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Coexisting > Pain > Flashcards

Pain Flashcards

1
Q

Pain is difficult to assess because it is subjective and each patient’s experience of pain is unique. What factors have an influence over this?

A
  1. Unique physiology (peripheral and central nervous system circuitry)
  2. Pathophysiology (not one injury is exactly the same)
  3. Personality
  4. Previous life experience
  5. Cultural and religious background
  6. Age
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2
Q

What goes into ascertaining a patient’s history of pain?

A
  1. Existence of pain
  2. Previous injuries
  3. Adjunctive therapies (acupuncture, TENS, injection therapy, SCS (what are they doing for the pain?)
  4. Coexisting psychological/physical diseases
  5. Assess other factors which may influence pain history: social, cultural, and spiritual factors
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3
Q

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
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4
Q

Appropriate population for Wong-Baker FACES

A

3 years old and up; “younger and/or not as verbal”

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5
Q

Purpose of Behavioral Pain Scales

A
  • Provide a means for consistent evaluation of pain in non-verbal pt populations
  • Allows pts who cannot self report pain a method for pain assessment
    • Pediatric patients, neonates, babies
    • Pts w/ cognitive impairment
    • Critically ill patients
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6
Q

Appropriate population for the Checklist of Non-verbal Pain Indicators (CNPI)

A

Adults

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7
Q

Appropriate population for the Payen Behavior Pain Scale

A
  • Developed for critically ill, intubated ICU pts
  • Has reliability &validity & correlates to NPI ratings (even in sedated pts)
  • Uses a 0 to 12 pain rating scale (3-12???)
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8
Q

Appropriate population for FLACC

A

2 months – 7 years

Face/Legs/Activity/Cry/Consolability

(scale = 0-10)

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9
Q

Appropriate population for CRIES Pain Scale

A

0-6 months old

Crying

Requires O2 for SaO2 less than 95%

Increased vitals (BP/HR)

Expression

Sleepless

(scale = 0-10)

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10
Q

Considerations in Methods to Relieve Pain

A
  • Duration of pain relief (shorter vs longer acting)
  • Acute vs Chronic pain?
  • Patient history
  • Goals of management
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11
Q

Nonpharmacologic pain treatment modalities

A
  1. PT/ rolling
  2. Heat/cold
  3. Acupuncture
  4. Relaxation behaviors
  5. Massage
  6. Positioning
  7. Immobilization
  8. TENS
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12
Q

Pain Treatment Modalities: Medications

A
  • Types:
    1. Opioids
    2. Non-steroidals
    3. Corticosteroids
    4. Local anesthetics
    5. Ketamine
    6. Alpha 2 Adrenergic Agonists
    7. Antidepressants
    8. Anticonvulsants
  • Prescription or OTC
  • Continuous or PRN
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13
Q

Physical Exam

A
  1. General physical examination
  2. Examine affected area
  3. Neurological exam
  4. Musculoskeletal system examination (ROM; muscle wasting)
  5. Skin (redness, wounds, edema, temp changes)
  6. Assessment of psychological factors: un-kept personal hygiene
  7. Vital signs
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14
Q

Specific Diagnostic Studies

A
  1. Quantitative sensory testing (QST) for pain thresholds and pain tolerance
  2. “Poor man’s sensory testing”
  3. Diagnostic nerve blocks
  4. Pharmacologic tests
  5. X-rays, CT, MRI, ultrasound
  6. EMG (Electromyography nerve test)
  7. NCV (Nerve Conduction Velocity test)
  8. Bone scans
  9. Blood tests: looking for co-conditions (RA, chronic inflammation)
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15
Q

What is acute pain?

A
  • Pain caused by noxious stimulation d/t injury, trauma, an acute disease process, or abnormal function of muscle or viscera.
  • Almost always nociceptive pain
  • Results in a neuroendocrine response
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16
Q

Why manage pain?

A
  • Control of postop pain allows for:
    • Reduction of the stress response
    • Shorter times to extubation, shorter ICU stay
    • Improved respiratory function
    • Earlier return of bowel function
    • Early mobilization = decreased risk DVTs
    • Early discharge
    • Reduction in sensitization, neuroplasticity, wind-up phenomenon, and transition to chronic pain
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17
Q

What is the “poor man’s sensory testing”?

A
  • Cold water in a glass tube (cold allodynia)
  • Warm water in a glass tube (heat allodynia)
  • Cotton wool and artist’s brush (dynamic mechanical allodynia)
  • Blunt needle (hyperalgesia)
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18
Q

Methods to relieve pain intra-op

A
  • Preemptive Analgesia- best postop pain management begins preop.
  • Opioids and NSAIDs in GA
  • Regional blocks
  • Local infiltration at surgical site could be used to control acute pain (hernia repair, tonsilar bed.)
  • Regional Anesthesia-pts do better overall
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19
Q

How do we see patients doing better with regional anesthesia as a method for intra-op pain relief?

