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Anaesthetics > Pain and Pain Relief > Flashcards

Pain and Pain Relief Flashcards

1
Q

What is pain, according to the International Association for the Study of Pain?

A

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage

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2
Q

What fraction of people live with persistent pain?

A

1 in 4

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3
Q

What percentage of people attending A&E seeking help for pain will have made around 3 visits to their health care practitioner in the preceding weeks?

A

66%

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4
Q

What is the number 1 disease for years lost to disability worldwide?

A

Low back pain

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5
Q

What are the benefits of treating pain for the patient?

A 
Physical
- improved sleep, better appetite
- fewer medical complications 
Psychological 
- reduced suffering 
- less depression and anxiety
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6
Q

What are the benefits of treating pain for the family?

A

Improved functioning as a family member

Able to keep working

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7
Q

What are the benefits of treating pain for society?

A

Lower health costs

Able to contribute to the community

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8
Q

How is pain classified?

A

By;
Duration
Cause
Mechanism

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9
Q

How is pain classified according to duration?

A

Acute
Chronic
Acute on chronic

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10
Q

How is pain classified according to cause?

A

Cancer

Non-cancer

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11
Q

How is pain classified according to mechanism?

A

Nociceptive

Neuropathic

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12
Q

What is the difference between acute and chronic pain?

A

Acute pain is pain of recent onset and probable limited duration

Chronic pain is;

  • pain lasting for more than 3 months
  • pain lasting after normal healing
  • often no identifiable cause
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13
Q

What is the difference between cancer and non-cancer pain

A

Cancer pain

  • progressive
  • may be a mixture of acute and chronic

Non-cancer pain

  • many different causes
  • acute or chronic

This classification is more about the context in which pain occurs and how this influences management

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14
Q

What are the features of nociceptive pain?

A

Obvious tissue injury or illness
Also known as physiological or inflammatory pain
Protective function
Sharp/dull, well-localised

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15
Q

What are the features of neuropathic pain?

A

Nervous system damage or abnormality - neuropathic dysfunction
Tissue injury may not be obvious
Does not have a protective function
Burning, shooting, numbness, pins and needles, not well-localised

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16
Q

What are the 4 steps of pain physiology?

A

Periphery
Spinal cord
Brain
Modulation

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17
Q

What is the mechanism of pain physiology in the periphery?

A

Nociceptors in the periphery
Tissue injury - results in release of chemicals e.g. prostaglandins
Signal travels in Aδ or C fibres to spinal cord

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18
Q

What is the mechanism of pain physiology in the spinal cord?

A

Dorsal horn is the first relay station
Aδ or C nerve synapses with second nerve
Second nerve travels up the opposite side of the spinal cord

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19
Q

What is the mechanism of pain physiology in the brain?

A

Thalamus is the second relay station
Connects to many parts of the brain - cortex, limbic system, brainstem
Pain perception occurs in the cortex

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20
Q

What is the mechanism of pain modulation?

A

Descending pathway from brain to dorsal horn

Usually decreases pain signal

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21
Q

What is the gate theory?

A

When transmission cell is stimulated, pain signal is transmitted to the brain
The inhibitor neurone switches off anything stimulating the transmission cell so signals that stimulate the inhibitor neurone will reduce pain transmission and pain sensation

Light touch and pressure turn on the inhibitor neurone
Noxious stimuli inhibit the inhibitor neurone

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22
Q

Why does neuropathic pain occur?

A

Abnormal processing of pain signal
Nervous system damage or dysfunction
e.g. nerve trauma, diabetic pain, fibromyalgia

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23
Q

What are the pathological mechanisms of neuropathic pain?

A

Increased receptor numbers
Abnormal sensitisation of nerves - peripheral or central
Chemical changes in dorsal horn
Loss of normal inhibitory modulation

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24
Q

What are the simple analgesics?

A

Paracetamol

NSAIDs

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25
Q

What are the opioids used?

A

Mild - codeine, dihydrocodeine

Strong - morphine, oxycodone, fentanyl

26
Q

What are other drugs used as analgesics?

A 
Tramadol
Anti-depressants e.g. amitriptyline
Anti-convulsants e.g. gabapentin
Ketamine
Local anaesthetics
Topical agents e.g. capsaicin
27
Q

What are the non-drug treatments for peripheral pathologies causing pain?

A

Rest
Ice
Compression
Elevation

28
Q

What are the drug treatments for peripheral pathologies causing pain?

A

NSAIDs

Local anaesthetics

29
Q

What are the non-drug treatments for spinal cord pathologies causing pain?

A

Acupuncture
Massage
TENS

30
Q

What are the drug treatments for spinal cord pathologies causing pain?

A 
Local anaesthetics
Spinal anaesthetics 
Epidural 
Opioids
Ketamine
31
Q

What are the non-drug treatments for brain pathologies causing pain?

A

Psychological treatment

32
Q

What are the drug treatments for brain pathologies causing pain?

