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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
Peripheral Nerve Blocks
* **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
Exparel®️
* 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
What is the recommended dose of EXPAREL for local infiltration in adults?
Up to a max dose of **266 mg (20 mL)**
28
What is the recommended dose of EXPAREL for interscalene brachial plexus nerve block in adults?
**133 mg (10 mL)**
29
_Neuraxial (Spinal/Epidural) Analgesia_: Benefits
* 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
_Neuraxial (Spinal/Epidural) Analgesia:_ Disadvantages
* Cannot be used w/ anticoagulants * Infection
31
Single-Dose Neuraxial (Spinal/Epidural) Opioids
* Sole or adjuvant analgesic * Intrathecal (spinal) or epidural * Opioid selection depends on degree of lipophilicity vs hydrophilicity
32
Adjunct Treatments for Acute Pain Management
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
Subpopulations w/ Special Considerations
* 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
Chronic Pain Management: Pharmacology
* **N**SAIDS/Acetaminophen * **O**pioids * **T**ramadol * **A**ntidepressant Drugs * **C**orticosteroids * **O**thers * **M**uscle Relaxants * **A**nticonvulsant Drugs
35
Tricyclic Antidepressants
* 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
Anticonvulsant Drugs
* 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
Corticosteriods
* Reduce inflammation and swelling * Reduce inflammatory mediators * Prevent release of prostaglandins * _Example_: Dexamethasone
38
Adjuvant: Muscle Relaxants
* Reduction of muscle spasms * Analgesia * ? Mechanism *(release of muscle tension)* * _Examples_: baclofen, cyclobenzaprine, carisoprodol, skelaxin
39
Adjuvant: NMDA receptor antagonists example
Ketamine
40
Adjuvant: Alpha-2 adrenergic agonists
* 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
Nerve Blocks
* **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
Neurolytic Blocks
* **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
Spinal Cord Stimulation
* **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
TENS
* Transcutaneous electrical nerve stimulation * Hyperstimulation of nervous system drowns out pain
45
Radiofrequency Ablation
* Radio frequency ablation (RFA) is procedure where **dysfunctional tissue is ablated using microwave energy** * **Cryoneurolysis** with cold-freeze
46
Cancer Pain
* 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
Cancer Pain Management
* 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
WHO Analgesic Ladder
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
What is Inadequate Pain Relief Related to?
* 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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