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Exam 2 (and 3) - CNS, mental health, renal and liver > Pain clinical > Flashcards

Pain clinical Flashcards

1
Q

How can you measure pain?

A

Pain scales:
- Visual scale (VAS)- pointing
- Numerical rating scale (NRS)- Rate from 0-10
- Use facial expressions charts (good in younger patients)

Examinations:
colour changes
swelling
asymmetry
tenderness
range of movement
weakness

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2
Q

Compare acute and chronic pain.

A

Acute:
- sudden
- Treated by resolving cause
- Usually due to trauma/injury/surgery
- Lasts <6months
- OTC or WHO pain ladder

Chronic:
- Gradual
- Usually result of condition difficulty to treat
- >6months
- Hard to find lasting releif
- Often movement and physio helps (in acute, usually just rest)
- Can have social and psychological factors
- 7 x more likely to leave job

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3
Q

What are the different types of pain?

A
  • Nociceptive pain
  • Neuropathic pain
  • Nociplastic pain
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4
Q

What is nociceptive pain?

A

This is the ability to detect a painful stimulus via nociceptors e.g. reflex when touching something hot
- prevents tissue damage and occurs in response to tissue damage

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5
Q

What is neuropathic pain?

A

Malfunction in the nervous system or damage to nerves e.g. diabetic neuropathy
- usually described as a burning electrical shock sensation/shooting pain

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6
Q

What is nociplastic pain?

A

Altered nociceptionin body in the absence of nerve or tissue damage.
- Causes widespread intense pain e.g. fibromyalgia
- Management is exercise, physiological non-pharmacological management e.g. physio, accupuncture

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7
Q

Describe the stages of the WHO pain ladder

A
  1. Non-opiod
    e.g.
    Paracetamol ( check weight, liver function)
    NSAIDs- consider renal function,GI- co-prescibe gastric protection e.g. PPI
    Topical preparations e.g. NSAID gel, lidocaine, capsaicin
  2. If pain persists or increases:
    Mild opioid- as an alternative or addition to the above
    e.g.
    Codeine
    Dihydrocodeine
    Tramadol
    - have limited potency at mu opioid receptors
  3. if pain persists or increases
    Strong opioids for moderate/severe pain
    e.g.
    Morphine
    Diamorphine
    Oxycodone
    - These have strong potency at the mu receptor
    NOTE- these should REPLACE mild opioids and not added to them

And Adjuvants throughout:
- Anti-epileptics- mainly for neuropathic pain e.g. Gabapentin, Pregablin, Carbamazepine (Carbamazepine I used in trigeminal myalgia)
- Anti-depressants- mainly for neuropathic pain e.g. Amitriptyline, SSRIs, Trycyclics
- Dexamethasone- bone pain in palliative care or oncology
- Non-pharmaceutical (ideal): physio, exercise, psychological therapies, acupuncture

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8
Q

What are examples of adjuvants that may be used alongside the WHO pain ladder?

A
  • Anti-epileptics- mainly for neuropathic pain e.g. Gabapentin, Pregablin, Carbamazepine (Carbamazepine I used in trigeminal myalgia)
  • Anti-depressants- mainly for neuropathic pain e.g. Amitriptyline, SSRIs, Trycyclics
  • Dexamethasone- bone pain in palliative care or oncology
  • Non-pharmaceutical (ideal): physio, exercise, psychological therapies, acupuncture
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9
Q

What drugs have limited efficacy in long term pain?

A

Opioids- if don’t achieve useful pain relief in 2-4 weeks, unlikely to gain long term benefit.

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10
Q

What types of pain are opioids not indicated for?

A

Widespread
back pain
headaches

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11
Q

What is the risk concerning metabolism of weak opioids?

