Pain Flashcards
Pain that persists beyond the usual course of an acute disease or after a reasonable time for healing to occur?
- ___ may be a predictor of transition to chronic pain.
- Emotional and psychosocial component.
Chronic Pain
-Poorly controlled acute pain
- Imbalance of neuromodulation controls?
- Attenuated or absent ___ response
- Decreased levels of ___ and ___
- Predominance of ___
- Associated with Chronic Inflammation in the ?
- Chronic Pain
- neuroendocrine
- endorphins and serotonin
- C-neuron stimulation
- Periphery
*Pain caused by cancer?
-___ is most common cause of cancer pain
-___ is #2 cause
•Pain due to treatment
•___ effects - worse due to loss of sleep, appetite, nausea and vomiting
•___ effects - heightened anxiety, feelings of loss, low self-esteem, changes in life goals, disfigurement
*Cancer Pain
-Tumor invasion of bone
-Tumor compression of peripheral nerves
Physical
Psychological
A syndrome of sustained burning pain, allodynia, and hyperpathia after a traumatic nerve lesion, often combined with vasomotor and motor dysfunction and later trophic changes?
Causalgia
An unpleasant abnormal sensation, whether spontaneous or evoked?
Dysesthesia
Diminished pain in response to a normally painful stimulus?
Hypoalgesia
Increased sensitivity to stimulation, excluding the special senses?
Hyperesthesia
1) Pain due to a stimulus that does not normally provoke pain?
2) Increased pain from a stimulus that normally provokes pain?
3) Pain in the distribution of a nerve or nerves?
1) Allodynia
2) Hyperalgesia
3) Neuralgia
Management of Postoperative Acute Pain:
Preoperative Evaluation
•___ = Pain history - Physical exam - Self report measurement scales - Medications for pain - Document
•___ = Adjustments and/or continuation of meds
•Develop ?
Evaluate Pain
Preparation
Plan
Pain Management: Control of postoperative pain allows for:
–Reduction of the ___ –Shorter times to ___, shorter ___
–Improved ___ function –Earlier return of ___
–Early ___, decreased risk for ___
–Early discharge
–Reduction in sensitization, neuroplasticity, wind-up phenomenon, and transition to chronic pain
- stress response
- extubation, ICU stay
- respiratory
- bowel function
- mobilization, DVTs
Blockade of noxious stimuli response with the extension of this block into the postoperative period?
•Reduces postoperative pain and accelerates recovery
•Thought to attenuate (stop) ___ and ___ and ___ to pain and therefore the development of chronic pain.
Preemptive Analgesia
peripheral and central sensitization and hyper-excitability
*___ = Principle: Control postoperative pain and attenuate the perioperative stress response through the use of regional anesthetic techniques and a combination of analgesic agents (?)
•An extension of “clinical pathways” into effective postoperative ___
Multimodal Approach
(multimodal analgesia)
rehabilitation pathways
Benefits of the Multimodal Approach: •Pain control •Early \_\_\_ •Early \_\_\_ nutrition •Attenuate the \_\_\_ •Minimize side effects •Earlier discharge •Improve patient satisfaction
mobilization
enteral
stress response
Mode of Administration:
- ___ = preferred administration of postop opioid therapy
- Subcutaneous
- Intramuscular
- Oral
- Sublingual
- Rectal
- Buccal
- Intranasal
- Transdermal patch
-Intravenous
- Gold standard in pain management?
- Exert their analgesic effect through __ and __ __ receptors in the CNS
- No analgesic __
- Disadvantages include SIDE EFFECTS (esp. __ and __, nausea/ vomiting, sedation, pruritus, urinary retention), VARIABILITY, and TOLERANCE
- Opioids
- mu and kappa opioid receptors
- ceiling
- respiratory depression and hypotension
All examples of ? •Morphine Sulfate •Fentanyl •Sufentanyl •Alfentanil •Remifentanil •Hydromorphone •Meperidine
Opioids
PCA Systemic Opioids: *Features
- __ and __ controller
- Button pushed by patient = Demand (bolus), Lockout interval, Continuous, background infusion
- Most common drugs used?
