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NURA 620 Anesthesia and Coexisting Conditions > Pain > Flashcards

Pain Flashcards

1
Q

Pain is difficult to assess because it is SUBJECTIVE AND UNIQUE. It is influenced by:

A

unique physiology (peripheral and central nervous system circuitry)

pathophysiology (not one injury is exactly the same)

personality

previous life experience

cultural and religious background

age

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2
Q

Elements of Pain Assessment

A 
P = precipitating events (What leads to the pain?)
Q = quality (stabbing, burning, dull, etc.)
R = region/radiation
S = severity
T = temporal relationship/timing
A = associated symptoms
--functional impairment
--previous treatment
--inflammation
PAIN GOALS
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3
Q

Wong-Baker FACES scale: appropriate population

A

> 3 years old and up

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4
Q

Behavioral pain scales: appropriate populations

A

provides a means for consistent evaluation of pain in NON VERBAL patient populations

allows patients who cannot self report pain a
method for pain assessment
--pediatric patients, neonates, babies
--pts with cognitive impairment
--critically ill patients
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5
Q

Checklist of Non verbal pain indicators (CNPI): appropriate population

A

adults

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6
Q

Payden behavioral pain scale: appropriate population

A
  • developed for critically ill, intubated ICU patients
  • has reliability & validity & correlates to NPI ratings (even in pts who are on sedation)
  • uses a 0-12 pain rating scale
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7
Q

FLACC pain scale: appropriate population

A

2 months to 7 years

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8
Q

CRIES pain scale: appropriate population

A

0 - 6 months

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9
Q

Nonpharmacologic treatment modalities

A
  • acupuncture
  • positioning
  • immobilization
  • heat/cold
  • massage
  • relaxation behaviors
  • PT/rolling
  • TENS
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10
Q

Pain: physical exam

A

general physical examination
examine affected area
neurological examination
musculoskeletal system examination (ROM, muscle wasting)
skin (redness, wounds, edema, temp changes)
assessment of psychological factors: unkept personal hygiene
vital signs: inc HR, BP, etc

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11
Q

Acute pain: definition

A

pain caused by noxious stimulation due to injury, trauma, an acute disease process, or abnormal function of muscle or viscera

almost always nociceptive pain –>results in neuroendocrine response

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12
Q

Pain management: why do it?

A
  • reduction of the stress response
  • shorter times to extubation, shorter ICU stay
  • improved respiratory function
  • earlier return of bowel function
  • early mobilization, decreased risk of DVTs
  • early d/c
  • reduction in sensitization, neuroplasticity, wind up phenomenon, and transition to chronic pain
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13
Q

The best postoperative pain management begins when?

A

PREOPERATIVELY

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14
Q

Benefits of regional anesthesia

A

“patients do better overall”

  • less morbidity
  • less mortality
  • less infections
  • less urinary cortisol
  • -regional at a site > L1 have a significant effect on the neuroendocrine response to surgery
  • lower overall post op complication rate
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15
Q

Advantages of patient controlled analgesia (PCA)

A

cost effective
higher degree of pt satisfaction
total drug consumption is less than IM?
harder to over medicate self

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16
Q

PCAs prevent…

A

“the pain no pain cycle”

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17
Q

PCA use: findings

A

patients consume less drug
male use more than female
shortens hospital stays

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18
Q

ERAS protocols: pre hospital

A

pain management plan

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19
Q

ERAS protocols: pre operative

A

initiation of multimodal medications and regional block placement

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20
Q

ERAS protocols: intraoperative

A

short acting, opioid sparing medications
multimodal medications
regional anesthesia/analgesia

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21
Q

ERAS protocols: post operative

A

regional anesthesia

non opioid analgesics/NSAIDs

22
Q

Pain management: peripheral nerve blocks

A

single injection or continuous infusion of local anesthetic applied at a peripheral nerve site
-can add opioid and/or steroids to mixture

can be used for intraop analgesia 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 single injection

23
Q

What is Exparel?