A

Weak opioids have a low affinity for mu-receptors and they are partially metabolised in the liver via CYP 2D6 ( a cyp450) to morphine (codeine-> morphine).
- There is an inter patient variability on this metabolism dependent on gene expression- metabolism is impacted by expression of this CYP enzyme.
- Some patients are ‘Super metabolised’ meaning they are good metabolisers. Note if breastfeeding, super-metabolisers are more likely to pass through to baby as mum is metabolising more codeine to morphine
- = unpredictable variation in efficacy and toxicity

Also risks:
- In impaired renal function- opioids are highly renal excreted
- Monitor dependence/addiction

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12
Q

What are possible side effects of opioids?

A
  • N+V
  • Constipation- often co-prescribe laxatives- a stimulant and osmotic (e.g. Senna and Laxido)- NOT Bulk laxatives
  • drowsiness
  • sedation
  • respiratory depression
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13
Q

What laxatives are often co-prescribed with opioids?

A

Constipation- often co-prescribe laxatives- a stimulant and osmotic (e.g. Senna and Laxido)- NOT Bulk laxatives

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14
Q

What are the signs of opioid overdose/toxicity?

A
  • Stimulation of the PNS:
    pinpoint pupils- less/no response to light shined to the eye
  • Hypoxia- lox O2- blue lips, pale skin
  • Respiratory depression- activation of mu-opioid receptors un brainstem (pre-Bötzinger complex) that help coordinate the respiratory rhythm, opioids binding = decreases ability to coordinate rhythm:
    Resp rate < 8bpm
    O2 saturation <85%
    tachycardia
    High sedation score
    BP can be high or low
    unconsciousness, raspy breath, snoring, shallow or slow breathing
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15
Q

How do you manage lower back pain?

A

1.6 million adults in the uk have back pain for >3 months

Non-pharmacological:
- Exercise programmes and manual therapies e.g. massages
- Psychological therapies e.g. CBT
- return to work programmes

Pharmacological;
- NSAIDs- caution in at-risk groups e.g. GI issues, renal, age. add PPI
- Weak opioid if NSAID Cid/ineffective
- Not paracetamol alone0 efficacy is ineffective

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16
Q

How do you reverse opioid-induced respiratory depression/ opioid toxicity?

A

Opioid-induced respiratory depression is potentially fatal but may be reversed by the opioid receptor antagonist naloxone

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17
Q

What is and how do you manage sciatica?

A

Sciatica is shooting pain down the leg.
- Is leg pain secondary to lumbosacral nerve root pathology- due to compression or irritation of the sciatic nerve in the Lower spine.

Non-pharmacological: (main)
- Exercise programmes and manual therapies e.g. massages
- Psychological therapies e.g. CBT
- return to work programmes

Pharmacological:
- No gabapentinoids, anti-epileptics benzodiazepines (If already prescribed, discuss withdrawal)
- NSAIDs- have limited benefit
- No opioids for chronic sciatica
- epidural injections- corticosteroids and local anaesthetic
- spinal decompression surgery
- paracetamol is unlikely to help

18
Q

What are the management options for osteoarthritis?

A

Osteoarthritis is the breakdown of cartilage in joints- pain, tenderness, swelling, grating

Treatments
- Exercise- physio
- Weight loss- decreases the pressure on the joints
- Manual therapies
- Topical NSAID
- May consider paracetamol or weak opioids
- intra-articular corticosteroid injections
- joint replacements

19
Q

What drugs may be used for neuropathic pain?

A

4 drugs used:
- Amitriptyline
- Duloxetine
- Gabapentin
- Pregablin

Try 1, if not effective, try another
- Consider tramadol only if acute rescue therapy is needed

Also,
- Capsaicin cream for localised pain (made from chilli peppers- may cause burning or stinging on application- this is normal)
- Carbamazepine- used in trigeminal neuralgia

20
Q

Do you follow the WHO ladder in palliative care?

A

Adapted WHO ladders- often skip to strong opioids
Requires individualised and holistic care

21
Q

Discuss pain relief in palliative care.