Reservoir and Infusion
morphine sulfate and hydromorphone
PCA Systemic Opioids - Advantages: –Cost-effective –Higher degree of \_\_\_ –Total drug consumption is \_\_\_ –Harder to \_\_\_ self –Prevents the \_\_\_
- Patient satisfaction
- less
- over-medicate
- “pain/ no pain” cycle
NSAIDS = Exert their analgesic effect through inhibition of ___, preventing the synthesis of ___
-Used in ___ and pain related to ___ conditions
•Useful adjunct to ___
•As a result, the nociceptive response to ___ is attenuated, both peripherally and in spinal cord
cyclooxygenase (COX) prostaglandins mild to moderate pain inflammatory conditions opioids inflammatory mediators
NSAIDS - Side effects:
- Decreased ___ = ___ dysfunction, Inhibition of ___
- ___ and ___ dysfunction
- GI ___
- Effects on ___
-Hemostasis platelet thromboxane A2 -Renal and Liver -Hemorrhage -bone healing/osteogenesis
Examples of \_\_\_: *Given PO, PR, IV, IM •Ketorolac (Toradol) •Piroxicam (Feldane) •Nabumatone (Relafen) •Indomethacin (Indocin) •Celecoxib (Celebrex) •Parecoxib •ASA •Acetaminophen
NSAIDS
Examples of \_\_\_: •Ketamine •Tramadol (Ultram) •Nalbuphine (Nubain) •Methadone •Gabapentin •Celebrex
Adjuvant Drugs
Single injection or continuous infusion of local anesthetic applied at a peripheral nerve site?
-Can be used intraoperative or as an adjunct to postop anesthesia
•Limit the path of ___
•Superior ___
•Few side effects
•Can have analgesia for up to ___ after single injection
Peripheral Nerve Blocks
- nociceptive impulses
- analgesia
- 24 hours
*Examples of ??? Catheters can be placed in all of these sites except? –Brachial plexus blocks –Lumbar plexus blocks –Femoral nerve blocks –Sciatic-popliteal nerve blocks –Paravertebral blocks –Intercostal blocks –Intrapleural blocks –Intra-articular blocks
Peripheral Nerve Blocks
Lumbar plexus
Paravertebral
Intra-articular
Neuraxil Analgesia - Benefits:
•Provide superior analgesia compared with ?
•Reduced ___
•Facilitates return of ___
•Decrease incidence of ___
•Decreased incidence of ___ adverse events
systemic opioids stress response GI motility pulmonary complications coagulation-related
- Sole or adjuvant analgesic
- Intrathecal or epidural
- Opioid selection depends on degree of lipophilicity vs hydrophilicity
Single-Dose Neuroaxial opioids
Neuraxial Opioids:
- Hydrophilic opioids - Name 2 examples?
- Tend to ___
- Onset of action?
- Duration?
- ___ CSF spread
- ___ of side effects
Morphine and Dilaudid
- remain within CSF
- Delayed
- Longer
- Extensive
- High incidence
Neuraxial Opioids:
- Lipophilic opioids - Name 2 examples?
- Onset of action?
- Duration?
- ___ CSF spread
- ___ of side effects
- Fentanyl and Sufentanil
- Rapid
- Shorter
- Minimal (due to segmental analgesic effect)
- Less occurrence
*Examples of \_\_\_ •Morphine •Fentanyl •Sufentanil •Meperidine •Hydromorphone
Neuraxial Opioids
***Analgesia delivered through an indwelling epidural catheter? Benefits: -Superior analgesia to \_\_\_ •Faster patient \_\_\_ •Attenuates \_\_\_ to surgery •Lessens \_\_\_
- **Continuous Epidural Analgesia
- systemic drugs
- recovery
- stress response
- pulmonary complications
Continuous Epidural Analgesia Need to Consider: –Choice and dose of analgesic agents –Location of catheter placement –Onset and duration of perioperative use –Side effects and risks –Availability of \_\_\_
-pain management personnel
Pain caused by noxious stimulation due to injury, trauma, an acute disease process or abnormal function of muscle or viscera?