A

Paracetamol (most effective when used in adjunct with other pain treatments)
Opioids
Amitriptyline
Clonidine

33
Q

What are the advantages of paracetamol?

A

Cheap, safe
Can be given orally, rectally or intravenously
Good for mild pain when used alone, and moderate-severe pain when used with other drugs

34
Q

What are the disadvantages of paracetamol?

A

Liver damage in overdose

35
Q

What are the commonly used NSAIDs?

A

Aspirin
Ibuprofen
Diclofenac

36
Q

What are the advantages of NSAIDs?

A

Cheap
Generally safe
Good for nociceptive pain (works best when given regularly with paracetamol)

37
Q

What are the disadvantages of paracetamol?

A

Gastrointestinal and renal side effects

Can aggravate asthma

38
Q

What are the advantages of codeine?

A

Cheap
Safe
Good for mild-moderate acute nociceptive pain
Works best when given regularly with paracetamol

39
Q

What are the disadvantages of codeine?

A

Constipation

Not good for chronic pain

40
Q

How does tramadol work?

A

Weak opioid effect plus inhibitor of serotonin and noradrenaline reuptake

41
Q

What are the advantages of tramadol?

A

Less respiratory depression
Can be used with opioids and simple analgesics
Not a controlled drug

42
Q

What are the disadvantages of tramadol?

A

Nausea

Vomiting

43
Q

What are the advantages of morphine?

A 
Cheap
Generally safe
Can be given orally, IV, IM or SC
Effective if given regularly 
Good for moderate-severe acute nociceptive pain e.g. post-op, chronic cancer pain
44
Q

What are the disadvantages of morphine?

A

Constipation
Respiratory depression in high dose
Misunderstanding about addiction
Controlled drug

45
Q

What is the safest way to administer morphine? Why?

A

Titration is generally the safest way to administer it as safety is dose-dependent

46
Q

How does amitriptyline work?

A

Tricyclic antidepressant, increases descending inhibitory signals

47
Q

What are the advantages of amitriptyline?

A

Cheap
Safe in low doses
Good for neuropathic pain
Also treats depression and poor sleep

48
Q

What are the disadvantages of amitriptyline?

A

Anti-cholinergic side effects

Many other side effects

49
Q

What are some anti-convulsant drugs?

A

Carbamazepine
Sodium valproate
Gabapentin

50
Q

How do anti-convulsants work?

A

Reduce abnormal firing of nerves (membrane stabilisers) - good for neuropathic pain

51
Q

What are the possible delivery routes for analgesia?

A 
Oral
Rectal 
Sublingual 
Subcutaneous 
Transdermal 
Intramuscular
Intravenous
52
Q

What are the possible delivery routes for local anaesthetics?

A 
Epidural 
Intrathecal
Wound catheters
Nerve plexus catheters 
Local infiltration of wounds
53
Q

What can be used for pain assessment?

A 
Verbal rating score
Numerical rating score
Visual analogue scale 
Smiling faces
Abbey pain scale
54
Q

What are the non-drug treatments that can be offered for pain?

A

Physical

  • rest, ice, compression, elevation (RICE)
  • surgery
  • acupuncture, massage, physiotherapy

Psychological

  • explanation
  • reassurance
  • counselling
55
Q

What type of pain is not responsive to the WHO pain ladder drugs?

A

Neuropathic

56
Q

How does the WHO pain ladder link assessment to prescribing for acute nociceptive pain?

A

Mild pain - start at bottom of ladder
Moderate pain - bottom of ladder plus middle rung
Severe pain - bottom of ladder plus top of ladder, miss out middle

As pain resolves, move down the ladder, passing the middle rung first, continue bottom rung drugs at all times

Lastly, stop NSAIDs then paracetamol

57
Q

What is the RAT approach to pain management?

A

Recognise

  • does the patient have pain
  • do other people know the patient has pain (family etc.)

Assess

  • severity (pain score)
  • type i.e. acute or chronic, cancer or non-cancer, nociceptive or neuropathic
  • other factors e.g. how it is affecting the patient

Treat

  • non-drug treatments
  • drug treatment
58
Q

What features should you look for when assessing a patient’s pain?

A

Neuropathic features

  • burning or shooting pain
  • phantom limb pain
  • pins and needles, numbness
59
Q

What other factors might affect a patient’s pain?

A

Physical factors e.g. other illnesses

Psychological and social factors e.g. anger, anxiety, depression, lack of social support

60
Q

What are the drug treatments advised on WHO pain ladder?

A

Mild - paracetamol (+/- NSAID)
Moderate - paracetamol + codeine/alternative (+/- NSAID)
Severe - paracetamol + morphine (+/- NSAID)

61
Q

What drugs (not on WHO pain ladder) should be used early in neuropathic pain treatment?

A

Amitriptyline
Gabapentin
Duloxetine

Anaesthetics (5 decks)

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