A

Aim is to increase the quality of life for patients and their families.
- Give 24 hour pain relief- with simple analgesia or string opioid
- No max opioid dose
- Begin with anticipatory PRN injection: The choice depends on the patients renal function
Morphine SC 2.5-5mg 2-4 hourly (eGFR >60)
Oxycodone SC 1.25-2.5mg 2-4 hourly (30-60)
Alfentanil SC 125-250 mcd 2-4 hourly (<30)
If the patient needs ~ 3 of these injections in a 24 hour period, they should be switched to a syringe driver.
- if worried about toxicity e.g. following a dose increase, give Naloxone.

Syringe driver:
- 24 hr continuous sc infusion
- need a diluent for volume e.g. NaCl, water for injection
- can also use to deliver other drugs e.g. Buscopan, drugs for nausea/agitation

22
Q

What factors are considered when choosing an analgesic for post-op pain?

A

Patient factors:
- Co-morbidities
- Renal/liver clearance abilities
- Age- sedation, falls, dizziness risk
- Frailty
- Allergies
Patient discussion:
- Risks and benefits
- Duration anf fischarge pains
- consider any pain-relief they’re on pre-op

23
Q

When can NSAIDs not be used for post-op pain?

A

if patient has has a hip or pelvis sugeries- they affect the bone recovery

24
Q

When are oral opioids used or not used in post-op pain?

A
  • Used in moderate-severe pain e.g. in large or more complex procedure e.g. gastro or orthopaedic operation
  • Don’t use if have PCA or opiate epidural infusion- only 1 route at a time. However, patients on Buprenorphine to fentanyl patches prior to admission are often continued alongside PO
  • they aid recover- allow patients to mobilise, return of cough reflex- getting patients moving asap increases prognosis
25
Q

When is Gabapentin used post-op?

A

If suspected neuropathic post-op pain

26
Q

What is PCA?

A

Patient controlled analgesia- they control when and how much pain relief they receive by pressing a button.
- IV
- Usually contains opioids or opiates

27
Q

How is PCA given?

A

Normally, a patients given a loading dose in recovery and then PCA
e.g. 100mg Morphine in 100mL NaCl 0.9%
- The drug given is usually morphine or fentanyl. This is decided based on renal function- if this function is decreased = fentanyl
- When patient presses button, 1mg is given
- the device is then locked for 5mins to stop patient keep pressing
- these smaller and more frequent doses via PCA reduce peaks and troughs caused by bolus doses.

28
Q

What are the advantages and disadvantages of PCAs?

A

Advantages:
+ Faster pain alleviation
+ decrease distress in waiting for nursing staff
+ less time consuming for nurse
+ easy to titrate according to response/need
+ patient has ownership and independence

Disadvantages:
- Patient may not be responsive or dextrous enough to use
- May lack understanding/be scared to use
- Liable to abuse- but there is a lockout time
- S/Es- N+V, decreased BP, drowsy, constipation (all same of oral though)

29
Q

What monitoring is required for post-op patients (patients on PCA)?

A

Monitor hourly for the first 8 hours
Then 2 hourly from 8-24 hours
The 4 hourly from 48 hours onwards
- monitor BP, Pulse, RR, sedation, Pain score, N+V

30
Q

How do you manage the side effects of PCA opioid analgesia?

A
  • N+V: Cyclizine or ondansetron
  • Pruritus- Chlorphenamine 4mg TDS
  • Respiratory deprssion <8:
    Oxygen and monitor sats
    Stop PCA
    Consider Naloxone 200-500mcg (has short half-life so repeated doses may be needed)- reverses opioid toxicity
  • Excess sedation:
    remove PCA
    O2 sats, pain, sedation monitoring
    prescribe adequate non-opioid analgesia
31
Q

What is an epidural?

A

The administration of analgesics into the epidural space- injected close to the spinal cord and nerves for a powerful analgesic effect.

32
Q

How are epidurals administrated and how do they then work?