- Almost always ___ pain.
- Results in a ___ response.
Acute Pain
- nociceptive
- neuroendocrine
Analgesic Agents for Epidural: ___
–High failure rate
–High incidence of motor blockade
–Hypotension common
Local Anesthetics Only
Analgesic Agents for Epidural: ___
–Avoids motor block
–Less hypotension
–Side effects resp. depression, pruritus
Opioids Only
Analgesic Agents for Epidural: ___
•Better choice for epidural analgesia
•Limits regression of sensory block
•Less motor block
•Decreases total dose of local anesthetic
•Great choice for abdominal, pelvic, thoracic, orthopedic procedures of lower extremities
Local anesthetics plus opioids
Epidural Drugs
•Local anesthetics - name 3???
•Opioids - name 4 ????
–Lidocaine –Bupivicaine –Ropivacaine –Morphine, Dilaudid –Fentanyl, Sufentanil
Adjuvant Neuraxil Drugs
*___ = selective alpha2 agonist, prolongs duration of block
–limited by side effects: ___, ___, ___
*___ and ___
–prolongs duration and intensity of block
- Clonidine
- hypotension, bradycardia and sedation
- Epinephrine and Neosynephrine
Patient Controlled Epidural Anesthesia: -Allows for \_\_\_ •\_\_\_ drug use •Increased patient satisfaction •Side effects similar to continuous epidural infusions •\_\_\_ infusion with \_\_\_ common
- individualization
- Lower
- Background
- demand dose
Location of Epidural Catheter
The insertion of the epidural catheter congruent to the ___ results in optimal postoperative analgesia by infusing analgesic agents to the appropriate ___, providing ___, utilizing less drug, minimizing side effects, and decreasing morbidity
incisional dermatome
incisional dermatomes
superior analgesia
Recommended Catheter Insertion Site for Surgery: •Thoracic surgery = ? •Upper abdominal, cholecystectomy = ? •Nephrectomy = ? •Lower abdomen = ? •Lower extremity = ?
T4-T8 T6-T8 T7-T10 T8-T11 L1-L4
Side Effects of Neuraxial Analgesia - Medication-related –Hypotension –\_\_\_ blockade –Nausea/vomiting –\_\_\_ –\_\_\_ depression –\_\_\_ retention
- Motor
- Pruritus
- Respiratory
- Urinary
Risks of Epidural Analgesia: *Complications of Placement –Epidural \_\_\_ or \_\_\_ –\_\_\_ injury *Intravascular, intrathecal, or subcutaneous injection of medications *Anticoagulants: –\_\_\_ anticoagulants
- hematoma or abscess
- Neurologic
- Postoperative surgical anticoagulants
Adjunct Treatments for Acute Pain Management:
- ___!
