Lecture 9: Pain Management Flashcards
What are the three parts of anesthesia?
- Analgesia (pain relief)
- Amnesia (loss of memory)
- Immobilization
What is the difference b/t analgesia and sedation?
analgesia - consciousness not altered, just lack of pain
sedation - consciousness altered (depression of awareness to the environment and decreased responsiveness)
What are the differences b/t sedative and analgesic drugs?
Sedatives - anxiolysis, amnesia, analgesia, more serious S/Es
Analgesics - some anxiolysis, NO amnesia, mild sedation, less serious S/Es
What type of drug class make up the commonly used sedatives?
BZs (-pam, -lam)
When should diazepam NOT be used?
In pts w/ cirrhosis or liver dz
In patients with kidney or liver failure what type of BZ should be used for pain management?
Lorazepam
When/what type of procedures should Midazolam (Versed) be used to control pain?
Best for amnesia - use for short procedures or in ED
A patient is taking diazepam for pain management, but the nurse accidentally gave the patient way too much, what medication should be used in this situation?
Flumazenil
What is the timeframe for acute vs chronic pain?
Acute pain: typically last less than 3 months
Chronic pain: last 3-6 months or more and is beyond the expected period of healing
A patient presents w/sudden, sharp onset of pain after falling off of his bike and breaking his arm but he is feeling better after the bone is casted, what type of pain is this?
Acute pain
- started suddenly, sharp, intense
- has identifiable cause
- warning present
- pain disappears when Tx
note: Chronic pain has gradual onset from acute, has unknown cause, no alarm system, will persist despite Tx
What are the objective tools to assess pain?
- VAS/Numerical Scale/Wong-Baker Faces
- Functional Status
- PE
- Pathology, imaging, diagnostics
- Pain medication usage (is it helping?)
note: subjective assessment = CHLORIDE PAC
What is the difference b/t hyperalgesia and allodynia?
Hyperalgesia is an amplified/exaggerated response to mildly noxious stimuli (curve shifts L)
Allodynia is a painful response to a normally NON-NOXIOUS stimuli
ASA, Tylenol, NSAIDs, and COX2 inhibitors fall under which drug class?
Non-opioid analgesics
What are the first line drugs used for pain?
Acetaminophen (Tylenol) and NSAIDs (ibuprofen)
Elavil (amitriptyline), Cymbalta (duloxetine), and Pamelor (noritriptyline), and Paxil all belong to what drug class?
Anti depressants
Neurontin (gabapentin) and Lyrica (pregabalin) belong to what drug class? and what is their use?
Anticonvulsants/GABA analogs
- used for post herpetic neuralgia, CRPS
What medication can be topically for pain relief (post herpetic neuralgia)?
Capsaicin
What medications can be applied as patches for pain relief?
Fentayl, Lidocaine, Salonpas
What type of opioid should be used for severe or chronic pain, provides pain relief at a constant steady state level, and should not be crushed/split/chewed?
Long Acting Opioids (Extended Release)
note: short acting are for mild-mod pain, need dosed more freq, are taken PRN, and are easier to titrate
When giving morphine sulfate to pts w/renal failure what should you be concerned about?
prolonged respiratory depression
- d/t impaired elimination of drug
What drug varies in schedule based on its formulation?
Codeine
What schedules are allowed to be called into a pharmacy?
Schedule 3-5
A patient is on hydrocodone, can it be called in?
No it is a schedule 2 drug
What the 5 common S/Es of opioid use and their Tx?
- Respiratory depression/arrest - Narcan
- Delirium/CNS effects - Narcan, opioid rotation, decr dose
- GI disturbance - Reglan (Metoclompramide)
- Constipation - Movantik
- Pruritus - Diphenhydramine
What is the Tx for opioid OD?
Narcan (Naloxone)
What are the CIs for using Movantik? (3)
Sensitivity to Naloxgel, GI obstruction, risk of concurrent obstruction
When weaning someone off opioids when should you consider an inpatient setting?
- medically unstable
- psych diagnosis
- polysubstance abuse
- non-adherent/failed outpatient detox
What is the general goal for weaning pts off opioids?
Decrease daily regimen by 10-25% w/each visit
*ER/LA forms can be decreased more rapidly
What is utilized in PCAs to avoid peaks and valleys by delivering a Small, CONSTANT flow of pain medication?
Basal rate
What are the advantages to PCAs?
- avoids peaks/valleys
- Less OD, S/E and lag time
- Can be used in pts > 7 y/o
note: not for use in kids < 4 y/o
A cancer patient requires pain medication while in the hospital, what should you set their basal rate to?
2/3 of the hourly requirement (also for chronic pain pts)
note: 1/3 used if acute pain, 1/2 used for bolus
A patient is placed on oxycodone post-operatively after his hip replacement, what should be started prophylactically and why?
bowel regimen - to prevent opioid induced constipation
Ex: stool softener + laxative
What are the indications for Docusate and Sennakot (Senna)?
Docusate - prevent post-op ileus
Sennakot (Senna) - relieve constipation
When transitioning to PO pain medication/changing opioids why should you decrease the dose by 25%?
To adjust for incomplete cross tolerance
How does regional anesthesia work & what are the methods of administration?
Blocks Na channels to prevent AP propagation (nerve impulses) using local anesthetics
Neuraxial –> Epidural and Spinal
What are the advantages to neuraxial anesthesia?
- decreases ileus, opioid requirements, stress response
- facilitates early PO intake, mobilization & return of bowel function
What are the absolute CI to neuraxial anesthesia?
Refusal, Allergy to LA, Uncorrected hypovolemia, Site infection, Elevated ICP, Coagulopathy
How does TENS (transcutaneous electrical nerve stimulation) work to decrease pain signals sent to the brain?
Gain Control Theory
- utilizes faster pain pathways to get to the brain (via the A beta fibers)
When using ER/LA opioids what should you never use as a first choice?
Fentanyl and Methadone
What drugs should not be combined w/opioids due to risk of sleepiness, respiratory depression, coma and death
BZs