A
  • Less morbidity
  • Less CV failure
  • Less infections
  • Less urinary cortisol
    • >L1 significant effect on the neuroendocrine response to surgery.
  • Lower overall post op complication rate
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20
Q

Patient Controlled Analgesia (PCA): Advantages and Findings

A

Advantages:

  • Cost-effective
  • Higher degree of patient satisfaction
  • Total drug consumption less than IM
  • Harder to over-medicate self
  • Prevents the “pain no pain cycle”

Findings:

  • Patients consume less drug
  • Male use more than female
  • Shortens hospital stays
21
Q

Patient Controlled Analgesia (PCA): Features

A
  1. Reservoir
  2. Infusion controller
  3. Pushbutton operated by pt only (not family and visitors)
  4. Delivers specific dose
  5. Lockout (minimal intervals b/t doses)
  6. Basal infusion (background infusion)
22
Q

Patient Controlled Analgesia (PCA): Considerations/Disadvantages

A
  • Prescription: Relieve pain before starting PCA.
  • Too little each hit discourages pt. If demand dose too much = adverse reactions also discourage pt (distrust)
  • Side Effects: Onset of respiratory depression parallels analgesia and is more rapid with lipophilic opioids.
  • N/V constipation, pruritis. Nearly all overdoses have been d/t errors in programming parameters.
23
Q

Principle behind Multimodal Approach

A
  • Control postop pain and attenuate periop stress response through use of regional anesthetic techniques and combo of analgesic agents (multimodal analgesia)
  • An extension of “clinical pathways” into effective postop rehabilitation pathways
24
Q

ERAS Protocols

A
  • Early Recovery After Surgery
    • Pre-hospital:
      1. pain management plan
    • Pre-op:
      1. initiate multimodal meds
      2. regional block placement
    • Intra-op:
      1. short-acting
      2. opioid-sparing meds
      3. multimodal meds
      4. regional anesthesia/analgesia
    • Post-op:
      1. non-opioid analgesics/NSAIDS
      2. regional anesthesia
25
Q

Peripheral Nerve Blocks

A
  • Single injection or continuous infusion of LA applied at a peripheral nerve site
    • Can add opioid and/or steroids to mixture
  • Can be used for intraop anesthesia or adjunct to postop analgesia
  • Limits path of nociceptive impulses
  • Superior analgesia
  • Few side effects
  • Can have analgesia for up to 24 hrs after single injection
26
Q

Exparel®️

A
  • Bupivicaine liposome injectable suspension
  • Approved for single-dose local infiltration and interscalene brachial plexus nerve blocks
  • Lasts up to 96 hrs post-infiltration and 120 hrs post-p.n.block
  • Side effects: N/V, fever
27
Q

What is the recommended dose of EXPAREL for local infiltration in adults?

A

Up to a max dose of 266 mg (20 mL)

28
Q

What is the recommended dose of EXPAREL for interscalene brachial plexus nerve block in adults?

A

133 mg (10 mL)

29
Q

Neuraxial (Spinal/Epidural) Analgesia: Benefits

A
  • Provide superior analgesia compared w/ systemic opioids
  • Facilitates return of GI motility
  • ↓ stress response
  • ↓ incidence of pulmonary complications
  • ↓ incidence of coagulation-related adverse events
30
Q

Neuraxial (Spinal/Epidural) Analgesia: Disadvantages

A
  • Cannot be used w/ anticoagulants
  • Infection
31
Q

Single-Dose Neuraxial (Spinal/Epidural) Opioids

A
  • Sole or adjuvant analgesic
  • Intrathecal (spinal) or epidural
  • Opioid selection depends on degree of lipophilicity vs hydrophilicity
32
Q

Adjunct Treatments for Acute Pain Management

A
  1. Ice
  2. Surgical
    • Local infiltration
    • Intra-articular analgesia
    • Pain pumps (onQ)
  3. TENS
  4. Acupuncture
  5. Psychological Approaches
    • Hypnosis
    • Distraction, relaxation, imagery, music
33
Q

Subpopulations w/ Special Considerations

A
  • Ambulatory (pts are going home, so consider short-acting and control of PONV)
  • Pediatric (assessment; PO/rectal pre-meds)
  • Elderly (sensitive; regional might be better)
  • Obesity (pulmonary considerations)
  • Obstructive Sleep Apnea (OSA) (pulmonary considerations)
  • Opioid-tolerant Patients (alcohol users; chronic pain pt that might require more meds in acute setting)
34
Q

