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Surgery sara > Pain and management > Flashcards

Pain and management Flashcards

1
Q

why is morphine not recommended in those with pancreatitis?

A

causes sphincter of oddi to contract which can actually increase pressure and thus pain.

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2
Q

what is entanox and when should it be avoided?

A

oxygen and nitrous oxide

avoided in pneumothorax.

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3
Q

what is pain?

A

An unpleasant sensory and emotional experience associated with actual or potential tissue damage. can be acute or chronic

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4
Q

Explain the difference between acute and chronic pain.

A

acute pain: has rapid onset, limited duration <3 months, identifiable cause

chronic pain: lasts beyond healing time >3 months, no identifiable cause.

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5
Q

outline the physiology behind pain?

A

nociceptors at tissue surfaces that can detect damage
This results in activation of Ad (sharp) and C fibres (dull pain) to the spinal cord and up to the brain.

within the spinal cord there is an area called the substantia gelatinosa which allows descending inhibitory neurons to modify the amount of transmission of ascending pain fibres.

Thus pain is influenced by descending inputs (emotion)

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6
Q

what scoring systems can be used for pain?

A

APACHE II: score from 0-71 based on age, health and many other factors

ask patient to score 1-10
ask patient to describe pain

in children harder so may have to score based on HR, Resp rate, facial expression, skin colour and crying

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7
Q

what are the non-pharamacological ways of controlling pain?

A

hypnosis, music, exercise, CBT, mediation
anything changing emotion - e.g. increase socialisation

fix the original problem e.g. gastritis - give omeprazole

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8
Q

Describe the WHO analgesic ladder

A
  1. non-opiods: NSAIDs, paracetamol, aspirin
  2. weak opioids: codeine, tramadol
  3. strong opioids: morphine, fentanyl and pethidine

can also used adjuvants such as ketamine, Entonox and midazolam

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9
Q

how does the management of acute and chronic pain differ with regards to the WHO analgesic ladder?

A

acute: start high and reduce (come down ladder)
chronic: start at bottom and work way up.

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10
Q

why is it important to manage pain?

A

pain increases sympathetic NS and leads to vasoconstriction which reduces tissue perfusion and healing.

also reduces mobilisation and thus increases likelihood of VTE and pneumonia

also reduces depth of breathing and coughing - therefore more likely to get pneumonia/ atelectasis

reduces muscle wasting from lack of movement
reduces risk of chronic pain developing

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11
Q

what are the adverse effects of pain?

A

tachycardia, increased BP and increased myocardial demand for O2
Increased resp rate but reduced tidal volume,
N&V, ileus

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12
Q

name 3 NSAIDs

A

Ibuprofen
Diclofenac
naproxen

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13
Q

what are the indications of NSAIDs?

what additional indications does aspirin have?

A

anti-inflammatory
analgesia
anti-pyrexial

good for MSK pain

Aspirin:

  • thromboprophylaxis
  • prevention of DVT, Stroke, MI, pre-eclampsia
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14
Q

How do NSAIDs work?

A

inhibition of COX enzymes
reduces production of prostaglandins which are involved in pain (activate nociceptors)
also prostaglandins in brain cause pyrexia.

NSAIDS reversible inhibit COX enzymes

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15
Q

how does aspirin work?

A

irreversibly inhibit COX enzyme

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16
Q

what are the contraindications to NSAIDs/ asprin?

A

contraindications in renal impairment, gastric ulceration, asthma (bronchoconstriction), allergies, coagulation defects

aspirin should not be given to people with Gout - can precipitate it.

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17
Q

what are the ADRs of asprin/ NSAIDs?

A 
gastric ulceration
bronchoconstriction 
bleeding 
skin reactions
drop in GFR

aspirin can precipitate gout

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18
Q

what serious complication is aspirin associated with in children/

A 
reyes syndrome (swelling of liver and brain) 
can occur in children who are treated with aspirin for a viral infection.
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19
Q

what are the indications of paracetamol?

A

analgesia

anti-pyretic

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20
Q

what are the side effects of paracetamol?

A

very minimal

but can be hepatotoxic in overdose

21
Q

when should the dose of paracetamol be reduced?

A

in those <50kg

hepatic impairment or alcoholics

22
Q

what dose of paracetamol is safe?

A

1g every 4 hours

max 4g/day

23
Q

describe the biochemistry behind paracetamol overdose?

A

paracetamol is normally conjugated with glucuronide in phase 2 metabolism
however a small % undergoes phase 1 metabolism to produce NAPQI which is toxic

in overdose phase 2 metabolism becomes saturated and more NAPQI is produced.

