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N928 Basic Principles of Anesthesia > Postop Pain Management > Flashcards

Postop Pain Management Flashcards

1
Q

Pain is considered the

A

5th vital sign

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2
Q

Pain is defined as an

A

unpleasant sensory and emotional experience associated with actual or potential tissue damage

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3
Q

In 2001, JCAHO identified responsibilities including

A

assessment of pain in all patients
educate about pain management strategies
orient staff to be competent to assess pain
record assessments and reassessment of pain

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4
Q

The categories of pain include

A

acute: primarily due to nociception
chronic: may be due to nociception but also affected by psychological and behavioral factors

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5
Q

Nociception refers to the

A

detection, transduction, and transmission of noxious stimuli

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6
Q

Acute pain is

A

of short duration (<6 weeks)
cause usually known
temporary and located in area of trauma or damage
Resolves spontaneously with healing

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7
Q

Chronic pain is

A

persists beyond normal duration of recovery from acute injury or disease
cause may not be identifiable
affects patients self image and sense of well being

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8
Q

Procedures with high incidence of chronic pain include:

A

thoracotomy, sternotomy, mastectomy, hysterectomy, inguinal hernia repair

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9
Q

Pain can be classified by:

A

etiology: postoperative, cancer
pathophysiology: nociceptive, neuropathic, idiopathic, psychogenic
affected area

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10
Q

Psychogenic pain is

A

sustained by psychological factors

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11
Q

Idiopathic pain is

A

not attributable to identifiable causes

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12
Q

Nociceptive pain is

A

the appropriate response to identifiable tissue damage

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13
Q

Nociceptive pain is due to the

A

activation or sensitization of peripheral nociceptors that transduse noxious stimuli
the result of four processes: transduction, transmission, modulation, and perception

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14
Q

Transduction is

A

stimuli translated into electrical energy at the site

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15
Q

Transmission is

A

propagation of the impulse through the nervous system

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16
Q

Modulation is

A

alteration of the stimuli that can be amplified or attenuated

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17
Q

Perception is

A

based on the psychological framework of the patient

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18
Q

Subtypes of nociceptive pain include:

A

Somatic & visceral pain

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19
Q

Somatic pain can be

A

superficial: arises from skin, subcutaneous tissues, or mucous membranes
characterized as well-localized, sharp, pricking, throbbing, or burning
Deep somatic pain: arises from muscles, tendons, joints or bones
dull, aching quality that is less well-localized

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20
Q

Visceral pain is due to

A

disease process or abnormal function of internal organ

may be localized or referred

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21
Q

Neuropathic pain is the result of

A

injury or acquired abnormalities of peripheral or central neural structures

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22
Q

Neuropathic subtypes include

A

Central generator: central pain due to injury to brain or spinal cord; phantom pain
Peripheral generator: originates in nerve root, plexus, or nerve; polyneuropathies, mononeuropathies

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23
Q

Idiopathic pain is perceived to be

A

excessive for the extent of the pathology

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24
Q

Allodynia is the

A

perception of an ordinarily non-noxious stimuli as pain

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25
Q

Analgesia is the

A

absence of pain perception

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26
Q

Anesthesia is the

A

absence of all sensation

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27
Q

Hyperalgesia is the

A

exaggerated response to noxious stimuli

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28
Q

Neuralgia is

A

pain in nerve distribution

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29
Q

Paresthesia is an

A

abnormal sensation perceived without stimulus

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30
Q

Radiculopathy is the

A

functional abnormality of one or more nerve roots

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31
Q

Peripheral nerve afferent fibers are categorized into three groups based on

A

size, degree of myelination, speed of conduction, and distribution of fibers

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32
Q

The three groups of afferent nerve fibers include:

A

Class A- alpha, beta, delta, gamma
Class B
Class C

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33
Q

Class A peripheral nerve fibers are

A

large, myelinated fibers
have low threshold for activation
1-20 micrograms in diameter

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34
Q

Class A delta fibers

A

mediates pain sensation- transmits fast or first pain
sharp, stinging, pricking type pain
conducts impulses at 5-25 m/s