Chronic Pain Management: Pharmacology

A
  • NSAIDS/Acetaminophen
  • Opioids
  • Tramadol
  • Antidepressant Drugs
  • Corticosteroids
  • Others
  • Muscle Relaxants
  • Anticonvulsant Drugs
35
Q

Tricyclic Antidepressants

A
  • Block reuptake of serotonin and NE at neuronal membrane
  • Elevate mood, help w/ sleep
  • Potentiate narcotic analgesics
  • Use smaller doses than indicated for depression
  • Monitor drug levels
  • Anticholinergic side effects
    • Dry mouth, sedation, fatigue, orthostatic hypotension, arrhythmias
  • Examples: Amitriptyline, Doxepin
36
Q

Anticonvulsant Drugs

A
  • Alter ion channels along nerve fiber = blocking pain stimuli by blocking action potential
  • Used for tx neuropathic pain resulting from lesions to peripheral (DM, herpes) or CNS (stroke)
  • Side effects: sedation, dizziness, ataxia
  • Examples: carbamazepine, clonazempan, phenytoin, gabapentin
37
Q

Corticosteriods

A
  • Reduce inflammation and swelling
  • Reduce inflammatory mediators
    • Prevent release of prostaglandins
  • Example: Dexamethasone
38
Q

Adjuvant: Muscle Relaxants

A
  • Reduction of muscle spasms
  • Analgesia
    • ? Mechanism (release of muscle tension)
  • Examples: baclofen, cyclobenzaprine, carisoprodol, skelaxin
39
Q

Adjuvant: NMDA receptor antagonists example

A

Ketamine

40
Q

Adjuvant: Alpha-2 adrenergic agonists

A
  • Work pre- and post-synaptically within dorsal horn to inhibit neuron firing
  • Also works centrally by inhibiting release of substance P (Precedex)
  • Examples: Clonidine, Dexmedetomidine (Precedex)
41
Q

Nerve Blocks

A
  • Trigger Point injections
  • Epidural steroid injections
  • Provide high dose of steroid at level of pathology to:
    • Reduce swelling of nerve root
    • Block C-fibers
    • Stabilize nerve membranes
    • Decrease ectopic discharges from inflamed tissue
42
Q

Neurolytic Blocks

A
  • Permanent destruction of nerve
  • Most common neurolytic blocks are:
    • Lumbar sympathetic chain
    • Celiac plexus
    • Hypogastric plexus
    • Ganglion impar (retroperitoneal plexus)
    • Also intercostal blocks
  • Alcohol and Phenol
43
Q

Spinal Cord Stimulation

A
  • Stimulating electrodes in epidural space surrounding entry level of noxious input into spinal cord
  • Activation of descending modulating system and therefore inhibit sympathetic outflow
  • Used with:
    • phantom limb pain
    • ischemic pain
    • PVD
    • spinal cord lesions
44
Q

TENS

A
  • Transcutaneous electrical nerve stimulation
  • Hyperstimulation of nervous system drowns out pain
45
Q

Radiofrequency Ablation

A
  • Radio frequency ablation (RFA) is procedure where dysfunctional tissue is ablated using microwave energy
  • Cryoneurolysis with cold-freeze
46
Q

Cancer Pain

A
  • 70-90% of CA pain can be effectively treated w/ pharmacotherapy alone & 40-50% of pts experiencing CA-related pain do not receive effective analgesia
  • Pain caused by cancer
    • Most common cause: Tumor invasion of bone
    • 2nd most common cause: Tumor compression of peripheral nerves
  • Pain d/t treatment
  • Physical effects—worse d/t loss of sleep, appetite, N/V
  • Psychological—heightened anxiety, feelings of loss, low self-esteem, changes in life goals, disfigurement
47
Q

Cancer Pain Management

A
  • Treat disease
  • Assessment of pain
    • Onset & duration of pain
    • Aggravating and relieving factors
    • Past treatment
    • Impact of pain in overall suffering
  • Physical and neurologic/psychological exam
  • Multi-disciplinary team
48
Q

WHO Analgesic Ladder

A

Therapeutic Ladder for Pain Management in Terminally Ill Patients:

  1. Step One, Mild Pain: Non-opioid analgesics
  2. Step Two, Mild-Moderate Pain: Weak oral opioids
  3. Step Three, Moderate-Severe Pain: Potent parenteral opioids
  4. Step Four, Intractable Pain: Invasive Therapy
49
Q

What is Inadequate Pain Relief 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

Coexisting (5 decks)

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