- Surgical = Local infiltration, Intra-articular analgesia, Pain pumps (onQ)
- TENS
- Acupuncture
- Psychological Approaches = Hypnosis, Distraction, relaxation, imagery, music
-ICE
These are all examples of ?? •Ambulatory •Elderly •Pediatric •Obesity •Obstructive Sleep Apnea (OSA) •Opioid-tolerant Patients
Special Subpopulations
Ambulatory Patients •\_\_\_ prolongs hospital stays •\_\_\_ pain common •\_\_\_ problem •\_\_\_ approach best
Postoperative pain
Post discharge
N/V
Multimodal
*Elderly Patients •Changes in physiology, pharmacodynamics, pharmacokinetics, and processing of nociceptive information •Increase in \_\_\_ and decreases in \_\_\_ •Barriers to pain management •\_\_\_ titration •\_\_\_ may be better
comorbidities
physiologic reserves
Slow
Regional
Opioid Tolerant Patients
*___ of analgesics needed to relieve pain
*Fear of ___; fear of ___
*Goals
–Provide baseline ___
–Anticipate an increase in ___
–Maximize the use of adjunct drugs; consider ___
Higher doses Addiction, medication related side effects opioid requirements postop analgesia requirements regional anesthesia
*___ = •Problems with undertreatment •Assessment can be difficult
- ___ techniques; ___ encouraged
- ___ discouraged
- Pediatric patients
- Regional
- PCA
- IM discouraged
Obesity and Sleep Apnea: -High risk for \_\_\_ -High risk for \_\_\_ ***Goals: •Avoid ? •\_\_\_ anesthesia, without \_\_\_ •NSAIDS •Post-op \_\_\_
-pulmonary complications
-respiratory arrest
respiratory depressants
Epidural anesthesia without opioids
CPAP
Chronic Pain Management: •Evaluation -History and physical -Psychological evaluation -\_\_\_ = -Nerve conduction studies -Muscle potentials
Multidisciplinary Approach
Electromyography
*\_\_\_ Pharmacology •NSAIDS/Acetaminophen •Opioids •Tramadol •Antidepressant Drugs •Antiepileptic Drugs •Corticosteroids •Muscle Relaxants •Others
Chronic Pain Management Pharmacology
Chronic Pain Management:
*___ = Elevate mood, help with sleep
•Block the reuptake of __ and __ at the neuronal membrane
•Potentiate ___
•Use ___ than indicated for depression
•Must monitor ___
•___ side effects = dry mouth, sedation, fatigue, orthostatic hypotension, arrhythmias
Tricyclic Antidepressants
- serotonin and norepinephrine
- narcotic analgesics
- smaller doses
- drug levels
- anticholinergic
Chronic Pain Management:
Alter the ion channels along the nerve fiber, thereby blocking pain stimuli by blocking the action potential?
Anticonvulsant Drugs
Chronic Pain Management - Anticonvulsant Drugs:
-Used for the treatment of neuropathic pain resulting from lesions to the ___ (?) or ___ (?)
-Examples include =????
•Side effects sedation, dizziness, ataxia
periphery (DM, herpes)
CNS (stroke)
Carbamazepine, phenytoin, gabapentin, clonazepam
Chronic Pain Management:
*___ = Reduce inflammation and swelling, reducing inflammatory mediators (prevent release of ?)
•Example?
Corticosteroids
prostaglandins
Dexamethasone
Chronic Pain Management Adjuvants:
- ___ = Reduction of muscle spasms, Analgesia (? mechanism)
- NMDA receptor antagonists = ? and ?
Muscle Relaxants
–Ketamine and dextromethorphan
*Chronic Pain Management Adjuvants = ___
–Work pre- and postsynaptically within the dorsal horn to inhibit neuron firing
-Name 2 examples?
–Also works centrally by inhibiting the release of substance P = ?
Alpha 2 Adrenergic Agonists
Clonidine
Dexmedetomidine (Precedex)
Precedex
Chronic Pain Management:
*___ = Inhibitory neurotransmitter
Example? - Acts in the spinal cord to prevent the release of excitatory neurotransmitters
*___ = ___ and Tocainide-PO meds
*GABA Receptor Agonists
Baclofen
*Local Anesthetics
Mexiletine
Techniques to Assist in the Management of ? •Nerve Blocks •Neurolytic Blocks •Spinal Cord Stimulation •TENS •Acupuncture •Physical Therapy •Radiofrequency Ablation and Cryoneurolysis
Chronic Pain
Chronic Pain Nerve Blocks: ***\_\_\_ = Trigger Point injections –Inject rope-like tight bands or focal areas of maximal tenderness in muscle –Use \_\_\_ or \_\_\_ –\_\_\_ ***Lower back pain use ?
