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Coexisting Test 3 > Pain Assessment and Mgmt in Anesthesia > Flashcards

Pain Assessment and Mgmt in Anesthesia Flashcards

1
Q

Pain impact?

A
  • One of the top reasons for visitng primary care provide
  • rcosts of $40 billion /year
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2
Q

What is pain assessment difficult?

A
  • Difficult because pain is subjective and each patient’s experience of pain is unique
    • influenced by
      • unique physiology (peripheral and central nervous system cicuitry)
      • pathophy (not on einjusty is exactly the same
      • personality
      • previous life experience
      • cultural and religious backgorund
      • age
  • HCP who have difficulty believing the pt’s report or who do not understand science behind the variabilyt in response- may lead to under treatment of pain
  • The joint commission: pain assessment high priority
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3
Q

Elements of pain assessment

A
  • P= precipitating events
  • Q= quality
  • R= region/radiation
  • S= severity
  • T= temporal relationship/timing
  • A= associated symptoms
    • functional impairment
    • previous treamtnet
    • inflammation
  • pain goals
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4
Q

History to gather from patient regarding pain?

A
  • Existense of pain
  • previous injuries
  • adjunctive therapies use?
    • acupuncture. tens, injection, SCS?
  • Coexisting psychological diseases/physical diseases
    • assess other factors which may influence pain hx (social, cultural and spiritual factors)
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5
Q

What are behavioral pain scales?

A
  • Provide a means for consistent evalutation of pain in non-verbal patients population
  • allows patients who cannot self-report pain a method for pain assessment
    • ped pt, neonates, babies
    • pt with congitive impairement
    • critically ill patients
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6
Q

What is Payen Behavioral Pain scales?

A
  • Developed for critically ill, intubated ICU pt
  • Has reliability and validiity and correlates to NPI rating s(even in pt on sedation)
  • uses 0-12 pain rating scale. looks at:
    • facial expression
    • upper limbs
    • compliance with ventilation
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7
Q

What is the FLACC scale?

A

2 months-7 yo

  • Face
  • Legs
  • Activity
  • Cry
  • Consolability
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8
Q

WHat ist he CRIES pain scale?

A
  • 0-6 months old
  • Crying
  • Requires O2 for sao2<95%
  • increased VS (BP and HR >20% above baseline)
  • expression
  • sleepless
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9
Q

Methods to relieve pain?

A
  • Duration of pain relief
  • pt history (what’s worked before)
  • goals of mgmt
  • acute vs chronic pain?
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10
Q

What ar enonpharmacologic modalities for pain relief?

A
  • Acupuncture
  • positioning
  • immobilization
  • heat/cold
  • massage
  • relaxation behaviors
  • PT/rolling
  • TENS
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11
Q

Types of meds used?

A
  • Opioids
  • non-steroidals
  • LA
  • antidepressant
  • antconvulsants
  • corticosteroids
  • ketamine
  • alpha 2 adrenergic agonists
  • prescription or OTC
  • Continous or PRn
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12
Q

Physical exam for pain?

A
  • General physical exam
  • exam affected area
  • neuro exam
  • MS system exam (ROM, muscle wasting)
  • skin (redness, wounds, edema, temperature changes)
  • assessment of psychological factors: unkept personal hygiene
  • VS
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13
Q

What are some specific diagnostic studies for pain?

A
  • Quantitative sensory testin g(QST) for pain thresholds and pain tolerance
  • “poor man sensory testing” cold water in a glass tube (for cold allodynia), one glass tube with warm water (heat allodynia), cotton wool and artist’s brush for dynamic mechanical allodynia, blunt needle for hyperalgesia
  • diagnostic nerve blocks
  • pharmacologic tests
  • conventional radiography, computerized tomographjy, MRI, US imaging
  • EMG electromyogrpahy nerve test- see how muscle react along nerve
  • NCV Nerve conduction velocity test
  • Bone scans
  • blood tests: looking for co-conditions IE RA, CHronic inflammation
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14
Q

What is acute pain?

A
  • Caused by novious stimulation due to injury, trauma an acute disease process, or abnormal funciton of muscle or viscera
  • almost always nociceptive pain
  • results in a neuroendocrine response

Acute Pain:

  • Tissue damage: “Protective response”
  • Peripheral nociceptive neuron stimulated by intense noxious stimuli – sends signal to CNS
  • CNS: brain and spinal cord process the afferent input and this results in sensation of pain
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15
Q

What do we do pain management?

