Pain Flashcards
1
Q
What is acute pain?
A
- Caused by tissue damage– it is a protective response
- Peripheral nociceptive neuron is stimulated by intense noxious stimuli which sends a signal to the CNS
- CNS: brain and spinal cord process the afferent input and this results in sensation of pain
2
Q
What is chronic pain?
A
- Neural dysfunction in the peripheral and/or CNS pain pathways
- extends beyond the expected 3-6 months healing period and often has no identifiable cause
- serves no purpose
3
Q
What are the consequences of pain?
A
- Activation of stress response- SNS and adrenocortical stimulation
- elevated blood sugar
- immunosuppression
- urinary retention
- altered coagulation
- psychosocial- anxiety, depression, impact of relationships and productivity
4
Q
What makes pain assessment difficult?
A
- It is difficult because it is subjective and each patient’s experience of pain is unique
- Pain can be influenced by:
- unique physiology (PNS and CNS circuitry)
- pathophysiology
- personality
- previous life experience
- cultural and religious background
- age
- Healthcare providers may undertreat pain if:
- they dont believe the pt
- they dont understand the science behind it
5
Q
What should you assess regarding the history of pain?
A
- existence of pain
- assess each type of pain/pain problem separately
- previous injuries
- Adjunctive therapies
- acupuncture, TENS, injection therapy, SCS
- Coexisting psychological disease/physical disease
6
Q
What are the elements of a pain assessment?
A
- P- precipitating events
- Q- quality
- R- Region/radiation
- S- severity
- T- Temporal relationship/Timing
-
A- associated symptoms
- functional impairment
- previous treatment
- inflammation
- Pain goals
7
Q
What is the benefit of behavioral pain scales?
A
- provides a means for consistent evaluation of pain in non-verbal patients
- pediatric pts
- pts with cognitive impairment
- critically ill patients
8
Q
What pain scale would be appropriate for a pediatric patient >3 yrs old?
A
- Wong-Baker FACES scale
9
Q
What is the Payen Behavioral pain scale?
A
- It was developed for critically ill intubated ICU patients
- Is reliable and valid and correlates to NPI ratings, even in patients who are on sedation
- uses a 0-12 pain rating scale
10
Q
For what patients would you use the FLACC score?
A
2 months to 7 years
11
Q
For what patients would you use the CRIES pain scale?
A
0-6 month olds
12
Q
What else should you assess in a patient with chronic pain?
A
- General medical history- comorbidities contributing to complex pain condition
- How does pain effect:
- sleep?
- physical functions?
- ability to work?
- your mood?
- family/social life?
- What treatments have you received? Effects? adverse effects?
- Are you depressed
13
Q
What should you assess on the physical exam of pain?
A
- General physical examination
- affected area
- neurological exam
- musculoskeletal system
- ROM
- muscle wasting
- skin- redness, wounds, edema, changes
- assessment of psychological factors: un-kept personal hygiene
14
Q
What are some specific diagnostic studies that can be done?
A
- Quantitative sensory testing for pain thresholds and pain tolerance
- diagnostic nerve blocks
- pharmacologic tests
- conventional radiography, tomography, MRI, ultrasound imaging
- Electromyography nerve test (EMG)- assess nerve impulses into muscle
- Nerve conduction velocity test (NCV)- to see how rapid an impulse comes through a nerve
- bone scans- cancer pain
- blood test- looking for comorbidites
15
Q
How can you test for different types of allodyna?
A
- “poor man’s sensory testing”
- Cold allodynia- cold water in a glass tube
- heat allodynia- glass tube with warm water
- dynamic mechanical allodynia- cotton wool and artist’s brush
- hyperalgesia- blunt needle
16
Q
What is the neuroendocrine response that is caused by acute pain?
A
An SNS response, release of cortisol and Renin
17
Q
What may be a predictor of chronic pain?
A
Poorly controlled acute pain
18
Q
What ways may cancer cause pain?
A
- By the cancer
- tumor invading bone (most common)
- tumor compressing peripheral nerves
- Pain due to treatment
- Physical effects- pain can worsen due to loss of sleep, appetite, nausea, and vomiting
- Psychological- pain can worsen with heightened anxiety, feelings of loss, low self-esteem, changes in life goals, disfigurement
19
Q
Why is it important to manage post-operative pain?
A
- Reduces stress response
- shorter times to extubation, shorter ICU stay
- improved respiratory function
- earlier return of bowel function
- early mobilization, decreased risk of DVTs
- early discharge
- patient satisfaction
- reduction in sensitization, neuroplasticity, wind-up phenomenon and transition to chronic pain
20
Q
What is the wind-up phenomenon?
A
- The idea that pain will increase when a stimulus is delivered repeatedly above a critical rate
- Caused by repeated stimulation of C fibers
21
Q
What is preemptive analgesia?
A
- Blockade of response to noxious stimuli and extending this block into the postoperative period
- Reduced post-op pain and accelerates recovery
- Thought to stop peripheral and central sensitization and hyperexcitability to pain and therefore the development of chronic pain
22
Q
What is the principle of the multimodal approach?
A
- Control postoperative pain and attenuate the perioperative stress response through the use of regional anesthetic techniques and a combination of analgesic agents (multimodal analgesia)
- It is an extension of “clinical pathways” into effective postoperative rehabilitation pathways
23
Q
What are the ERAS protocols regarding pain?
