NY Memory Deck Flashcards
Risk factors for CPSP
- Patient:
○ Younger age (very young age <3mth may be protective)
○ Female
○ Psychological factors: anxiety, depression, catastrophising , fear of surgery, hypervigilance
○ Parental catastrophising
○ Pre-operative chronic pain
○ Pre-op opioid use
○ Genetic predisposition/variability
○ Workers Compensation- Trauma (polytrauma chronic pain rates (46-85%)
- Surgery where nerve trauma is inevitable or surgery in richly innervated areas
○ Amputations, Caesarean section, Craniotomy, Knee arthroplasty, Mastectomy, Sternotomy , Thoracotomy, inguinal herniotomy
○ Severe acute pain - 10% increase in % of time -> 30% increase in incidence of CPSP
○ Repeat surgery - Post-op factors
○ Pain
○ XRT
○ Neurotoxic chemo
○ Depression
○ Psychological: vulnerability, neuroticism, anxiety, pain and anxiety trajectories
What are modifiable risk factors for CPSP?
Pre-op: MI reduction, management of pre-op pain, psychological factors
Post-op: effective acute pain management, limit opioid exposure, psychological support in rehab, recovery of normal functioning
What is chronic post-surgical pain?
Chronic post-surgical pain is pain developing or increasing in intensity after a surgical procedure in the area of the surgery, persisting beyond the healing process (>3months) and not better explain by other causes (eg. Infection, malignancy, pre-existing pain condition)
What interventions are effective in perioperative management of chronic post-operative surgical pain?
Regional analgesia and LA
- evidence in open thoracotomy (epidural), mastectomy (PVB), C/S, amputation (epidural)
Ketamine - decreases CPSP at 3 and 6 months (NNT 12 and 14) but not at 12 months
Lignocaine infusion - preventative
Venlafaxine (breast pre-op)
Surgical: VATs yes but not minimally invasive or laparoscopic surgery
Preservation of nerves in inguinal hernia repair and mastectomy with AxD
Perioperative CBT - reduces severity of CPSP (systematic review)
NB: high dose opioids esp remifentanil associated with CPSP
Gabapentinoid - no effect (2x meta-analyses)
What is pre-emptive analgesia?
Analgesic treatment administered PRIOR to incision. May also be preventative. Premise is that pre-emptive analgesia will be more effective if provided prior to incision.
What is the evidence for pre-emptive analgesia?
Opioid timing pre-incision - may reduce consumption over next 24hrs but no effect on pain scores
Pre-emptive paracetamol - reduces pain scores up to 2hrs and opioid consumption up to 24hrs and decreases PONV
Post-op Epidural - significant effect on post-op pain relief
What is preventative analgesia?
Analgesic intervention which results in reduction in post-operative pain and/or analgesia consumption at a point in time beyond expected duration of action of the intervention (eg. >5.5 half lives of the drug) compared to another treatment/placebo/non-treatment.
Which interventions demonstrate preventative analgesic effects?
Epidural, regional , systemic LA - preventative for CPSP (cochrane review)
Ketamine - reduces CPSP for select procedures (Cochrane review)
Which patients are classified as high thrombosis risk per ACC/AHA 2024?
VTE - Recent VTE <3 months
AF - CHADSVASC >=7. AF +rheumatic valvular heart disease
Mechanical Valves - Mechanical MV, Caged ball or tilting disc valve, any mech valve + TIA/stroke <3 months
Other - severe thrombophilias (homozygous Factor V leiden, homozygous G20210A, protein C, protein S, multiple thrombophilias or double heterozygous), APLS, stroke <3 months, active cancers assoc with high VTE risk
Which patients are classified as low thrombosis risk per ACC/AHA 2024?
VTE >12 months
AF - CHADSVASC 1-3 (w/o prior stroke hx)
Mechanical valve - bileaflet mech AVR (without major stroke risk factors - recent TIA/stroke, AF, prior periop stroke, prior valve thrombosis)
Which patients are classified as moderate thrombosis risk per ACC/AHA 2024?
VTE 3-12 months or recurrent VTE
AF - CHADSVASC 5-6
Mechanical valve - bileaflet mech AVR + major stroke risk factors; MV without stroke risk factors
Non severe coagulopathy (heterozygous factor V leiden or prothrombin G20210A mutation), active cancer
STEMI criteria
○ STEMI is defined as presentation with clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
§ ≥ 2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
§ ≥ 1.5 mm ST elevation in V2-3 in women
§ ≥ 1 mm ST elevation in other leads
New LBBB (LBBB should be considered new unless there is evidence otherwise)
What is Smith-Modified Sgarbossa Criteria?
≥ 1 lead with ≥1 mm of concordant ST elevation
≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE, as defined by ≥ 25% of the depth of the preceding S-wave.
What are the ECG criteria for NSTEMI?
Dynamic ST and T wave changes
* ST depression >=0.5mm depression at J point in >=2 contiguous leads indicates myocardial ischaemia
- usually widespread - if localised to particular territory then more likely reciprocal STEMI related changes
* T wave inversion
Hyperacute T waves, U wave inversion
What is the trifascicular block and how to differentiate between LAFB and LPFB
1st or 2nd degree AV block + RBBB + left anterior OR posterior fascicular blocks
Left axis deviation. -left anterior fascicular block
Right axis deviation - left posterior fascicular block
What are the potential complications of cardiac catheter ablation?
see image
What are the components and scoring of the HAS-BLED Score?
9 point scoring system - risk of bleeding to help determine if should anticoag for AF
- Gives risk of major bleeding - Lip etal. 2011 validation study over mean 500 day follow up
- Hypertension (uncontrolled BP >160mmHg)
- Abnormal renal (dialysis, Tx or Cr >200) or liver disease (Cirrhosis, Br 2x normal with AST/ALT/AP >3x normal) (1pt each renal and liver)
- Stroke Hx
- Bleeding Hx
- Labile INR (unstable/high INR, time in therapeutic range <60%)
- Elderly - age >65
Drugs (aspirin, clopidogrel, NSAIDs)/Alcohol (>=8 std/week)
Scoring: bleeding risk
0 - low risk 0.9% - consider anticoagulation
2 - moderate 4.1% - anticoag can be considered
3 - high risk 5.8% - alternatives should be considered
5- 9.1%
