Peri-op & Anaesthesia : Pain Assessment and Management Flashcards
Assessment of pain in a surgical patient:
give some causes
- hunger
- anxiety
- hypovolemia
- delirium
- infection
- hemorrhage.
Post: op pt complains of pain….what are signifiant clincial features if found to be worried about
- mild pyrexia is common in the 48 hours after a procedure
Be worried if:
* hypotension and tachycardia -> signs of shock, which may be caused by a post-operative bleed.
Clincial Assessment of pain: What is a way of subjectively assessing a patients pain?
- Ask the patient to grade their pain on a scale of mild, moderate, or severe; this can be assessed regularly as part of the nursing observations.
- Scale of 1-10 used too - use in judging effect of interventions
Clincial Assessment of pain: What are objective features of pain?
- tachycardia
- tachypnoea
- hypertension
- sweating
- flushing
An unwillingness to mobilise or agitation may be present in those that are less able to communicate their pain
Practical tip: when assessing a pts pain where/what should you ask the to do ? to assess how their pain is affecting their functionality
Each patient should be assessed when:
* mobile
* when taking a deep breath
* when in bed
- (a pain-free patient in bed may well be in severe pain when they walk to the toilet).
What are consequences of poor pain control?›
WHO pain ladder: examples of simple analgesics
- non-opiod
- paracetamol and/or NSAIDs (e.g ibuprofen or diclofenac).
How do NSAIDs work?
- by inhibiting the synthesis of prostaglandins
- thereby reducing the potential inflammatory response causing the pain.
- These anti-inflammatory properties mean such analgesics are often used in musculoskeletal conditions
Side effects of NSAIDS
(I-GRAB)
- Interactions with other medications (such as Warfarin)
- **Gastric ulceration **(consider adding a PPI when prescribing NSAIDs long-term)
- **Renal impairment **(use NSAIDs sparingly in those with poor renal function)
- **Asthma sensitivity **(triggers 10% of individuals with asthma)
- Bleeding risk (due to their effect on platelet function)
How many steps are there on the WHO ladder- give some examples of drugs at each step
There are three steps:
- Step 1: Non-opioid medications e.g. Paracetamol and NSAIDs
- Step 2: Weak opioids e.g. codeine and tramadol
- Step 3: Strong opioids e.g. morphine, oxycodone, fentanyl and buprenorphine
What are some examples of adjuvant pain medication? Indication?
- Can combine with drugs in pain ladder OR use separately for neuropathic pain
- Amitriptyline: Tricyclic Antidepressant
- Duloxetine - SNRI antidepressant
- Gabapentin – Calcium Channel blocker used to manage epilepsy and neuropathic pain
- Pregabalin – Calcium Channel blocker used to manage epilepsy and neuropathic pain
- Capsaicin cream (topical)
What is the mechanism of action of opiates ?
They work by activating opioid receptors (MOP u, DOP, and KOP), which are distributed throughout the central nervous system.
How do NSAIDs increase the bleeding risk of a pt?
Reduce platelet function (they stop prostacyclin which usually promotes platelets)
If you are worried of a patient having NSAIDs for a long time due to side effects, what can you prescribe alongside it?
PPI
Why do NSAIDs cause renal impairment?
- NSAIDs inhibit prostaglandins.
- Usually, prostaglandin cause vasodilation of the afferent arteriole of the kidney to help maintain GFR.
- When a pt takes NSAIDS, they inhibit this vasodilation.
- SO you get poor renal perfusion - and kidney is more unable to respond to a reduced GFR
Side effects of opiates?
- Constipation
- nausea
- sedation
- confusion
- pruritus
- respiratory depression
- tolerance
- dependance
What to prescribe alongside opiates?
laxatives and anti-emetics
Opioid-induced PONV typically responds well to ondansetron (5-HT3 receptor antagonist) or cyclizine (H1 Histamine receptor antagonist)
Why to avoid prescribing weak and strong opiates in combination?
as they competitively inhibit the same receptor to varying degrees
If opioid analgesia is required in a patient with renal impairment… what to prescribe?
consider using oxycodone or fentanyl rather than morphine
How long does morphine take to work? think of different routes
- IV - 2-3 minutes
- IM - 15 mins
- oral - 20 mins
Local anaesthesia can be used as an adjunct following surgery to optimise pain relief. Give examples of local anaesthesia given intra-operatively to aid post-operative recovery.
- regional anaesthetic blocks (e.g. serratus anterior block for rib fractures)
- rectus sheath catheters (infusing local anaesthetic into the posterior rectus sheath)
- spinal or epidural anaesthesia
When is PCA ( Pt controlled analgesia) indicated?
for patients who require more intense or immediate analgesia and their requirements exceed the capacity of nursing staff to provide
PCA involves the use of intravenous pumps that provide a bolus dose of an analgesic when the patient presses a button. These are either started in theatre or on the wards, when the use of strong oral opiates is inadequate.
Advantages and disadvantages of Patient controlled analgesia?
Give pharmacological examples for treating neuropathic pain
- gabapentin
- amitriptyline
- pregabalin
- if these are not successful or not tolerated, specialist referral should be considered
Non-pharmacological treatment for neuropathic pain
- cognitive behaviour therapy
- transcutaneous electric nerve stimulation (TENS)
- capsaicin cream (typically for localised pain)
Treatment of acute pain in trauma
- with IV access
- wihtout IV access
- Traumatic brain injury
quesbook
- major trauma, IV morphine is first‑line analgesic.
- If no IV access, consider the intranasal diamorphine or ketamine.
- If suspected traumatic brain injury (TBI), the patient’s head should be positioned up at 30 degrees. This position helps to reduce intracranial pressure, and thus the risk of brain herniation.
Neuropathic drug: doses ( just to get an idea dont need to learn)
- gabapentin - 300 mg TID adjust according to response initially titrate up 300mg/day
- amitriptyline - start 10-25mg in evening then titrate up to 25-75 mg/day
- pregabalin - start 150 mg split into 2-3 doses titrate up if necessary
