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Anesthesiology 398 and 466 > Lecture 7 Pathophysiology and Assessment > Flashcards

Lecture 7 Pathophysiology and Assessment Flashcards

1
Q

What is Pain?

A

In animals, an aversive sensation & feeling associated with actual or potential tissue damage

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2
Q

What are the Negative Physiologic Sequela of pain & Stress

A
  1. ——↓ Pulmonary function
    • —atelectasis -> pneumonia
    • —↑ muscle tension,↓ lung compliance
  2. ——Cardiovascular
    • —↑ HR, BP⇒ ↑ myocardial work
  3. —↓ Immune function
    • —↑ WBC
    • —↓ lymphocytes & killer T cells
  4. —Endocrine -↑ stress hormones
    • —↑ catecholamines, aldosterone, AT II, ACH, cortisol, glucagon
  5. —Coagulation
    • —↑ platelet adhesion,↓ fibrinolysis
    • —Activation of coagulation cascade
  6. —GI & GU
    • —↑ sphincter tone, ↓ muscle tone ​
  7. —Immobility, inappetence, insomnia
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3
Q
  1. What is the Pre-emptive Pain Score
  2. Is it tailored to individual?
  3. Does it assess response to therapy?
A
  1. —Assign degree of pain based on underlying pathology, procedure performed & amount of tissue trauma involved
    • —No Pain
    • —Mild pain
    • —Moderate pain
    • —Severe pain
  2. —Not tailored to individual
  3. —not useful in assessing response to therapy
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4
Q
  • What are the 2 Types of Pain
  • How is each pain described (how it feels)?
A
  1. —Somatic – Originates from damage to bones, joints, muscle or skin
    • —described as localized, constant, sharp
  2. —Visceral – Arises from stretching, distention or inflammation of viscera
    • —described as deep, aching, without good localization
  3. —Neuropathic – Originates from injury or involvement of the PNS or CNS
    • —described as burning or shooting
    • —+/- neurological deficits
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5
Q

What is the order of pain transmission

A
  1. —Transduction
  2. —Transmission
  3. —Modulation
  4. —Projection
  5. —Perception
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6
Q
  1. Where in the body does transduction occur?
  2. How does transduction happen
A
  1. —Occurs at tissue level
  2. —Specialized nerve endings (nociceptors) transform mechanical, thermal, chemical stimuli into action potentials
    • —Release of local inflammatory mediators
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7
Q

What are the 2 types of nociceptors in transduction

A
  1. —Aδ nociceptors
  2. —C-fiber nociceptors
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8
Q

Which drugs work at the transduction level?

A
  1. Non-steroidal anti-inflammatory drugs (NSAIDS)
  2. Local Anesthetics
  3. Opioids (peripheral opioid receptors)
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9
Q
  1. —Aδ nociceptors are low, high or both thresholds?
  2. are they polymodal or use a single stimuli?
  3. What types of stimuli?
A
  1. —Low or high threshold
    • —high threshold respond only to tissue threatening/damaging stimuli
  2. —Polymodal or single stimuli
  3. mechanical, chemical, thermal
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10
Q
  1. —Aδ nociceptors discharge at rates greater than or less than c-fibers?
  2. How does the pain feel with these receptors?
A
  1. —Discharge at rates > than C-fibers
    • —more discriminative information to CNS
  2. —Sharp, pricking pain of ‘first pain’
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11
Q
  1. —C-fiber nociceptors are low, high or both thresholds?
  2. are they polymodal or use a single stimuli?
  3. Is there a large number in skin, muscle, joints or viscera
A
  1. —All high-threshold
  2. polymodal
  3. —Large # in skin, muscle, joints, few in viscera
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12
Q
  1. —C-fiber nociceptors are fast or slow onset?
  2. What do they signal?
A
  1. —Slow onset, ‘second’ pain; burning, aching
  2. —Signals tissue damage/inflammation => sensitizes/activates ‘silent/sleeping’ Aδ and C fibers
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13
Q

What happens during the transmission phase

A

Action potential is transmitted via sensory nerves to dorsal root ganglion => via dorsal root nerves to grey matter of spinal cord

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14
Q

Which drugs work at Transmission level

A
  1. Local Anesthetics
  2. α-2 agonists
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15
Q

What are the types of nerves that do transmission

A
  1. Aβ
    • non-noxious sensory information
    • myelinated
  2. Aδ
    • non-noxious & noxious info
    • myelinated
  3. C
    • Unmyelinated
    • Noxious info only
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16
Q

What happens in the modulation phase?

