Pain Management Flashcards
What are the two types of pain?
Nociceptive and Neuropathic
________ pain responds best to opiates
Nociceptive
Neuropathic pain responds best to _______
Neurontin (GABA), Lyrica (GABA), Methadone (NMDA), Anti-seizure meds
Stimulation of nociception occurs when a ___________ (chemical, thermal, mechanical) of nociceptors releases neural chemicals that also stimulate other nociceptors, the signal is transmitted to the _______
noxious stimulus
spinal cord
Transmission of nociception occurs when an Action potential moves from site of stimulus to the _______________, then to the_________. From the dorsal horn, _________ are released.
dorsal horn of the spinal cord
CNS
neurotransmitters ex) glutamate, substance P, Calcitonin related peptide
Perception of pain is the ___________ of pain. Pain impulses are relayed through the _______ and _____________ transmit pain.
Conscious experience
thalamus
higher cortical structures
Modulation is the inhibition of impulses via the _____________
brain stem
Neuropathic Pain is sustained by abnormal processing of
sensory output
- Nerve damage, persistent stimulation, autonomic dysfunction
- Burning, tingling, shocks, hyperalgesia, allodynia
Monitoring Pain:
P: palliative and provocative factors Q: Quality R: Radiation S: Severity T: Temporal relations
All pain is measured _______
subjectively
-No lab tests to “measure” pain
-All subjective
- External and Internal signs and symptoms
¨-Grimacing, guarding, sweating, nausea -Hypertension, tachycardia, tachypnea
Opioid receptors are located throughout the
brain, spinal cord, GI tract
The four subtypes of opioid receptors include
Delta
Kappa
Mu
Nociceptive
The mu receptors include:
Mu1: analgesia, dependence
Mu2: side effects: respiratory depression, euphoria, reduced GI motility, dependence
Mu3: unknown
Mu receptors are found on the presynaptic and postsynaptic clefts. THis is where morphine can work by pumping in _____ and pumping out ________. ________ is key!
Calcium in
Potassium Out
Hyperpolarization is key
Most opiates are ______ and work on the ____ receptor
agonists
mu
_______ is a natural opiate that has a ________ nucleus
Morphine
pheanthrene
_______ forms of opioids have agonist action
levo-rotary
Opioids must exist in an _______ state to form strong bonds at the opioid receptor
ionized
Morphine is most effective when given ______ acute surgical stimulus
before
Morphines metabolites include
M-3 inactive
M-6 active, will build up if not peed out (CKD)
Morphine causes a ________ release
histamine
Fentanyl does not cause a ______ release
histamine
Morphine use should be cautiously used in
head injury patients
During cholecysectomy _____ may cause a opioid induced spasm of the sphincter of ______. Tx is ______.
morphine
oddi
glucagon 2mg IV
Morphine side effects include
PONV, biliary colic, delayed gastric emptying, constipation, difficulty voiding
Opioids and ________ may cause an exaggerated CNS depression and hyperpyrexia. (especially Demerol)
MAO Inhibitors
Dilaudid lacks any ___________ , which makes it a good candidate for patients with renal failure.
active metabolites
Opioids and benzo combinations demonstrate a marked _________ effect, in regards to hypnosis and depression of ventilation
synergistic
All opioids demonstrate a decrease in plasma concentration with inititation of _______, especially __________.
cardiopulmonary bypass
especially fentanyl
Sufentanil is a _____ potent form of fentanyl
more
Alfentanil is a _____ potent form of fentanyl
less
______ is useful in quick, single, brief stimulus procedures, such as intubation and cardioversion
alfentanil
Remifentanil requires __________
high post operative analgesic requirements
Demerol is a
synthetic opioid agonist at mu and kappa receptors
Decreased renal function can cause an accumulation of __________, the metabolite of Demerol, which can cause toxicities.
normeperidine
Half life of normeperidine is _____ hours, and ______ hours in patients with renal failure
15 hours
>35 hours
Normeperidine causes CNS ________, and CNS toxicity leads to ______ and _______ and _______.
stimulation
myoclonus and seizures
Demerol induced delirium: confusion and headache
Demerol should not be taken for more than
48 hours. (600 mg/day max)
When Demerol is given with SSRI’s it may cause
Serotonin Syndrome -Autonomic Instability HTN Hyperthermia Hyperreflexia No true reversal, stop demerol, tx symptoms
Advantages of agonist-antagonists include
drugs have a ceiling effect
analgesic effect with hopefully less respiratory effect
Opioid antagonists demonstrate a high affinity for
the opioid receptor and result in displacement of the opioid agonist from the mu receptor
Use of Naloxone results in
prompt reversal of opioid depression of ventilation and induced analgesia
Toradol is a _______
Black box warning:
NSAID
5 day max (GI Bleed)
IV APAP
Reduced Opioid Use
Questionable mechanism