A
  • Control of postop pain allows for
    • reductionin stress resposne
    • shorter times to extubation, shorter ICU stay
    • improved respiratory function
    • earlier return of bowel function
    • early mobilization, decreased risk for DVT
      • increased plt aggregation
    • early discharge
    • reduction in sensitization, neuroplasticity, wind up phenonmenon, and transition to chronic pain
      *
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16
Q

Methods to relieve pain intraop?

A
  • Preemptive anaglesia- best postoperative pain mgmt begins preoperatively
  • Opioids and NSAIDs in GA
  • Regional blocks
  • Local infiltration at surgical site could be used to contorl acute pain (hernia repair, tonsilar bed)
  • Regional anesthesia- pt do better overall
    • less morbiidty
    • less CV failure
    • less infection
    • less urinary cortisol (handling stress of sx well)
      • >L1 significant effect on the neuroendocrine response to surgery
    • lower overall post op complication rate
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17
Q

PCA advantages?

A
  • Cost effective, higher degree of pt satisfaction.
  • total drug consumption is less than IM
  • harder to over medicate self
  • Features: reservoir
    • infusion controller
    • pushbutton to be operated by patient only
    • delivers a specific dose
    • lockout (minimal intervals between dosese)
    • basal infusion
  • Prevents the “pain no pain cycle”
    • put pt on drip, manage pain consistently and limit SNS response
  • findings
    • ​patients consume less drug
    • male use more than female
    • shortens hospital stays
18
Q

Prescription considerations and side effects of PCA?

A
  • Prescription- relieve the pain before starting PCE
    • too little each hit discourages the patient, too
    • if demand too much: causes adverse reactions that also discourage the patient (distrust)
  • Side effects
    • onset of respriatory depression parallels anaglesia nd is more rapid with lipophilic opioids
    • nausea, vomiting , constipation, pruritys
    • nearly all overdoses have been to erros in the programming of the parameters
19
Q

Multimodal approach?

A
  • Principle: contorl postop pain and attenuate the periop stress resposnes through the use of regional anesthetic techniques and a combo of analgesic agents
  • an extension of clinical pathways into effective postop rehab pathways
20
Q

What is ERAS protocol?

A
  • Early recoveyr after srugery
    • prehospital- pain management plan (high carb shake/drink)
    • preop- initiation of multimodal meds and regional block placement
    • intraop- short acting, opioid sparing meds, multimodal meds, regional anesthesia/analgesia
    • postop- regional anesthesia, non-opioid analgesics/NSAIDS
21
Q

What are peripheral nerve blocks? Benefits?

A
  • Single injection or continous unfusion of local anesthetic applied at peripheral nerve site
    • can add opioid and/or steroids to mixture
  • can be used for intraop aneshesia, or as an adjunct to postop analgesia
  • limits the path of nociceptiv eimpulses
  • superior anaglesia
  • few side effects
  • can have analgesia for up to 24 horus after single injections
22
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 PNB
  • Side efects: nausea, fever, vomiting
  • Recommedned dose of exparel for local infiltration in adults is up to a max dose of 266 (20 mL)
  • Recommended dose of exparel for interscalene brachial plexus nerve block in adults is 133 mg (10mL)
23
Q

Benefits/disadvantages ot neuraxial analgesia?

A
  • Benefits
    • provide superior analgesia compared with systemic opioids
    • reduced stress response
    • facilitates return of GI motility
    • decrease incidenc eof pulmonary complications
    • decreased incidence of coag-related adverse events
  • Disadvantage
    • cannot be used with anticoags or infection
24
Q

Single dose neuraxial opioids?

A
  • Sole or adjuvant analgesia
  • intrathecal (spinal) or epidural
  • opioid selection depends on degree of lipophilicity vs hydrophilicity
25
Q

Adjunct treatment for acute pain mgmt

A
  • ICE
  • Surgical
    • local infiltration
    • intra-articular analgesia (in joint)
    • pain pumps (on Q)
  • TENS
  • Acupunture
  • psychological approaches
    • hypnosis
    • distraction, relaxation, imagery, music
26
Q

Subpopulations with sepcial considerations?

A
  • Ambulatory
  • Elderly
  • pediatric
  • obesity
  • OSA
  • opioid tolerant pt
27
Q

What meds are used in chronic pain managemnet?

A
  • NSAIDS/acetaminophen
  • opioids
  • tramadol
  • antidepressant drugs
  • anticonvulsant drugs
  • corticosteroids
  • muscle relaxants
  • others
28
Q

Tricyclic Antidepressants use in chronic pain?