A
  • Local anaesthetic is given to numb the area and then hollow needle is inserted into the epidural space and a catheter line inserted to use for infusion.
  • Does NOT induce paralysis
  • The epidural bathes the nerve fibres to block the transmission of sensory impulses from the afferent nerve to the spinal nerve and then the efferent nerve.
  • Leads to decreased nociceptive transmission
  • It blocks tree groups of vertebra- blocks on dermatome (areas that correspond to areas in the spine). Post-op it is usually the low thoracic and high lumbar dermatomes that are targeted.
33
Q

What is the target of an epidural block?

A

Block between pain and deep pressure fibre- stop pain but can still feel pressure.

34
Q

What is the contents of an epidural bag?

A

OPIOID:
E.g. Morphine
Diffuses into the CSF and inhibits pain transmission in spinal cord by blocking spinal opioid receptors

ANAESTHETIC:
E.g. Bupivicaine
Diffuses across the myeline sheath into the nerve cell and inhibits sodium channels, preventing depolarisation of membrane and therefore action potential and signal transmission.

35
Q

What drugs are often preemptively prescribed alongside an epidural in case they are needed?

A
  • Cyclizine - 6hourly PRN for N+V
  • Ephedrine up to 30mg - for hypotension- if BP is less than 100mm/Hg and unresponsive to fluid
  • Naloxone- 200mcg if respiratory rate is less than 8bpm or patient is unrousable (is an opioid reverser)
36
Q

What are the advantages and disadvantages of epidurals?

A

+ High quality pain relief & at smaller opioid doses than systemic
+ Reduced incident of DVT
- Risk of permanent spinal damage
+ Less sedation
- Accidental IV administration
+ Post-op cover over 24 hours
+ improved pulmonary function
+ Improved cardiac morbidity and sepsis
+ Faster re-establishement of oral intake

  • Accidental injection into spinal cord can cause total spinal block
  • risk pf permanent spine damage
  • Risk of epidural bleed/haematoma
  • Migration of drug can lead to respiratory paralysis
  • Infection risk
  • Accidental IV administration
  • Dural puncture headache
37
Q

What are the possible side effects of epidurals?

A
  • Respiratory arrest- if epidural migrates to c3-c5, it blocks the phrenic nerves
  • Respiratory depression
  • dural headache- can be late onset e.g. within 72 hours- when epidural is given a small hole is made in the dura (contains csf)- If too much fluid leaks out through the hole in the dura, the pressure in the rest of the fluid around the brain is reduced. This causes the typical headache. If you sit up, the pressure around your brain is reduced even more. This lowered pressure makes the headache worse
  • N+V
  • Hypotension
  • Hypothermia
  • decreased cardiac output if T1-T4 affected
  • Reflex tachycardia
  • Overdose or give IV mistakenly – depression of myocardial excitability
  • Reduced hepatic/renal perfusion
  • Tinnitus, headache, N&V, Pruritis, Sedation
38
Q

What is the rescue therapy for the accidental administration of Bupivicaine via IV instead of epidural?

A
  • Accidental IV administration of Bupivicaine (instead of by epidural): Intralipidm 30%- reverses the cardia arrest and toxicity risk
39
Q

What is the rescue therapy for the the adverse effect of opioid toxicity following an epidural?

A

Naloxone 100-400mcg- may give repeated doses depending on response

40
Q

What is the rescue therapy for the the adverse effect of severe hypotension following an epidural?

A

Ephedrine

41
Q

What is the rescue therapy for the the adverse effect of a dural puncture headache following an epidural?

A

A blood patch- patient is injected with their own blood that seals the hole to stop leakage of CSF.

42
Q

What are the contraindications for epidurals?

A
  • Patient refusal
  • Infection at the proposed site of injection
  • Clotting abnormalities
  • Severe respiratory impairment
  • Uncorrected hypovolaemia (low blood volume)
  • Raised intracranial pressure
  • Neurological disease
  • Difficult anatomy – injury or deformity
  • Tattoos (yes/no)- controversial- risk of ink bleeding into the epidural space and causing ink toxicity. some anaesthetists say if the tattoo has healed, it is ok.

Exam 2 (and 3) - CNS, mental health, renal and liver (23 decks)

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