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
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
- influenced by
- 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
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
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)
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
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
7
Q
What is the FLACC scale?
A
2 months-7 yo
- Face
- Legs
- Activity
- Cry
- Consolability
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
9
Q
Methods to relieve pain?
A
- Duration of pain relief
- pt history (what’s worked before)
- goals of mgmt
- acute vs chronic pain?
10
Q
What ar enonpharmacologic modalities for pain relief?
A
- Acupuncture
- positioning
- immobilization
- heat/cold
- massage
- relaxation behaviors
- PT/rolling
- TENS
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
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
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
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
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
*
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
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
Adjunct treatment for acute pain mgmt
* ICE
* Surgical
* local infiltration
* intra-articular analgesia (in joint)
* pain pumps (on Q)
* TENS
* Acupunture
* psychological approaches
* hypnosis
* distraction, relaxation, imagery, music
26
Subpopulations with sepcial considerations?
* Ambulatory
* Elderly
* pediatric
* obesity
* OSA
* opioid tolerant pt
27
What meds are used in chronic pain managemnet?
* NSAIDS/acetaminophen
* opioids
* tramadol
* antidepressant drugs
* anticonvulsant drugs
* corticosteroids
* muscle relaxants
* others
28
Tricyclic Antidepressants use in chronic pain?
* 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
Anticonvulsant drugs used for chronic pain?
* 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
Corticosteroid use in chronic pain?
* Reduce inflmmation and swelling, reducing inflammatory mediates (prevent release of prostaglandins)
* exampls: dexamethasone
31
Adjuvants to pain meds in chronic pain?
* 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
What are nerve blocks?
* 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
What are neurolytic blocks?
* 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
What are spinal cord stimulators?
* 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
What are TENS units?
* Transcutaneous electrical nerve stimulation
* hyperstimulation of the nervous system drowns out the pain
* LEVEL 1 PAIN TREATMENT
36
Radiofrequency ablation?
* 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
Cancer pain management?
* 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
Assessment of pain in cancer pain?
* 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
WHO analgesic ladder? (FOR TERMINALLY ILL PT)
* 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
Inadequate pain releif?
* 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