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35
Q

Class A alpha fibers

A

transmits motor and proprioceptive impulses

60-120 m/s

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36
Q

Class A Beta fibers

A

cutaneous touch and pressure

60-120 m/s

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37
Q

Class A gamma fibers:

A

cutaneous touch and pressure

15-35 m/s

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38
Q

Class B peripheral nerve fibers are

A

medium sized myelinated fibers
conduction speed 3-14 m/s
diameter less than 3 micrometers
have higher threshold (lower excitability) than Class A fibers
Lower threshold than Class C fibers
Postganglionic sympathetic and visceral afferents are class B

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39
Q

Class C peripheral nerve fibers are

A

unmyelinated or thinly myelinated
conduction speeds of 0.5-2 m/s
Diameter 0.4-1.2 micrometers
Preganglionic autonomic fibers and pain fibers are Class C- transmits slow or second pain; burning, persistent, aching, throbbing pain

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40
Q

A-Delta Fibers transmit

A

“First” or “Fast” pain
it is well localized; sharp, stinging, pricking
duration of pain coincides with painful stimulus
pain from parietal peritoneum carried here

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41
Q

The major neurotransmitter involved in A-Delta fibers is

A

glutamate and binds to NMDA and AMPA receptors on postsynaptic membrae

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42
Q

C Fibers transmit

A

“Second” or “slow” pain

diffused and persistent; burning, aching, throbbing; duration exceeds stimulus; pain from viscera is carried here

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43
Q

The major neurotransmitter involved in C Fibers is

A

substance P which bids to NK-1 receptors on the postsynaptic membrane

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44
Q

Pain is modulated in the

A

descending dorsolateral spinal tract

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45
Q

IV opioids act primarily at other sites in the brain including

A

the limbic system, hypothalamus, and thalamus; this supraspinal analgesia is mediated by Mu-1 receptors

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46
Q

IV opioids can also produce

A

spinal analgesia by working in the periventricular/periaqueductal gray where they stimulate Mu-2 receptors

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47
Q

Neuraxial opioids work at the same receptor site as

A

enkephalin; their mechanism of action is to decrease the release of Substance P by binding to Mu-2 receptors; this is known as spinal anesthesia

48
Q

Pain management is important because

A

effective intraoperative and postoperative pain relief is vital to your patient’s outcome
Prompt treatment can help prevent the development of negative sequelae that pain can precipitate
Pain is not just an unpleasant experience; it causes a multitude of systemic effects

49
Q

The cardiovascular surgical stress response includes

A

HTN, tachycardia, enhanced myocardial irritability, increased SVR (angiotensin II), CO increases except in patients with compromised left ventricular function
May result in increased myocardial O2 demand and precipitate ischemia

50
Q

The respiratory surgical stress response includes

A

increase in total body O2 consumption and CO2 production causes increase in minute ventilation
increases work of breathing
pain may decrease chest expansion and result in atelectasis, intra-pulmonary shunting, hypoxemia, and hypoventilation
increases in skeletal muscle tension that results from pain impulses may lead to V/Q mismatch

51
Q

The endocrine surgical stress response includes

A

hyperglycemia- secondary to increased glucagon, increased epinephrine, and decreased insulin
Vasoconstriction, increased myocardial contractility, tachycardia- secondary to increased cortisol, increased catecholamines, activation of renin-angiotensin system
Salt & water retention (increased aldosterone & ADH) may lead to CHF

52
Q

The gastrointestinal surgical stress response includes

A

increased sphincter tone with decreased smooth muscle tone that may lead to formation of ileus and lead to PONV
decreased oral intake is associated with septic complications and delayed wound healing- hypersecretion of gastric acid promotes stress ulcers; abdominal distension further aggravates loss of lung volume and pulmonary dysfunction

53
Q

The immunological surgical stress response

A

produces leukocytosis with lymphopenia & depresses the reticuloendothelial system predisposing patients to infection

