIs are preferred in

A

those with cardiac disease

66
Q

Lidocaine patch MOA

A

local Na+ channel blockade

67
Q

Capsaicin cream MOA

A

reduces nerve fiber density w/ daily application

68
Q

Mexiletine is

A

PO lidocaine

69
Q

lidocain IV helps with

A

resistant neuropathic pain syndrome

70
Q

Lidocaine infusions show _____ in treatment with neuropathic pain

A

relief equal to morphine, gabapentin, amtriptyline

71
Q

Dexmedetomidine MOA (3)

A
  1. Peripheral analgesia effect
  2. central analgesia effect
  3. Local analgesia effect
72
Q

Dexmedetomidine peripheral analgesia effect MOA

A

inhibits A delta and C fibers

73
Q

Dex central analgesic effect MOA

A

Depolarizes blue plaque in descending pathway in spinal cord in pre-synaptic pathway

inhibits release of substance P –>inhibit spinal cord transmission –> terminates pain signal

74
Q

Dex local analgesia effect MOA

A

modulation of hyperalgesia - alpha2 receptor stimulator

*add to peripheral nerve block

75
Q

SE of dex in peripheral nerve block

A

N/V, resp depression, itching

76
Q

Corticosteroids in chronic pain

A

anti-inflammatory effect: inhibit phospholipase A2 = prevent release of arachiadonic acid

overall decrease in inflammatory cytokines

77
Q
A

Priniclpes Of Anesthesia (19 decks)

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