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Pharm Semester 2 > Pain > Flashcards

Pain Flashcards

1
Q

Where do local LA act at on the pain pathway

A

between transduction and transmission level

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2
Q

Transduction

A

Nerve/electrical impulses/signals start at the nerve endings

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3
Q

Transmission

A

Travel of nerve/electrical impulses to the nerve body connecting to the dorsal horn of the spinal cord.

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4
Q

Modulation

A

Process of altering (inhibitory/excitatory) pain transmission mechanisms at the dorsal horn to the PNS and CNS.

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5
Q

Perception

A

Thalamus acting as the central relay station for incoming pain signals & the primary somatosensory cortex serving for discrimination of specific sensory stimuli.

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6
Q

Nociception

A

transduction
transmission
modulation
perception

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7
Q

Where do the modulation of pain impulses occur?

A

Dorsal Horn

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8
Q

Location of Nociceptors
in periphery

A

Skin, muscles, joints, viscera, vasculature

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9
Q

Unmyelinated C- fiber

A

Afferent fibers; burning pain from heat and pressure from sustained pressure.
travels less than 2m/second

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10
Q

Myelinated A-fiber;

A

faster
Type I fibers ( Aβ & Aδ fibers): heat, mechanical, chemical
Type II fibers (Aδ fibers): heat
travels more than 2m/second

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11
Q

Peptides chemical mediators

A

Substance P, Calcitonin, Bradykinin [1st released w/ pain], CGRP

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12
Q

Lipids chemical mediators

A

Prostaglandins** (nsaids tx), Thromboxanes(nsaids tx),

Endocannabinoids (cannabis binds and causes no further transmission of pain))

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13
Q

Sensitization

A

increased sensitivity/ threshold is reached quicker

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14
Q

Hyperalgesia

A

Increased pain sensations to normally painful stimuli.

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15
Q

Allodynia

A

perception of pain sensations in response to normally non-painful stimuli

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16
Q

Primary Hyperalgesia

A

at the original site of injury from heat and mechanical injury.
Decreased pain threshold
Increased response to suprathreshold stimuli
Spontaneous pain
Expansion of receptive field

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17
Q

Secondary Hyperalgesia

A

uninjured skin surrounding the injury (only from mechanical stimuli(pressure/ injury/ inflammation).
Sensitization of central neuronal circuits

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18
Q

Spinal Dorsal Horn

A

Relay center for nociceptive & other sensory activity.

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19
Q

Lamina I (marginal layer):

A

afferent C Fibers

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20
Q

Lamina II

A

(substantia gelatinosa [opioids]): afferent C Fibers

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21
Q

Laminae I, IV, & VII, and ventral horn:

A

myelinated fibers (innervating muscles and viscera)

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22
Q

Laminae III & IV:

A

NKI (neurokinin) receptor with substance P

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23
Q

Gate open

A

pain is projected to supraspinal brain regions

Aδ (small diameter, myelinated) & C fibers (unmyelinated)

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24
Q

Gate closed

A

pain is not felt with simultaneous inhibitory impulses

Aβ fibers (large diameter, myelinated: faster) deliver information about pressure and touch (rubbing)

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25
Q

Limbic cortex and thalamus

A

Perception of motivational-affective pain components

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26
Q

Periaqueductal gray -rostral ventromedial medulla (PAG-RVM) system

A

Depress or facilitate the integration of pain info in the spinal dorsal horn towards the cns.

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27
Q

Excitatory impulses nt

A

Glutamate
calcitonin
neuropeptide Y
Aspartate
Substance P

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28
Q

Inhibitory impulses nt

A

GABA
Glycine
Enkephalin
sNE
dopamine

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29
Q

Ascending Pathways

A

Spinothalamic
Spinomedullary
Spinobulbar (hinebrain)
Spinohypothalamic

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30
Q

Where does the pain impulse originate if it is pertaining to the descending inhibitory tract?

A

PAG-RVM

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31
Q

Neuropathic pain

A

Persists after the tissue has healed -> allodynia and hyperalgesia
Increased risk: Cancer patients d/t chemo and radiation therapy
Treatment: symptomatic (opioids gabapentin, amitryptiline (antidepressant), cannabis)

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32
Q

Visceral Pain

A

Diffuse & poorly localized (referred to somatic sites: muscle & skin)- not specific
Causes: ischemia, stretching of ligamentous attachments, spasms, distention

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33
Q

Complex Regional Pain Syndromes

A

A variety of painful conditions following injury in a region with impairment of sensory, motor, and autonomic systems
Spontaneous pain, allodynia, hyperalgesia, edema, autonomic abnormalities, active and passive movement disorders, and trophic changes of skin & SQ tissues

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34
Q

Pain in Neonate and Infant

A

Pain perception at 23 weeks of gestation
Lower pain threshold & exaggerated pain responses

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35
Q

Opioid

A

All exogenous substances (natural & synthetic).

