Post-op pain management Flashcards
General anesthesia
a reversable state of unconsciousness produced by drugs with sufficient depression of reflexes to allow surgical procedure to be performed
Goals of general anesthesia
- unconsciousness
- analgesia
- muscle relaxation
- depression of autonomic endocrine reflexes
(want to reduce the risk of this pain becoming chronic pain)
Phases of medication administeration
- preoperative
GOAL: prepare pt for surgery - optimize medical status, decrease surgical complications
Antianxiety, PPIs, pre-emptive analgesia, depress reflex activity - Introp
- induction (pt awake to unconscious) - propofol, midazolam
- maintenance of induction
GOAL: unconscious, muscle relax, analgesia - reversal
GOAL: return pr to conscious state with breathing while maintaining analgesia - recovery
GOAL: airway maintenance and ventalation, cardio stability, normothermia, consciousness, freedom from N+V, analgesia
LOTTAARP
Location
Onset
Timing
Type
Associated symptoms
Alleviating factors
Radiation
Precipitating event
Regional Anesthesia (neuraxial blocks)
Spinal and epidural
Spinal Anesthesia location
Injection of local anesthetic/opioids into the CSF of the subarachnoid space (between arachnoid and pia mater)
below L2
nerves are in CSF
spinal anes insertion
spinal cord ends at L1L2, a fine gauge needle is inserted at L2L3 or lower to avoid spinal cord
A single done of opioid and local anesthetic is injected causing an autonomic, sensory and motor blockade (can cause rapid toxicity)
What is the pts experience of spinal anes?
vasodilation/hypotension (autonomic block)
no pain (sensory block)
unable to move (motor block)
What to monitor for spinal anes
VS
motor and sensory block
urinary output/bladder distention
headache assessment
Epidural anesthesia location
a catheter is placed in the epidural space located outside the 3 membranes covering the spinal cord between the dura mater and the ligamentum flavum - filled with BV, lymphatic vessels, spinal nerve roots
binds to the nerve roots as they enter and exit the spinal cord (local anes.)
allows for better titration and control of the extent of sensory and motor blockade
may be sole anesthetic for surgery or a catheter may be placed to allow intra and post op analgesia using lower doses of epidural local anes. and opioid
catheter may be in thoracic (less complications) or spine
Epidural anes monitoring
urinary output/bladder distention
assess for pruritis, N/V
Pain assessment
assessment for catheter migration (numbness, tingling)
assess pf drsg and insertion site
headache assessment
Function decline order
Sympathetic (vasomotor): dilation of skin and blood vessels
Temperature discrimination
pain recognition
Touch and pressure sense
motor function
as the anesthetic wears off, the above nerve function will return in reverse order will have motor function, but still pain management
Chronic Postoperative Pain (CPOP) risk factors
preop pain
psychological factor
female and younger age
open surgical approach
length of surgery is over 3 hours
intensity of pain in immediate post op period
What are the harmful effects of under treated acute pain
Cardio: tachycardia, increased heart O2 consumption, DVT, MI
Resp: decreased lung volumes, atelectasis, decreased cough, sputum retention, hypoxemia
GI/GU: decreased gastric and bowel motility, urinary retention
Metabolic: increased metabolic hormones (cortisol), decreased anabolic hormones (insulin)
Psychological: anxiety, dear, sleeplessness
Do you have to worry about stopping infusions with epidurals?
no, air bubbles are not a danger and it is ok to stop infusions for hours and restart without worry about catheter occluding
What to note about spinal nerves with regional anes?
each spinal cord segment is referred to as a level and when blocked with local anesthetic, it results in decreased sensory (dermatome) and motor (myotome) function
Spinal nerves carry 3 types of fibers (motor, sensory, sympathetic)
The do nots of continuous epidural anesthesia
sensation should never be at or above nipple line (T4) - lumbar
should be a band of decreased sensation in the thorax with normal sensation in the lower abdomen. The inner aspect of the inner arm or 5th finger should never be affected. these are indicators of high block - thoracic
Motor nerve assessment
used to monitor the level of motor block in a patient receiving CEA
There should be no upper or lower extremity weakness when a thoracic epidural is used
Notes about motor nerves
motor fibers are most resistant to local anesthetic because of their thickness
myotome is a group of muscles innervated by a single spinal cord segment (can be used to assess the level of motor block)
Indications for epidural analgesia
pain relief after surgery or trauma to the chest, abdo, pelvis or lower limbs where epidural anesthesia has been used primarily or with supplemental general anesthesia
epidurals help reduce the risk of post op complications
where acute pain is anticipated for 2-5 days
Contraindications for epidural analgesia
bleeding abnormalities or when pts are receiving anticoagulant therapy (could bleed into the spine)
local skin infection or systemic sepsis
abnormal anatomy
Allergy to opioid or local anesthetic being used
increased ICP
pt with fluctuating neurological status
pt refusal to consent to the procedure
What is typically used with epidural anesthesia?
bupivacaine and ropivacaine (local)
fentanyl
hydromorphone
Epidural assessments
resp rate
sedation
VS
Motor block
Sensory block
always know where epidural is inserted
Sedation scale
1=awake and alert
2=slightly drowsy, easily roused
3=Frequently drowsy, arousable, drifts off to sleep during conversation UNACCEPTABLE
4=somnolent, minimal or no response to verbal or physical stimulation UNACCEPTABLE
S=sleep, easy to rouse
Sensory block dermatome
dermatome is an area of skin that is mainly supplied by single spinal nerve (skin to brain)
apply ice to an unaffected area (cheek) so pt knows what it feels like
1. start at the upper anterior chest and work downwards until the pt can not feel it as cold (top of dermatome)
2. Continue downwards until pt can feel it again (bottom of dermatome)
3. repeat on both sides and dermatomes can be different
Motor block assessment
0=no block and full flexion of feet, knees, hips
1=just able to move knees and feet (unable to raise and extend legs)
2=able to move feet only (unable to bend knees)
3=unable to move hips, knees, feet
Removing an epidural
ensure order
check recent PTT and INR (within 2 days)
check heparin and dalteparin last dose and wait 2 hours to give dose after removal
position pt in fetal position
remove tape and dressing
apply sterile gauze over insertion site and slowly pull
apply pressure
apply bandaid
continue routine vitals
assess q4hx24 hours for signs of epidural hematoma
hip/dorsi/planta flexion and extension
monitor for changes in sensation to abdo and legs and new onset of backpain or headache
document removal date, time, catheter intactness, ease of difficulty, bleeding at site, redness or swelling
Complications of epidural
OPIOID RELATED
resp dep
N/V
Pruritis
urinary retention
decreased gastric motility
hypotension
LOCAL ANESTHETICS
hypotension
high block
urinary retention
nausea
local anesthetic toxicity (perioral numbness, tinnitus and dizziness)
Patient controlled analgesia
a method of pain control that gives pt the power to control their pain
a computerized pump contains a syringe of pain medication and connected directly to a pts IV line or epidural
the pt can control when they receive the pain medication
PCA pumps have built in safety features that will only allow a safe dose of analgesia