A
  • Elevate mood, help with sleep - lots of insomnia with pain d/t impact on reticular formation
  • Block the reuptake of serotonin and norepinephrine at the neuronal membrane
  • potentiate narcotic analgesic
  • use smaller doses than indicated for depression
  • must monitor drug levels
  • anticholinergic s/e
    • dry mouth, sedation, fatigue, orthostatic hypotension, arrhythmia
  • examples: amitriptyline, doxepin
29
Q

Anticonvulsant drugs used for chronic pain?

A
  • Alter the ion channels along the nerve fiber, thereby blocking pain stimuli by blocking the AP
  • Used for tx neuropathi pain resulting from lesions to the peripheral (DM, herpes) or CNS (stroke)
  • examples: carbamazepine, phenytoin, gabapentin, and clonazepam
  • S/E: Sedation, dizziness, ataxia
30
Q

Corticosteroid use in chronic pain?

A
  • Reduce inflmmation and swelling, reducing inflammatory mediates (prevent release of prostaglandins)
  • exampls: dexamethasone
31
Q

Adjuvants to pain meds in chronic pain?

A
  • Muscle relaxants
    • reduction of muscls spasms
    • analgesia
      • unknown mechanism
      • examples: cyclobenzaprine, skelaxin, baclofen, carisoprodol
  • NMDA receptor antagonist
    • ketamine
  • Alpha- 2 adrenergic agonists
    • work pre and postsynaptically within the dorsal horn to inhibit neuron firing
    • also works centrally by inhibiting the release of substance p (precedex)
    • examples: clonidine, dexmedetomidine (precedex)
32
Q

What are nerve blocks?

A
  • Nerve blocks
    • Trigger point injection
    • epidural steroid injections
  • provide high dose of steroid at the level of pathology to reduce swelling of the nerve root, block Cfibers, stabilize nerve membranes and decrease ectopic discharges from inflamed tissue
  • some studies have foudn that injecting NS is just as effective as steroids
  • may also decrease response from steroids overtime
  • LEVEL 2 PAIN TREATMENT
33
Q

What are neurolytic blocks?

A
  • Permanent destrution of nerve
  • most common neurolytic blocks are:
    • lumbar sympathetic chain
    • celiac plexus
    • hypogastric plexus
    • ganglion impar (retroperitoneal plexus)
    • intercostal blocks
  • alcohol and phenol combo
  • LEVEL 2 PAIN TREATMENT
34
Q

What are spinal cord stimulators?

A
  • Stimulating electrode in the epdiural space surrounding the entry level of the noxious input into the spinal cord
  • activation of descending modulating system and therefore inhibits sympathetic outflow
  • used with phantom limb pain, ischemic pain, PVD, spinal cord lesions
  • LEVEL 3 PAIN TREATMENT
35
Q

What are TENS units?

A
  • Transcutaneous electrical nerve stimulation
  • hyperstimulation of the nervous system drowns out the pain
  • LEVEL 1 PAIN TREATMENT
36
Q

Radiofrequency ablation?

A
  • Radiofrequency ablation (RFA) is a procedure where dysfuncitonal tissue is ablated using microwave energy
  • cryoneurolysis with cold-freeze
    • used with trigeminal neuralgia
  • LEVEL 3 PAIN TREATMENT
37
Q

Cancer pain management?

A
  • Studies ahve shown that 70-90% of cancer pain can be effectively treated with pharmacotherapy alone
  • survey suggests that 40-50% of patient experience cancer-related pain do not receive effective analgesia
  • pain caused by cancer
    • tumor invasion of bone is most common cause of cancer pain
    • tumor compression of peripheral nerves is #2 cause
  • pain due to treatment
  • physical effects- worse due to loss of sleep, appetite, nause and vomiting
  • psychological- heightened anxiety, feeling of loss, low self esteem, changes in life goals, disfigurement
38
Q

Assessment of pain in cancer pain?

A
  • Treat disease
  • assessment of pain
    • onset and uration of pain
    • aggravating and relieving factors
    • past treatment
    • impact of pain in overall suffering
  • physical and neurologic/psychological exam
  • multi-disciplinary team
39
Q

WHO analgesic ladder? (FOR TERMINALLY ILL PT)

A
  • Step one- mild pain
    • non opioid analgesics
  • Step two- mild- mod pain
    • weak opioids
    • oral route
  • step three- moderate- severe pain
    • parenteral potent opioids
  • Step 4- intractable pain
    • invasive therapy
40
Q

Inadequate pain releif?

A
  • Related to:
    • poor pain assessment
    • poor pain treatment plans
    • lack of knowledge of analgesics available
    • fear of addicton
    • fear of respiratory dpression
    • s/e of pain treatment

Coexisting Test 3 (8 decks)

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