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36
Q

Narcotic

A

Greek word stupor, which has the potential to produce physical dependence

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37
Q

Phenanthrenes

A

Morphine, Codeine, & Thebaine

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38
Q

Benzylisoquinoline

A

Papaverine (used in arterial injection of barbituates) & Noscapine

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39
Q

Brain opioid receptors

A

Periaqueductal gray (PAG), locus ceruleus, rostral ventral medulla (RVM), & hypothalamus

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40
Q

Spinal Cord Opioid Receptors

A

Interneurons and primary afferent neurons in the dorsal horn (substantia gelatinosa).
Direct application -> intense analgesia.

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41
Q

Outside CNS Opioid Receptors

A

Sensory neurons and immune cells.
Intraarticular morphine after knee surgery.

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42
Q

Mu 1 effect

A

analgesia (supraspinal, spinal)
euphoria
low abuse potential
miosis
bradycardia
hypothermia
urinary retention

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43
Q

Mu 1 agonists

A

endorphins
Morphine
Sythetic opioids

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44
Q

Mu1, Mu2, Kappa, Delta antagonists

A

Naloxone
naltrexone
nalmefene

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45
Q

Mu 2 effect

A

analgesia (spinal)
depression of ventilation
physical dependence
constipation (marked)

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46
Q

Mu 2 agonist

A

endorphins
morphine
synthetic opioids

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47
Q

Kappa Effects

A

analgesia (supraspinal, spinal)
dysphoria
sedation
low abuse potential
miosis
Diuresis

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48
Q

Kappa agonist

A

Dynorphins

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49
Q

Delta effect

A

anaglesia (supraspinal, spinal)
depression of ventilation
physical dependence
constipation (minimal)
urinary retention

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50
Q

Delta Agonist

A

Enkephalins

51
Q

Which receptor produces physical dependence?

A

Mu 2

52
Q

Physostigmine effect on ventilation

A

increased CNS levels of Acetylcholine (Ach) ->antagonize ventilatory depression but not analgesia

53
Q

Opioid side effects on chest wall and tx

A

Skeletal thoracic (chest wall) & abdominal muscle rigidity (looks like laryngospasm)
-Severe with mechanical ventilation
-Treatment: muscle relaxation or Naloxone

54
Q

GI side effect of opioids

A

Spasm of biliary smooth muscle
Sphincter of Oddi spams
Fentanyl (99%), Morphine (53%), and Meperidine (61%)

55
Q

Tolerance

A

the development of the requirement for increased drug doses (usually 2 to 3 weeks).
Morphine: 25 days

Cross-tolerance can develop between all opioids.

56
Q

Downregulation

A

opioid receptors on the cell membrane surfaces become gradually desensitized by reduced transcription & subsequent decreases in numbers of opioid receptors….will need more to effect the lower number of the R.

57
Q

Gold standard of opioids

A

morphine

58
Q

morphine effects

A

:Analgesia, euphoria, sedation, & diminished ability to concentrate, nausea, feeling of body warmth, heaviness of extremities, dryness of the mouth, and pruritis (histamine release).

Relieves visceral, skeletal muscles, joints and integumental dull > sharp, intermittent pain

59
Q

morphine dose

A

1-10 mg

60
Q

morphine onset im and IV

A

10-20 min

61
Q

Morphine IM peak

A

45-90 min

62
Q

Morphine IV peak

A

15-30 min

63
Q

morphine duration of action

A

4-5 hours

64
Q

Morphine accumulates where

A

Accumulates rapidly in kidneys, liver, and skeletal muscles.

65
Q

Morphine metabolism

A

Glucoronic acid conjugation in hepatic and extrahepatic sites.
Metabolites:
Morphine-3-glucuronide (75% to 95%) but inactive (long half life)
Morphine-6-glucuronide: active analgesic

66
Q

Meperidine receptor effects

A

agonist at µ and κ opioid receptors

67
Q

Meperidine analogues

A

Fentanyl
Sufentanil
Alfentanil
Remifentanil

68
Q

Meperidine potency

A

1/10th as potent as morphine

69
Q

Meperidine dose

A

12.5 mgs post op shivering

70
Q

Meperidine duration of action

A

2 to 4 hours

71
Q

meperieinde effects

A

sedation, euphoria, N/V, depression of ventilation

72
Q

meperidine metabolism

A

90% hepatic ->normeperidine

73
Q

Meperidine Protein binding

A

60% (elderly considerations)
Albumin level is decrease in Elderly = meperidine is 60% protein bound = sedate / higher effect on elderly because have less bound. Give less.

