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Anaesthetics > Post-operative Pain management > Flashcards

Post-operative Pain management Flashcards

1
Q

Causes of Post operative pain

A

Somatic, visceral and neuropathic

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2
Q

Negative effects of pain

A

Emotional and physical suffering, sleep disturbance
Hypertension and tachycardia, increased O2 use and decreased bowel movements
Delays mobilization leading to DVT

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3
Q

Positive effects of pain

A

Warning of tissue damage

Immobilization to aid wound healing

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4
Q

Anatomy of pain

A

Skin nocioceptors to C fibres up the spinothalamic tract to the thalamus and the limbic system

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5
Q

Why do we need analgesia?

A

Comfort
Mobility (reduces risk of DVT, pressure sores & stiffness)
Respiration and prevents pneumonia in thoracic or upper abdominal surgery

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6
Q

Reasons analgesia may be inadequate

A

Pain is subjective
Hard to predict severity
Inadequate knowledge of staff
Fear of side effects

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7
Q

What effects the severity of pain?

A

Site and extent of wound, Age (goes both ways)
psychological & personal factors (anxiety, experience), coexisting medical problems and Drug tolerance
Pre-operative patient education

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8
Q

Measurement of pain

A

Graded on subjective 1-10 or visual scales

pretty poor really

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9
Q

Surgical Pain ladder

A

Increasing pain relief depending on operation performed
Start with NSAIDs/paracetamol, then wound infiltration with LA, then peripheral nerve block, then systemic opioids then PCA or epidural

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10
Q

Minor surgery

A

Inguinal hernia, varicose veins, Gynae Laparotomy

Use paracetamol/NSAIDs + wound infiltration with LA and/or peripheral nerve block

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11
Q

Moderate Surgery

A

Hip replacements, hysterectomy or maxiliofacial

Use paracetamol/NSAIDs + wound infiltration with LA and/or peripheral nerve block or PCA

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12
Q

Major surgery

A

Thoracotomy, upper abdominal or knee surgery

Use paracetamol/NSAIDs + epidural/LA opioids or PCA

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13
Q

Management of Pain

A

Combinations of drugs are best

Usually try to use the best combination of LAs, Opioids and NSAIDs/Cox-2 inhibitors

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14
Q

Opioids

A

Morphine is gold standard - also diamorphine, papaveretum, fentanyl, codeine, tramadol

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15
Q

Indications for using opioids

A

Moderate to severe pain
Prescribe on age not weight
Choose route: PO, SC, IV, IM, sub-lingual

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16
Q

Effects of Opioids (6,4,3,3)

A

CNS: analgesia, sedation, euphoria, coma, tolerance/addiction, pupil constriction
GI: N&V, constipation, biliary spasm, slow gastric emptying
Resp: resp depression, apnoea, cough reflex suppression,
CVS: bradycardia, hypotension + urinary retention
SEs are worse in elderly & in combination with other drugs

17
Q

Analgesic corridor

A

The dose range where pain is adequately controlled by side effects are minimised

18
Q

Sedation score

A

Awake and alert (0)
Mild sedation (1)
Sleepy but rousable (2)
Unrousable (3)

19
Q

Methods of administering opioids (4)

A

IM PRN
IV PRN
Continuous IV infusion
IV PCA

20
Q

Mangement of opioid overdose

A

ABC to stabilise

Naloxone 0.4-0.8mg but may need an infusion or to be on ITU/HDU

21
Q

PCA for opioids

A

Pros –> titrate to needs, safe, smaller peaks, placebo
Cons –> Needs more monitoring, risk of SEs or OD, N&V
1-2mg bolus with 5-15mins lockout

22
Q

Oral opioids

A

Usually codeine with paracetamol (min 3mg/kg/day)

Codeine is metabolised into morphine - similar SEs (sedation and constipation)

23
Q

Tramadol

A

IV, IM or oral 50-100mg 8hrly, 100mg = 5-15mg morphine

Reduces 5HT and NAdr reuptake and is a weak opioid agonist - risk of serotonin syndrome if used with SSRIs

24
Q

Antiemetics

A

Metoclopramide (benzamide?) - SE - agitation
Cyclizine (antihistamine+anticholinergic) - painful IM or IV
Ondansetron (5-HT3 antagonist) +Dex (unclear mechanism)
Domperidol (butyrophenone) (Prochlorperazine (DA agonist)

25
Q

Laxatives

A

Osmotic (lactulose) 15-30ml BD regularly

Stimulant (Senna) 2-4 tabs nocte - short term effect

26
Q

Oral mild opioid preparations

A

Codydramol: Dihydrocodeine 6-10mg + paracetamol 500mg

Cocodcamol Codeine 30mg + paracetamol 500mg 1-2 tabs 4-6hrly

27
Q

NSAIDs

A

15-60% effect of opioids –> inhibit the production of PGs

Eg Aspirin, ibuprofen, diclofenac

28
Q

Side effects of NSAIDS

A

GI–>Gastric irritation, ulceration and bleeding
Resp–>Bronchospasm
Renal–> oliguria, renal failure, elderly at special risk
Skin rashes and antiplatelet effect
Increased risk of MI?

29
Q

Cox-2 inhibitors

A

Selectively inhibit Cox-2 enzyme so should be GI sparing
Paracoxib 40mg IV or Celecoxib 200mg OP
Concern over CVS SEs –> may be increased MI risk

30
Q

Paracetamol

A

Good SE profile, possible works on cannibinoid or COX-3

1g 4hrly max 4g/24hrs

31
Q

IM morphine Doses

A 
20-39yrs     7.5-12.5mg
40-59yrs     5-10mg
60-69yrs     5-7.5mg
70-89yrs      2.5-5mg
>89yrs         2-3mg
32
Q

Opioids verses opiates

A

Opiates are naturally occuring substances similar to morphine - opioids are chemicals with an effect on the opioid receptor (Mew1/2, Kappa & delta)

33
Q

Aims of post-operative management

A

Reduce suffering and so improve clinical outcomes by increasing patients ability to move, cough, ADLs etc

Anaesthetics (9 decks)

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