- **Myofascial Pain
- local anesthetics or botulinum toxin
- TENS
- **Epidural steroid injections
Chronic Pain - Nerve Blocks
- **___ = -Cervicothoracic (Stellate) block -Thoracic sympathetic chain block -Splanchnic block -Lumbar sympathetic block
- Hypogastric plexus block
- **___ = -Trigeminal -Facial -Glossopharyngeal -Occipital
- Phrenic -Suprascapular -Cervical -Thoracic
- Lumber paravertebral -Trans-sacral -Pudendal
- **Sympathetic Nerve blocks
* **Somatic Nerve Blocks
Chronic Pain Management - ___:
•Permanent destruction of the nerve
•Most common neurolytic blocks are: 5 total ?????
•Alcohol and Phenol
Neurolytic Blocks –Lumbar sympathetic chain –Celiac plexus –Hypogastric plexus –Ganglion impar (retroperitoneal plexus) –Also intercostal blocks
Chronic Pain Management - Spinal Cord Stimulation:
•Stimulating electrodes in the ___ surrounding the entry level of the ___ into the ___
•Activation of ___ and therefore inhibit sympathetic outflow
•Used with ????
epidural space
noxious input into the spinal cord
descending modulating system
phantom limb pain, ischemic pain, PVD, spinal cord lesions
Chronic Pain Management = ___
•Hyperstimulation of the nervous system drowns out the pain
Transcutaneous electrical nerve stimulation aka TENS
Chronic Pain Management:
•___ = is a procedure where dysfunctional tissue is ablated using microwave energy (placing an insulated wire near the nerve tissue)
•___ with cold-freeze
Radio Frequency Ablation (RFA)
Cryoneurolysis
Cancer Pain
•Studies have shown that 70-90% of cancer pain can be effectively treated with ___
•Survey suggests that 40-50% of patients experiencing cancer-related pain do not receive ___
Pharmacotherapy alone
effective analgesia
Cancer Pain Inadequate Pain Relief Related to: •\_\_\_ pain assessment •\_\_\_ pain treatment plans •Lack of knowledge of \_\_\_ •Fear of \_\_\_ •Fear of \_\_\_
Poor Poor analgesics available addiction respiratory depression
Cancer Pain Management:
•Treat ___
•Assessment of ___ = Onset and duration of pain, Aggravating and relieving factors, Past treatment, Impact of pain on overall suffering
•___ and ___ examination
disease
pain
Physical and Neurologic
WHO Analgesic Ladder - Therapeutic Ladder for Pain Management in Terminally Ill Patients:
1) Step One, Mild Pain = ?
2) Step Two, Mild-Moderate Pain = ?
3) Step Three, Moderate-Severe Pain = ?
4) Step Four, Intractable Pain = ?
1) Non-opioid analgesics
2) Weak opioids, oral route
3) Parenteral, potent opioids
4) Invasive therapy
Cancer Pain Management - Adjuncts:
- ___ = Prevent release of prostaglandins and stimulate appetite
- ___ = Psychotherapy, guided-imagery, hypnosis, PT
- ___ = Elevate mood, help with sleep, block reuptake of serotonin, potentiate opioid analgesics
- Corticosteroids
- Non-invasive analgesics
- Antidepressants
Adverse Effects of Pain Treatment for Cancer/Terminally Ill Patients: •Constipation •Nausea/vomiting •Sedation •\_\_\_ impairment •\_\_\_phoria •\_\_\_ retention •\_\_\_ depression
cognitive
Dysphoria
urinary
respiratory
Other Treatment Modalities for Cancer or Terminally Ill patients:
•___ = disadvantage—short term relief
•___ = disadvantage—motor loss
•___
- Regional analgesia
- Neurolytic blocks
- Hospice