74
Q

Meperidine use

A

intrathecal, IM for postop analgesia, postop shivering (_ receptors; potent agonist at _2 receptors)

75
Q

Meperidine elimination 1/2 time

A

3 to 5 hours (35 hours with renal failure)

76
Q

Meperidine S/E

A

: tachycardia & mydriasis with dry mouth, (-) inotropy, serotonin syndrome (MAOIs & TCAs), impaired ventilation, crosses placenta,
Withdrawal symptoms develop more rapidly > morphine

77
Q

Fentanyl potency

A

75 to 125 times more potent > morphine

78
Q

Fentanyl Blood:Brain Effect site equilibration

A

6.4 minutes
-Potent, rapid onset, very lipid soluble

79
Q

Fentanyl metabolite

A

Norfentanyl

80
Q

Fentanyl Vd

A

Large
IV (<5 mins 80% is gone)
->highly vascular tissues
->inactive tissue sites

81
Q

Fentanyl context senstive half time

A

Context-Sensitive Half-Time is greater than Sufentanil
d/t saturation of inactive tissue ->return to plasma replaces those metabolized

82
Q

Fentanyl analgesia dose

A

1-2 mcg/ kg IV

83
Q

Fentanyl Induction dose

A

1.5 to 3 µg/kg IV 5 mins prior

84
Q

Fentanyl Adjunct with inhaled anesthetics

A

2 to 20 µg/kg IV

85
Q

Fentanyl Surgical Anesthesia (solo)

A

50 to 150 µg/kg IV

86
Q

Fentanyl Intrathecal

A

25 mcg

87
Q

Fentanyl Transmucosal (Oral)

A

5 to 20 µg/kg

88
Q

Fentanyl 2 to 8 yo

A

15 to 20 µg/kg PO 45 minutes prior

89
Q

Fentanyl mg compared to morphine

A

1 mg of PO Fentanyl = 5 mgs of IV Morphine

90
Q

Fentanyl Transdermal

A

75 to 100 µg (18 hours steady delivery)

91
Q

Fent cns s/e

A

Seizure like activity
SSEP and EEG (>30 µg/kg IV)
Modest increase in ICP (6 to 9 mmHg)

92
Q

Sufentanil potency

A

5 to 12 times more potent > fentanyl

93
Q

Sufentanil protein binding

A

92.5% protein binding (smaller Vd < fentanyl): α1-acid glycoprotein

94
Q

Sufentanil first pass uptake

A

60% lung first-pass uptake

95
Q

Sufentanil analgesia dose

A

0.1 - 0.4 µg/kg IV

96
Q

Sufentanil induction dose

A

18.9 µg/kg IV

97
Q

Sufentanil S/E

A

Bradycardia -> decreased cardiac output
Rigidity: chest wall and abdominal muscles

98
Q

Alfentanil potency

A

1/5th less potent than fentanyl

99
Q

Alfentanil onset

A

1.4 minutes > fentanyl & sufentanil

100
Q

Alfentanil Metabolite

A

noralfentanil (hepatic P450 3A4)

101
Q

Alfentanil Induction laryngoscopy

A

15 to 30 µg/kg IV (90 seconds prior)

102
Q

Alfentanil Induction alone

A

150 to 300 µg/kg IV

103
Q

Alfentanil Maintenance

A

25 to 150 µg/kg/hour IV with inhaled anesthetics

104
Q

Remifentanil receptor

A

Selective µ opioid agonist

105
Q

Remifentanil potency

A

15 to 20 times as potent as alfentanil (almost same as fentanyl)

106
Q

Remifentanil metabolism

A

Because its ester structure
Hydrolysis by nonspecific plasma and tissue esterases

107
Q

Remifentanil Onset

A

Brief action, rapid onset and offset (15 mins)
Precise and rapid titratable effect
Lack of accumulation
Rapid recovery when discontinued

108
Q

Remifentanil dose based on

A

Dose in IBW

109
Q

Remifentanil Peak effect site time

A

1.1 minute

110
Q

Remifentanil Clearance

A

3L/min (8x more rapid > alfentanil)

111
Q

Remifentanil Plasma Steady state with infusions

A

@ 10 minutes

112
Q

Remifentanil Elimination half-time:

A

Elimination half-time: 6.3 minutes (99.8%)

113
Q

Remifentanil induction

A

1 µg/kg IV over 60 to 90 seconds
0.5 to 1.0 µg/kg IV x 10 minutes

114
Q

Remifentanil Maintenance

A

0.25 to 1 µg/kg IV or 0.005 to 2 µg/kg/min IV

115
Q

Remifentanil S/E

A

Seizure-like activity
N/V
Depression of ventilation
Decreased BP and HR
Hyperalgesia d/t
Previous acute exposure to large opioid doses
Tolerance

116
Q

Hydromorphone potency

A

5x more potent than Morphine

117
Q

Hydromorphone dose

A

Dose 0.5 mg IV ->1 to 4 mgs total
Re-dose every 4 hours

118
Q

Codeine Elimination half time

A

3 to 3.5 hours
only PO or IM

119
Q

Codeine as Cough suppressant dose

A

15 mgs

120
Q

Codeine Analgesia dose

A

60 mgs (120 mgs = 10 mgs of Morphine)

121
Q

Tramadol potency

A

5 -10x less (morphine)

122
Q

Tramadol receptor

A

µ with weak κ & δ

123
Q

Tramadol dose

A

PO: 3 mg/kg
Interacts with Coumadin

124
Q

Which pharmacokinetic category best describes onset of action

A

effect site of equilibration

Pharm Semester 2 (6 decks)

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