A

bupivicaine liposome injectable suspension

approved for single dose local infiltration and interscalene brachial plexus nerve blocks

lasts up to 96 hours post infiltration and 120 hours post peripheral nerve block

24
Q

Exparel: side effects

A

nausea, fever, vomiting

25
Q

Exparel: recommended dose for local infiltration in adults

A

Up to maximum dose of 266 mg (20 ml)

26
Q

Exparel: recommended dose for interscalene brachial plexus nerve block in adults

A

133 mg (10 ml)

27
Q

Neuraxial (spinal/epidural) analgesia: Benefits

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
28
Q

Neuraxial (spinal/epidural) analgesia: disadvantages

A
  • cannot be used with anticoagulants

- infection

29
Q

Adjunct treatments for acute pain management

A
  • ICE
  • Surgical (local infiltration, intra-articular analgesia, pain pumps (on Q))
  • TENS
  • acupuncture
  • psychological (hypnosis, distraction, relaxation, imagery, music)
30
Q

Chronic pain management: pharmacology

A 
NSAIDs/acetaminophen
opioids
tramadol
antidepressant drugs
anticonvulsant drugs
corticosteroids
muscle relaxants 
others - ketamine
31
Q

Chronic pain management: Tricyclic Antidepressants (TCAs)

A
  • elevate mood, help with sleep
  • block the reuptake of serotonin and NE at the neuronal membrane
  • potentiate narcotic analgesics
  • use smaller doses than indicated for depression
  • must monitor drug levels
32
Q

Chronic pain management: anticonvulsant drugs

A
  • alter the ion channels along the nerve fiber, thereby blocking pain stimuli by blocking the action potential
  • used for the tx of neuropathic pain resulting from lesions to the peripheral (DM, herpes) or CNS (stroke)
33
Q

Chronic pain management, anticonvulsant drugs: Agents and SE

A

carbamazepine, phenytoin, gabapentin, and clonazepam

SE: sedation, dizziness, ataxia

34
Q

Chronic pain management, Tricyclic Antidepressants (TCAs): Agents and SE

A

amitriptyline, doxepin

anticholinergic SE: dry mouth, sedation, fatigue, orthostatic hypotension, arrhythmias

35
Q

Chronic pain management: use of corticosteroids

A

reduce inflammation and swelling, reducing inflammatory mediators (prevent release of prostaglandins)

Example: dexamethasone

36
Q

Chronic pain management, muscle relaxants: use + examples

A

reduction of muscle spasms
analgesia: mechanism unsure

Examples: cyclobenzaprine, skelaxin, baclofen, carisoprodol

37
Q

Chronic pain management, NMDA receptor antagonists: example

A

Ketamine

38
Q

Chronic pain management, alpha 2 adrenergic agonists: use + examples

A

work pre and post synaptically within the dorsal horn to inhibit neuron firing

also works centrally by inhibiting the release of substance P (precedex)

Examples: clonidine, dexmedetomidine

39
Q

chronic pain management, nerve blocks: use

A

nerve blocks

  • trigger point injections
  • epidural steroid injections

provide high dose of steroid at the level of pathology to reduce swelling of he nerve root, block C fibers, stabilize nerve membranes, and decrease ectopic discharges from inflamed tissue

40
Q

chronic pain management, neurolytic blocks: use + examples

A

permanent destruction of the nerve

most common neurolytic blocks are:

  • lumbar sympathetic chain
  • celiac plexus
  • hypogastric plexus
  • ganglion impar (retroperitoneal plexus)
  • also intercostal blocks

Alcohol and Phenol

41
Q

chronic pain management, spinal cord stimulation: use + populations used for

A

stimulating electrodes in the epidural space surrounding the entry level of the noxious input into the spinal cord

activation of descending modulating system and therefore inhibit sympathetic outflow

used with phantom limb pain, ischemic pain, PVD, spinal cord lesions

42
Q

chronic pain management: TENS

A

transcutaneous electrical nerve stim

hyperstimulation of the nervous system drowns out the pain

43
Q

chronic pain management: radiofrequency ablation (RFA)

A

procedure where dysfunctional tissue is ablated using microwave energy

cryoneurolysis with cold freeze

44
Q

cancer pain: physical effects

A

worse due to loss of sleep, appetite, nausea & vomiting

45
Q

cancer pain: psychological effects

A

heightened anxiety, feelings of loss, low self - esteem, changes in life goals, disfigurement

46
Q

WHO analgesic ladder: step one, mild pain

A

non opioid analgeics

47
Q

WHO analgesic ladder: step two, mild-moderate pain

A

weak opioids, oral route

48
Q

WHO analgesic ladder: step three, moderate - severe pain

A

parenteral, potent opioids

49
Q

WHO analgesic ladder: step four, intractable pain

A

invasive therapy

50
Q

Cancer pain, inadequate pain relief can be related to:

A

poor pain assessment

poor pain treatment plans

lack of knowledge of analgesics available

fear of addiction

fear of respiratory depression

side effects of pain treatment

NURA 620 Anesthesia and Coexisting Conditions (7 decks)

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