54
Q

The hematological surgical stress reponse

A

increases platelet adhesiveness and diminished fibrinolysis promotes a hypercoagulable state; immobility exacerbates this problem

55
Q

Describe the impact that general anesthesia has on the surgical stress response:

A

not effective in attenuating the response except with high dose narcotic technique

56
Q

Describe the impact that regional anesthesia has on the surgical stress response:

A

diminishes the intensity of afferent impulses getting to the spinal cord
reduces catecholamine and other stress hormone responses during perioperative period

57
Q

Pain management points:

A

effective pain program is based on an understanding of pain
pain management requires patient evaluation preoperatively, postoperatively and thru discharge
education of the patient is key to pain management
pain management is geared at balancing the advantages, disadvantages, and patient considerations

58
Q

A pain assessment involves

A

history of current and persistent pain
physical examination
pain attributes- intensity, onset, duration, location, descriptors of what exacerbates or relieves pain
behavioral manifestations
impact of pain on ADLs
current & past treatments
are the patient’s expectations for pain relief realistic

59
Q

Postoperative pain intensity is rate the highest in

A

orthopedic/trauma on extremities

60
Q

These surgeries are ranked among 25 with highest pain intensity:

A

appendectomy, cholecystectomy, hemorrhoidectomy, tonsillectomy
some laparoscopic procedures are ranked unexpectedly high

61
Q

Opioids are the ____and can be given___

A

mainstay for postoperative analgesia; may be given IV, PO, IM, subQ, PCA, or neuraxial

62
Q

Opioids are safe and effective in treating

A

moderate to severe pain

63
Q

Opioids should be administered via

A

the most effective route and limiting side effects

64
Q

Side effects of opioids include

A

N/V, constipation, lethargy, sedation, and respiratory depression

65
Q

The minimum effective analgesic concentration is the

A

analgesic blood level at which the patient experiences analgesia and the severity of pain rapidly diminishes

66
Q

Opioids can lead to opioid-induced

A

hyperalgesia; patients receiving opioids may exhibit diminished pain threshold and enhanced pain sensitivity
-escalating opioids worsens pain perception

67
Q

The mechanism for opioid-induced hyperalgesia is possibly due to

A

enhanced release of neurotransmitters
sensitization of primary and secondary afferents
upregulation of spinal and supraspinal pathways- critical component is activation of excitatory NMDA receptor & central glutamatergic system
Demonstrated in patients receiving high-dose intraoperative opioids such as fentanyl and remifentanil

68
Q

Pain perception can be decreased by using

A

analgesics capable of inhibiting CNS sensitization before painful stimulus occurs
clinical role of preemptive analgesia still uncertain and much debated

69
Q

Drug options for preemptive analgesia include

A

NSAIDs, opioids, local anesthetics, NMDA antagonists, alpha-2 agonists

70
Q

A multi-modal approach is

A

use of different agents allows reduced dosages of each thus, reduced side effects
may include more than 1 route of administration

71
Q

The synergistic effects between drug classes enhances

A

analgesic effects of each drug

72
Q

Multi-modal approach is effective in patients at risk of

A

side effects from large doses of opioids such as obstructive sleep apnea, chronic pain, and frail elderly

73
Q

NSAIDs are effective in treating

A

mild to moderate pain

74
Q

Adverse effects of NSAIDs include

A

GI bleeding, ARF, and hepatotoxicity

75
Q

NSAIDs should be avoided in patients with

A

hypersensitivity, significant renal compromise, & PUD

76
Q

NSAIDs should be used in caution in

A

elderly patients due to increased risk for renal impairment

77
Q

Ketamine is a

A

NMDA receptor antagonist

78
Q

Ketamine dosage is

A

0.5 mg/kg bolus followed with infusion at 4 mcg/kg/min.

