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MSK Week 6 > ICL 7.3; Acute Post-Surgical Pain > Flashcards

ICL 7.3; Acute Post-Surgical Pain Flashcards

1
Q

what are the psychological and physiologic effects of untreated pain?

A
  1. increase morbidity and mortality
  2. compromise recovery
  3. increase incidence of chronic pain
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2
Q

what are the ASA Pain Task Force 2012 Guidelines?

A
  1. when possible, use a multimodal approach = opioids are supplemental treatments after you’ve used NSAIDs!
  2. non-opioid treatment plans like local anesthetic or NSAIDs
  3. opioids are supplemental treatments like IVA PCA, neuraxial opioids
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3
Q

what usually causes acute pain?

A

acute pain normally occurs after surgery

in a sample of 1490 surgical inpatients more than 85% experienced pain

after orthopedic, general, or cardiac surgery, 63% of patients experience pain resolution within 6 days but that means 37% continue to have pain

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4
Q

what is preventive analgesia?

A

attenuating central sensitization resulting from painful insults and subsequent inflammation

it has a lot of effectiveness and duration of analgesic intervention because it is clinically relevant in blocking noxious stimulus and decreasing sensitization to pain

intensive multimodal analgesic intervention is needed for effectiveness

interventions should be maintained into the post-operative phase in addition to the intraoperative phase

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5
Q

what is multimodal analgesia?

A

using two or more analgesic agents that exert effects via different mechanisms and ideally act synergistically

this was introduced > 15 years ago to allow for early ambulation, improve rehabilitation, hasten recovery, and reduce hospital length of stay

strong evidence for use of local anesthetics, acetaminophen and NSAIDs because this reduced opioid use!

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6
Q

what are the two types of systemic analgesics?

A
  1. opioids (IV PCA pump)

2. non-opioid analgesics

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7
Q

what is the MOA of opioids?

A

main effect of analgesia is from agonism at mu-opioid receptors found in both the central nervous system and peripheral nervous system

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8
Q

what are the side effects of opioids?

A

adverse effects of nausea, vomiting, pruritus, ileus, respiratory depression, addiction

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9
Q

how can you give opioids?

A

Subcutaneous, PO, IV, IM, intranasal, transmucosal, neuraxial

Usually oral or parenteral delivery ideal post-operatively

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10
Q

what is the receptor physiology of opioids?

A

you can develop tolerance and sensitization to opioids which leads to increased dose requirement for similar analgesic effectiveness

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11
Q

what is patient controlled analgesia?

A

ideal for delivering medications to patients

it compensates for variability in analgesic needs, serum levels, nursing/staff delays

these safety mechanism through biofeedback (respiratory monitoring)

they’re programmable because there’s a demand dose, lockout interval and basal infusion rate

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12
Q

what are the pros of a PCA pump?

A
  1. superior postoperative analgesia
  2. improved patient satisfaction
  3. decreased risk of pulmonary complications
  4. decreases demand on nursing staff
  5. no change in opiod consumption, cost or length of hospital stay or adverse opiod related effects
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13
Q

what’s the conversion of dose between parenteral and oral route of opiod administration?

A

parenteral dose is always less than the oral dose

everything gets converted into terms of oral morphine

ex. morphine: parenteral dose is 10 mg and the oral dose is 30 mg

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14
Q

which drugs are non-opioid analgesics?

A
  1. NSAIDS and Acetaminophen
  2. ketamine
  3. gabapentin and Pregabalin
  4. muscle Relaxants
  5. topical Agents
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15
Q

what are fentanyl patches used for?

A

NOT recommended for acute pain

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16
Q

what is the MOA of NSAIDs and acetaminophen?

A

Inhibits COX enzymes which reduces prostaglandin synthesis

they inhibit mediation of hyperalgesia and inflammation

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17
Q

what are the pros of NSAIDs over opioids?

A

decrease opioid consumption

improve post-operative pain

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18
Q

what are the cons of NSAIDs?

A
  1. GI bleeding
  2. renal dysfunction
  3. inhibition of platelet aggregation
19
Q

what is the MOA of ketamine?

A

NMDA-receptor antagonist

so it attenuates the central sensitization to pain

20
Q

what are the pros of ketamine over opioids?

A

Reduce opioid use and side effects

No respiratory depression from ketamine

21
Q

what are the cons of ketamine?

A
  1. hallucinations, cognitive impairment

2. sympathetic stimulation = increased heart rate so for a cardiac patient this would be horrible

22
Q

what is the MOA of gabapentin and pregabalin?

A

inhibits α2δ subunit of voltage-dependent calcium channels

shown promising early results in lowering pain scores

23
Q

which drugs are muscle relaxants?

A
  1. baclofen
  2. tizanidine
  3. cyclobenzaprine
  4. methocarbamol
24
Q

when should you use topical pain relief medication?