A
  1. —Synapse with neurons in dorsal horn of spinal cord grey matter
  2. —Impulses are amplified or suppressed
    • —Neurotransmitters act on excitatory/inhibitory receptors (AMPA, NMDA/GABA, glycine)
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17
Q

What drugs work at the Modulation level

A
  1. NSAIDS
  2. Local Anesthetics
  3. Opioids
  4. α-2 agonists
  5. NMDA antagonists
  6. NK-1 antagonists
  7. Tricyclic anti-depressants
  8. Anticonvulsants
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18
Q
  1. What happens in the projection phase
  2. What tracts does it go through? (1 main one)
A
  1. —Nociceptive information conveyed to brain by nerve tracts
  2. Tracts:
    • —Spinothalamic tract**
    • —Spinoreticular tract
    • —Spinomesencephalic Tract
    • —Spinohypothalmic tract
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19
Q

What happens in the perception phase

A

—Integration, processing, recognition of sensory information occurs in multiple areas of brain

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20
Q

What drugs work at the perception phase

A
  1. Opioids
  2. α-2 agonists
  3. NMDA antagonists
  4. NK-1 antagonists
  5. Tricyclic anti-depressants
  6. Anticonvulsants
  7. Benzodiazepines
  8. Phenothiazines
  9. Anesthetics
    • Inhalants
    • Injectable
21
Q

What are the 3 parts of the brain that perception happens in

A
  1. —Reticular Activating System
  2. —Periaqueductal gray area
  3. Thalamus
22
Q

Explain what happens in the Reticular activating system for perception

A
  • —integration of sensory experience
  • —mediates motor, autonomic, endocrine response
23
Q

Explain what happens in the periaqueductal gray area in perception

A
  • —transfers info to thalamus/hypothalamus
  • —relay for descending facilitative/inhibitory modulation
    • —Descending facilitation important in chronic pain syndromes
24
Q

Explain what happens in the thalamus in perception

A

—transfers information to cerebral cortex & limbic system

25
Q
  1. Once the thalamus sends information to the cerebral cortex and limbic system, what is the area that percieves fear and axiety?
  2. Emotion?
  3. Memory?
A
  1. —Amygdala => fear, anxiety
  2. Cingulate gyrus => emotion
  3. —Hippocampus => memory
26
Q

What are the Basic Tenets of pain management

A
  1. —Pre-emptive pain management
    • —=> Analgesics must be given BEFORE painful stimulus to help prevent central nervous system ‘wind-up’
  2. —Classification of severity & types of pain
  3. —Followed by intra/post op
  4. —Customized, multi-modal approach
    • —Adjunct analgesic drugs & modalities
    • —‘one size fits all approach’ may not work for all patients
  5. —Patient evaluation, reassess analgesic plan => intra/post-op ​

All to decrease peripheral & central sensitization/ ‘wind-up’

27
Q

What is Peripheral Sensitization

A
  • —Tissue damage releases chemical mediators =>
  • recruit inflammatory cells =>
  • ‘Sensitizing Soup’ =>
  • ↓ excitation threshold, activates silent nociceptors =>
  • ↑nociceptive input to spinal cord
28
Q

What are 2 ways to prevent peripheral sensitization (drug and a technique)

A
  1. NSAIDS
  2. ***Good Surgical Technique***
29
Q

What is Central Sensitization

A
  • —Frequent, severe, prolonged activation of nociceptors =>
  • leads to ↑ excitatory neurotransmittors (glutamate, Substance P) in dorsal horn of spinal cord =>
  • activates NMDA, NK, AMPA receptors =>
  • ↑signal molecules, gene expression, neuroplasticity =>
  • chronic pain
30
Q

What is Multi-modal Pain Management

A

—Use variety of drugs & techniques => affects different receptors & levels of pain pathway

31
Q

Why do you do a Multi-modal Pain Management

A
  1. —↑ efficacy & ↓ dose of each drug
  2. —↓ doses, ↓ side effects =>
    • eg. respiratory depression, hypotension
32
Q
  1. Can you use physiologic data to do pain assessment?
  2. Vocalization?
A
  1. —Physiologic data can be misleading
    • —Heart rate could be low but still painful
    • respiratory rate, pupil size, cortisol
  2. Not really because Vocalization can be caused by:
    • —Pain, anxiety, dysphoria, nursing care needs
33
Q

What are the 2 mentioned Behavior based Pain Scales in class (there are more out there)

A
  1. —Glasgow Composite
  2. Colorado State APS
34
Q

are Behavior based Pain Scales subjective or objective

A

—All have a subjective component

35
Q

What are Pain Behaviors in Dogs that can be used to assess pain

A
  1. —Body posture/activity
  2. —Reluctance to move/lie down
  3. —Changing positions/restlessness
  4. —Vocalization
  5. —Facial expression/appearance
  6. —Appetite/bowel,urinary habits
36
Q

