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Basics of Anesthesia > Postop Pain > Flashcards

Postop Pain Flashcards

1
Q

What are the three groups of peripheral nerve afferent fibers?

A

Class A (alpha, beta, gamma, delta)
Class B
Class C

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2
Q

Class A Peripheral Nerve Fibers (3)

A
  1. large, myelinated
  2. low threshold for activation
  3. 1-20 um in diameter
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3
Q

A-Delta speed

A

5 - 25 m/s

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4
Q

A-Alpha & A-Beta Speed

A

60 - 120 m/s

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5
Q

A-Gamma

A

15 - 35 m/s

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6
Q

What does class A-Delta mediate?

A

pain sensation; transmits fast or first pain

-sharp, stinging, pricking

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7
Q

What does class A-Alpha mediate?

A

motor & proprioceptive impulses

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8
Q

What does class A-Beta mediate?

A

cutaneous touch & pressure

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9
Q

What does class A-Gamma mediate?

A

cutaneous touch & pressure

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10
Q

Class B Peripheral Nerve Fibers (4)

A

medium sized & myelinated
speed 3 - 14 m/s
diameter < 3 um
postganglionic sympathetic & visceral afferents

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11
Q

Threshold for Nerve Fibers

A

class a < class b < class c

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12
Q

Speed for Nerve Fibers

A

class a > class b > class c

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13
Q

Size for Nerve Fibers

A

a > b > c

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14
Q

Class C peripheral Nerve Fibers

A

myelinated or unmyelinated
speed = 0.5 - 2 m/s
diameter 0.4 - 1.2 um
preganglionic autonomic fibers & pain fibers

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15
Q

What type of pain does Class C transmit

A

slow or second pain
burning, persistent, aching, throbbing
duration exceeds stimulus

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16
Q

What fiber carries visceral pain?

A

Class C

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17
Q

What is the major NT & receptor in Class C Fibers?

A

Substance P –> NK-1 on postsynaptic membrane

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18
Q

What is the major NT & receptor in A-Delta Fibers?

A

Glutamate –> NMDA & AMPA on postsynaptic membrane

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19
Q

A-Delta Fibers

A

myelinated
1 - 4 um
first or fast pain

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20
Q

What fiber carries parietal peritoneum?

A

A-Delta

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21
Q

What tract modulates pain

A

Descending Dorsolateral Spinal Tract

@SC in dorsal horn or @ brainstem & midbrain

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22
Q

Name inhibitory NT (7)

A 
AMPA
NMDA
Enkephalin
NE
GABA
GAMMA
opioid
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23
Q

Name substances released after cells are damaged

A 
bradykinin
cations (protons, potassium ions)
free radicals (nitric oxide)
histamine
prostaglandins, leukotrienes
ATP
serotoinin
tachykinins (NK-a, Substance P)
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24
Q

Discuss pain pathway

A

Stimulus –> (C&A delta fibers) Dorsal root ganglion –> dorsal horn
crosses
brainstem –> midbrain –> thalamus

limbic, cingulate, somatosensory cortex

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25
Pain pathway is called...
spinothalamic tract
26
What tract modulates pain?
descending dorsolateral spinal tract
27
Where do IV opioids primarily act?
limbic hypothalamus thalamus SUPRASPINAL ANALGESIA- MU 1
28
Other than supraspinally, where do opioids act at?
periventricular/periaqauductal gray SPINAL ANALGESIA- MU2
29
Spinal anesthesia
neuraxial opioids work at same receptor site as enkephalin MOA: decrease substance P by binding to Mu-2
30
Surgical stress response - cardiac (5)
1. HTN & tachycardia 2. enhanced myocardial irritability 3. increased SVR (AT2) 4. CO increases 5. MVO2 increases
31
Surgical stress response - respiratory (4)
1. increase in O2 consumption & CO2 production increasing minute ventilation 2. wob increases 3. pain decreases chest expansion 4. skeletal muscle tension increases - v/q mismatch
32
Surgical stress response - endocrine (3)
1. hyperglycemia 2. vasoconstriction, contractility, tachycardia (d/t increased cortisol) 3. salt & water retention (aldosterone and adh)
33
Surgical stress response - GI (2)
1. increased sphincter tone, decreased sm. muscle tone = ileus = PONV 2. decreased oral intake --> septic complications, ulcers, abdominal distention
34
Immune & Hematology complications from surgical stress
leukocytosis w/lympopenia, depression of reticuloendothelial system (infection risk) increased plt adhesiveness diminished fibrinolysis
35
Anesthetic influence on surgical stress response
GA does not attenuate it | Regional does decrease catecholamine and other stress hormone responses
36
Highest POP scores
ortho/trauma
37
Top 25 highest POP scores (4)
appendectomy, cholecystectomy, hemorrhoidectomy, tonsillectomy
38
opioid induced hyperalgesia
diminished pain threshold & enhanced pain sensitivity 1. enhanced NT release 2. sensitization 3. upregulation of spinal & supraspinal pathways
39
main NT in hyperalgesia
glutamate (activation of NMDA receptor)
40
How do you target hyperalgesia?
alpha 2: clonidine NMDA: ketamine COX2: METHADONE
41
what pt are at risk of se from opioids
osa, elderly, chronic pain
42
drugs that act central, spinal, & peripherally
clonidine, dexmedetomidine ketamine lidocaine
43
drugs that act centrally and spinally
gabapentin, magnesium
44
where does decadron act
peripherally
45
nsaids adr
GI bleeding, ARF, hepatotoxicity
46
nsaids c.i
hypersensitivity, renal problems, pud | *caution w/elderly*
47
ketamine
0.5 mg/kg bolus | 4 mcg/kg/m infusion
48
methadone
d-isomer nmda antagonist | 0.2 mg/kg
49
gabapentin
anticonvulsant that blocks VG ca ch inhibiting glutamate - manages spontaneous firing of sensory neurons associated w/neuropathic pain - reduces incidence of chronic postop pain 600 mg q8h or 1200 mg IV 2h onset
50
dexmedetomidine
0.5 - 1 mcg/kg bolus over 15m 0.2 - 0.7 mcg/kg/h onset: 5m DOA: 203h CYP450 hypotension bradycardia risk decreased PONV and opioid consumption
51
acetaminophen
pre-emptive 15mg/kg
52
magnesium
1-2 g/h or 30-50 mg/kg bolus blocks VG Ca Ch, blocks NMDA hypotension, bradycardia prolongs nmbd
53
regional anesthesia advantage vs disadvantage
eliminate need for IV pain meds, earlier d/c block failure, bleeding, neuro injury
54
neuraxial opioid adr
itching nausea/urinary retention sedation cns excitation
55
hydrophilic opioids
slow onset, prolonged duration
56
hydrophilic opioids intrathecal
late respiratory depression (6-12h) rostral | minimal systemic circulation uptake
57
hydrophilic opioids epidural
early respiratory depression (2h) may occur | late respiratory depression d/t rostral spread in CSF
58
lipophilic opioids
rapid onset, short duration
59
lipophilic opioids intrathecal
early respiratory depression d/t systemic uptake
60
lipophilic opioids epidural
early respiratory depression d/t systemic uptake *more pronounced*

Basics of Anesthesia (2 decks)

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