A

when there’s pain in focal area

may take 3 days to 2 weeks to work

do NOT use when there’s skin irritation

25
Q

which medications are topical pain relief?

A
  1. Lidocaine patch or cream
  2. Diclofenac gel
  3. Capsaicin cream
26
Q

what are neuraxial and peripheral analgesia?

A

Better analgesia than systemic opioids

continuous administration allows for decreased adverse events, improved patient outcomes

ex. epidural infusion or peripheral nerve blocks

27
Q

what are the pros of neuraxial and peripheral analgesia?

A

Longer duration than single injection
Superior to systemic opioids

Decreased pulmonary, cardiovascular, gastrointestinal complications in high-risk patients/procedures

Outcome dependent on:
Catheter location
Surgical incision site
Type of analgesic regimen (sole method or multimodal)

Local anesthetic +/- Opioid is superior to Opioid alone

Premature discontinuation of epidural may thwart its overall benefit

28
Q

what are regional analgesia?

A

Variety of peripheral regional techniques used for postoperative pain control, reducing side effects

Can be in the form of single injection or continuous infusion with a perineural catheter

Largely performed using ultrasound and/or nerve stimulation

29
Q

what are some of the nerve blocks people can use for pain relief?

A
  1. Brachial Plexus Blocks
  2. Lower Extremity Blocks
  3. Truncal Blocks
30
Q

what are the different brachial plexus blocks?

A
  1. Interscalene Block
  2. Supraclavicular Block
  3. Infraclavicular Block
  4. Axillary Block
  5. Intravenous (Bier) Block
31
Q

what is an interscalene block?

A

C4-C7 block which blocks superior and middle trunks (can spare the inferior trunk)

useful for - Shoulder and upper arm procedures

misc – concomitant ipsilateral phrenic nerve block

32
Q

what is a supraclavicular block?

A

blocks trunks and divisions of brachial plexus, but misses dorsal scapular nerve

useful for upper arm and hand procedures but not shoulder

however, highest risk of pneumothorax….

33
Q

what is an infraclavicular block?

A

blocks cords of brachial plexus

useful for elbow, forearm, hand procedures (especially for patients who cannot abduct shoulder)

most stable site for a perineural catheter!

34
Q

what is an axillary block?

A

most common; blocks terminal branches of brachial plexus in the axilla; this is NOT involving the axillary artery

useful for elbow, forearm, and hand procedures (with supplemented blocks)

additional block of musculocutaneous is required for most procedures

35
Q

what is Bier block?

A

an intravenous block

the whole upper extremity is exsanguinate = there’s no blood in the whole arm

then you inject IV anesthetic in the arm which diffuses through the vein to the nerve endings from the tourniquet down to the fingers

if the tourniquet fails though, the local anesthetic can go to the rest of the body and cause seizures or cardiac toxicity….

36
Q

what are the lower extremity blocks that you can do?

A
  1. Lumbar Plexus Block
  2. Femoral Nerve Block
  3. Fascia Iliaca Block
  4. Sciatic Nerve Block
37
Q

what is a lumbar plexus block?

A

Blocks the L1-L4 spinal nerves that become the iliohypogatric, ilioinguinal, genitofemoral, lateral femoral cutaneous, femoral, and obturator nerves

Uses – hip joint surgeries, most knee surgeries

Misc – high-risk procedure with potential for epidural spread, hematoma, local anesthetic toxicity, nerve injury, unilateral sympathectomy

38
Q

what is a femoral nerve block?

A

you block the femoral nerve

Uses – surgeries around the knee

Misc – can make ambulation difficult and suboptimal

39
Q

what is a fascia iliaca block?

A

Anterior block for peripheral nerves arising from lumbar plexus

Uses – hip and knee procedures

40
Q

what is a sciatic nerve block?

A

Can be used as adjunct to femoral/lumbar plexus blocks

Can be blocked subgluteal or at popliteal fossa levels

Useful for posterior leg and coverage of the majority (minus saphenous nerve) of the lower leg and foot

41
Q

what are the different truncal blocks you can do?

A
  1. Paravertebral Block
  2. Interpleural Block
  3. Intercostal Block
  4. Transversus Abdominis Plane Block
42
Q

what is a paravertebral block?

A

Most effective of the truncal blocks

Analgesia via direct somatic/sympathetic/epidural blockade

Effective for thoracic, breast, and upper abdominal surgeries, and rib fracture pain

43
Q

what is an intercostal block?

A

provide relief for duration of local anesthetic

but there’s a high risk of pneumothorax

44
Q

what is a traverses abdominis plane block?

A

reduces pain and opioid requirements after abdominal surgery

requires high volume 15 ml or more on each side

MSK Week 6 (10 decks)

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