What are Pain Behaviors in cats that can be used to assess pain

A
  1. —Hunched position with head low, ‘humpy cat’
  2. —Facial expression
  3. —Squinted eyes, ‘squinty cat’
  4. —Sitting quietly, seeking no attention
  5. —Trying to hide, back of cage
  6. —Resentment at being handled, palpation
  7. —Presence/absence of normal behaviors (grooming)
  8. —Interactive behavior
37
Q

What does the Glasgow Composite Measure Pain Scale measure

A
  1. —Behaviors based on vet questionnaire
  2. —Two parts: observation, interaction
  3. —↓ observer bias, easy to use
  4. —Presence/absence of specific behaviors
  5. —Reassess analgesic plan
    • —6/24 or 5/20
      • A section is about lameness so if the animal is laying down you dont do that part and asess out of 20
38
Q

What are limitations to Glasgow Composite Measure Pain Scale

A
  1. —Only dogs
  2. —Does not consider prior demeanor
  3. —No assessment of level of sedation
39
Q

What does the CSU Acute Pain Scale measure

A
  • —observation/interaction
  • —Psychological/behavioral signs of pain
  • Has a section for —Non-assessment in sleeping patients
  • —Alert to ‘unarousable’
  • —Evaluates body tension
  • —‘reassess analgesic plan’ > 1.5 – 1.75
40
Q

The UNESP-Botecatu pain score assesses what things?

A
  1. —Miscellaneous behaviors
  2. —Reaction to palpation of surgical site
  3. —Reaction to palpation of abdomen
  4. —Vocalization
  5. —Posture
  6. —Comfort
  7. —Activity
  8. —Attitude
  9. —Arterial Blood Pressure
  10. —Appetite
41
Q

What are Pain Behaviors in Horses that have abdominal pain

A
  1. —Dullness, depression, lowered head carriage
  2. —Rigid stance, reluctance to move
  3. —Fixed stare, flared nostrils
  4. —Rolling, looking/kicking at abdomen
42
Q

What are Pain Behaviors in Horses that have lameness pain

A

—Weight shifting, abnormal weight distribution

—Pointing/hanging of limb

43
Q

What is the equine pain face

A
  1. Lowered ears (the distance between the ears increases at the base)
  2. Contraction of the muscle above the eye (m. levator anguli oculi medialis)
  3. Tense stare
  4. Nostril dilated in the medio-lateral direction
  5. Edged shape of the muzzle with lips pressed together and flattened chin
  6. Tension of the facial muscles
44
Q

What are Pain Behaviors in food animals

A
  1. —Postural stance – ‘statue stance’ after castration, abnormal tail carriage
  2. —Ear flicking, head shaking/scratching – dehorning pain
  3. —Foot stomping, easing of quarters, scrotal licking – castration pain
  4. —Distress calls
  5. —Escape behaviors
  6. —Pressure Alogometry
  7. —Thermal sensitivity
45
Q
  1. Should PRN (as needed) Analgesia be used?
  2. Why or why not?
A
  1. No
  2. —Dose/interval based on:
    • —underlying disease, surgical procedure
    • —level of pain expected
    • —Dose according to pharmacokinetic/dynamic recommendations for specific drug/species
    • —Patient pain evaluation

—Patients should not have to ‘prove’ pain for analgesics

46
Q
  1. Should Analgesics be withheld in sleeping patients?
  2. Why or why not?
A
  1. Don’t withold—!
  2. Because:
    • Adequate pain control => resting comfortably, sleeping
    • —Dose according to pharmacokinetic/dynamic recommendations for drug/species
    • —Allow to rest after response to treatment established
    • —Pain evaluation
    • —‘unarousable’
47
Q
  1. Should patients be woken up to evaluate pain?
  2. Why or why not?
A
  1. Not if they are just sleeping
  2. Why:
    • —Many analgesic drugs also cause sedation
    • —Sleep/rest is important for post-op patients
    • —Warm, dry, clean, quiet environment, day/night light cycle
    • —Patients must be arousable
    • —Evaluate level of sedation & adequacy of analgesia after expected onset of action of analgesic drug
48
Q

If a patient is unarousable what should be done and why?

A
  • —Assess for level of consciousness
  • —Best done after expected onset of action of analgesic drug(s)
  • —Risk of hypoventilation & hypoxemia, gastro-esophogeal regurgitation & aspiration pneumonia

Anesthesiology 398 and 466 (22 decks)

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