A
- Early Recovery After Surgery
- Pre-hospital: make a pain management plan
- Pre-op: initiation of multimodal medications and regional block placement
- Intra-op: short-acting, opioid-sparing medications; multimodal medications; regional
- Post-op: regional analgesia, non-opioid analgesics/NSAIDS
24
Q
What are the different modes of drug administration?
A
- IV- preferred
- SC
- IM
- Oral
- SL
- PR
- Buccal
- intranasal
- transdermal patch
- *ketamine nebulizers or gargles- have a systemic effect
25
Q
Opioids
how do they work?
advantages
disadvantages
A
- Were the standart in pain managment
- Work by affecting mu and kappa opioid receptors in the CNS
- Adv: no analgesic ceiling
- Disadv: side effects
- respiratory depression
- hypotension
- N/V
- sedation
- pruritus
- urinary retention
- dependence
26
Q
How do NSAIDS work?
When is it used?
A
- Analgesic effect achieved through inhibition of cyclooxygenase (COX), preventing the synthesis of prostaglandins
- results in the attenuation of the nociceptive response to inflammatory mediators
- peripherally and in the spinal cord
- Used in mild to moderate pain and pain related to inflammatory conditions
- useful in adjunct to opioids
27
Q
Side effects of NSAIDS?
A
- Renal dysfunction
- GI hemorrhage
- effects on bone healing/osteogenesis
- liver dysfunction
- decreased homeostasis
- platelet dysfunction
- inhibition of thyromboxane A2
28
Q
What are some NSAIDS?
A
- Ketorolac
- piroxicam (Feldane)
- Nabumatone (Relafen)
- Indomethacin (Indocin)
- Celecoxib (Celebrex)
- Parecoxib
- Caldolor (ibuprophen)
29
Q
What are some adjubant drugs that can help treat pain?
A
- Ketamine- IV, gargled, nebulized
- Nalbuphine (nubain)- IV
- Lortab elixir (hydrocodone and acetaminophen)- PO
- Gabapentin (Neurontin)- PO
- Mag sulfate- PO, IV
- Lidocaine lollipops
- lidocaine infusions
- Beta blockers
- Corticosteroids
30
Q
What are the benefits of peripheral nerve blocks?
A
- Single injection or continuous infuison
- can be used intraoperatively or as an adjunct to postoperative analgesia
- limits the path of nociceptive impulses
- superior analgesia
- few side effects
- can have analgesia for up to 24 hours after singel injection
31
Q
What are the benefits of neuraxil analgesia?
A
- provide superior analgesia compared with systemic opioids
- reduced stress response
- facilitates return of GI motility
- decreased incidence of pulmonary complications
- decreased incidence of coagulation-related adverse events
32
Q
Neuraxial opioids:
Difference between hydrophilic and lipophilic opioids
A
- Hydrophilic opioids:
- morphine and dilaudid
- tend to remain within the CSF
- delayed onset of action
- longer duration
- extensive CSF spread
- high incidence of side effects
- Lipophilic opioids
- Fentanyl and sufentanyl
- Rapid onset of action
- shorter duration
- minimal CSF spread due to segmental analgesic effect
- less side effects
33
Q
What do you need to consider regarding Continuous epidural analgesia?
A
- 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
34
Q
Regarding Analgesic agents for epidural:
LAs only
Opioids only
LAs combine with Opioids
A
- LAs only
- high failure rate
- high incidence of motor blockade- d/t density required to have effect
- hypotension common
- Opioids only
- Avoids motor block
- less hypotension
- side effects: resp dep, pruritis
- Combined LA and opioids
- Better choice for epidural
- limits regression of sensory block
- less motor block
- decreases total dose of LA
- great choice for abdominal, pelvic, thoracic, orthopedic procedures of lower extremeties
35
Q
What are some of the epidural drugs?
A
- LAs
- lidocaine
- bupivicaine
- ropivacaine
- Opioids
- morphine
- dilaudid
- fentanyl
- sufentanyl
36
Q
What are some adjuvant neuraxil drugs?
how do they work?
limits?
A
- Clonidine
- selective alpha 2 agonist
- prolongs duration of block
- limited by side effects:
- hypotension, bradycardia, sedation
- Epinephrine and Neosynephrine
- prolongs duration and intensity of block
37
Q
Medication related side effects of neuraxial analgesia
A
- Hypotension
- motor blockade
- N/V
- pruritis
- respiratory depression
- urinary retention
38
Q
What are the risks of epidural analgesia?
A
- complications with placement
- epidural hematoma
- abscess
- neurologic injury
- Intravenous, entrathecal, or subcutaneous injection of medications
- anticoagulants:
- post-op surgical anticoagulants
39
Q
What are some adjunct treatments for acute pain?
A
- Ice
- surgical
- local infiltration
- intra-articular analgesia
- pain pumps
- TENS
- acupuncture
- psychological approaches
- hypnosis
- distraction
- relaxation
- imagery
- music
40
Q
What are the advantages of a PCA?
A
- cost-effective
- higher degree of patient satisfaction
- total drug consumption is less
- harder to overmedicate self
- prevents the pain-no pain cycle