24
Q

how is paracetamol overdose managed?

A

if within 4 hours: activated charcoal orally

otherwise 0-36 hours: IV N-acetylcysteine
OR methionine by mouth (if no IV access)

25
Q

how is codeine given? what do we need to be aware about its metabolism?

A

orally

variable - some people cant metabolise it, some people more so.

26
Q

what is the action of tramadol?

A

opioid receptor agonist

but also inhibits NA and 5HT3 reuptake inhibitor - so improves emotional state and hence pain from another aspect

27
Q

what are the problems with using tramadol?

A

ADR like other opiods
+
lowers seizure threshold - so not good in epilepsy
- can also interfere with SSRIs - may lead to serotonin syndrome

28
Q

when is fentanyl used?

A

often used as a patch in chronic pain - it is a longer lasting analgesic
can also be used as spinal/epidural anaesthesia

29
Q

what is used to treat opioid overdose?

A

naloxone -

opioid receptor antagonist

30
Q

when are opioids contraindicated?

A

acute resp depression
at risk of paralytic ileus
head injury

be aware in those with dementia as can worsen confusion (but so can pain)

31
Q

how do opioids work?

A

bind to endogenous opioid receptors
result in hyperpolarisation of cells to reduce excitability and pain transmission
inhibit release of substance P within spinal cord

32
Q

What are the general ADRs of opioids?

A 
respiratory depression
constipation - so should be accompanied with laxative if using >3days
N&amp;V 
Miosis
euphoria
confusion
33
Q

how long can a fentanyl patch last and what are the benefits of this delivery?

how often do you change buprenorphine patches?

A

72 hours
less issues with compliance
absorbed directly into blood, no first pass effect

buprenorphine -change every 7 days

34
Q

why should codeine not be given to children?

A

unpredictable metabolism and because only small could overdose

35
Q

what is oromorph?

A

liquid morphine

36
Q

what should you do If there is an opioid allergy?

A

ensure it is an allergy and not sensitivity/ side effect
e.g. N&V is a side effect and can be managed with anti-emetic

sensitivities can be managed by lowering opioid dose and giving anti-histamine/emetic

if allergy then use local and regional anaesthetic techniques instead, paracetamol/NSAIDS, entanox

37
Q

what is a peripheral nerve block?

A

local anaesthetic is injected around a peripheral nerve.

done using ultrasound and electrical current to ensure it is injected into the right place

38
Q

what is patient controlled analgesia? what is the advantage of this?

A

this is an IV pump whereby a bolus of analgesic agent is given when patient presses the button.

Advantage of this is that analgesia is tailored to patients needs.
safe- risk of overdose is minimal
can measure how much is given
minimises time patient is in pain - quick feedback

39
Q

what should be monitored if a patient is on PCA?

A 
infusion should be checked hourly 
resp rate
level of pain
sedation
heart rate
vomiting
document all of these
40
Q

when is PCA not appropriate?

A

low GCS

poor manual dexterity

41
Q

how is spinal analgesia administered?

A

inject below level of L1 to avoid spinal cord

inject around spinal nerves i.e. past the arachnoid membrane and into the dural space

42
Q

what drugs can be used in a spinal/epidural analgesia?

A

levobupivacaine and can add fentanyl

43
Q

how is an epidural prepared?

A

A catheter is first inserted into the correct place - between 2 vertebrae and then through ligamentum flavum and stop just before arachnoid layer i.e into epidural space

44
Q

what observations should be made before and throughout an epidural?

A

resp rate, HR, BP
sedation score, pain score, vomit score
temperature, pulse oximetry

every hour

also check sensory and motor functions to ensure it has worked.

45
Q

at what level should an epidural be administed for abdominal surgery ?
for labour?

A

abdominal: thoracic level - T6/7

lumbar level for labour - L1/2

46
Q

List some side effects of an epidural

and how can each be solved?

A 
hypotension - due to sympathetic nerve block 
    - solved by fluids and IV phenylephrine 
epidural abscess/ haematoma
    - treat asap to avoid neuro problems 
standard opioid side effects
itching nose 
    - anti-histamine
infection
urine retention 
    - catheter
nerve damage - recovers in a few months 
paralysis - very rare
47
Q

how is bone pain treated?

A

bisphosphonates

48
Q

how is pain from muscle spasms treated?

A

diazepam

49
Q

give the 4 steps for managing nerve pain.

A

step 1 = TCA - amitriptyline
step 2 = anticonvulsants - gabapentin
step 3 = ketamine
step 4 = spinal analgesia

Surgery sara (10 decks)

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