79
Q

Ketamine is able to reduce

A

morphine consumption and pain intensity up to 6 weeks following spine surgery

80
Q

Methadone is a

A

D-isomer NMDA receptor antagonist

81
Q

The dose of methadone is

A

0.2 mg/kg

82
Q

Methadone results in a

A

50% reduction in post-op opioid consumption and pain scores at 48 hours after complex spine surgery

83
Q

Anticonvulsants include

A

pregabalin & gabapentin

84
Q

Anticonvulsants are used to manage

A

spontaneous firing of sensory neurons associated with neuropathic pain
-attenuate neuronal sensitization response

85
Q

Anticonvulsants are able to reduce the incidence of

A

chronic postoperative pain syndrome- decrease opioid consumption and neuropathic pain 3-6 months following total knee replacement

86
Q

Alpha 2 agonists include _____ and the risk associated with these drugs is

A

dexmedetomidine & clonidine

hypotension & bradycardia

87
Q

Dexmedetomidine is particularly useful in reducing

A

morphine consumption 2-14 hours post-op; decreased PONV

significantly reduces opioid consumption in obese population

88
Q

Clonidine results in

A

reduced morphine consumption 12-24 hours post-op; also decreased PONV

89
Q

Additional drugs that can be administered in a multi-modal approach include

A

acetaminophen and magnesium

90
Q

Infiltration of local anesthetic can be done

A

by the surgeon at the end of the case

ilioinguinal and femoral nerve blocks can be placed by the anesthetist

91
Q

Glucocorticoids are

A

potent anti-inflammatory agents that play a role in reducing postop pain and can help to manage PONV

92
Q

Side effects of neuraxial opioids include:

A

itching (most common)

nausea, urinary retention, respiratory depression (early & late), sedation, CNS excitation, neonatal morbidity

93
Q

Regional anesthesia is preferred to provide

A

postoperative pain control to a specific part of the body

94
Q

Benefits of regional anesthesia include

A

eliminating the need for IV pain medications and early discharge of ambulatory patients

95
Q

Disadvantages of regional anesthesia include

A

block failure, bleeding, hematoma, & neurological injury

96
Q

Central neuraxial blocks include

A

spinal & epidural

97
Q

Peripheral nerve blocks include

A

lumbar plexus blocks & interscalene nerve blocks

98
Q

Intrathecal placement of neuraxial opioids can lead to

A

LATE respiratory depression (6-12 hours) due to rostral spread
early respiratory depression does not occur because uptake by systemic circulation is minimal

99
Q

Epidural placement of neuraxial opioids can lead to

A

EARLY respiratory depression (within 2 hours) may occur since systemic uptake is greater then with intrathecal placement
late respiratory depression is more likely due to rostral spread in CSF

100
Q

Hydrophilic opioids onset of analgesia

A

is slow, duration, prolonged

101
Q

With lipophilic opioids the onset of analgesia is

A

rapid with short duration
EARLY respiratory depression occurs due to significant systemic uptake with both intrathecal & epidural placement
-respiratory depression is most pronounced after epidural placement

102
Q

Discuss lipophilic opioids and late respiratory depression.

A

Late respiratory depression DOES NOT occur because diffusion of lipophilic opioids out of the CSF is substantial, therefore rostral spread is minimal

103
Q

Distraction can be used

A

as an adjunct to analgesic interventions
can include music or imagery
requires patient cooperation

104
Q

The maximal benefit of distraction is when

A

it is introduced preoperatively

105
Q

Hypnosis is a

A

state of focused attention combined with decrease in external awareness

106
Q

Hypnosis may not be as frequently used because

A

it may not work on all patients
social stigma
conflicting data on efficacy

107
Q

Heat is used to

A

decrease joint stiffness and increase blood flow

easy to use

108
Q

Cold is used to

A

alter pain threshold, reduce swelling, and decrease tissue metabolism
easy to use

109
Q

Cold is contraindicated in patients with

A

decreased circulatory states such as Raynaud’s

110
Q

Transcutaneous electrical nerve stimulation (TENS) is thought to

A

produce analgesia by stimulating large afferent fibers

gate theory of pain suggests that the afferent input from large fibers competes with that from smaller pain fibers

111
Q

With a TENS unit,

A

electrodes are applied to the same dermatome as the pain

requires professional to instruct in use

112
Q

The benefit of using a TENS unit is that there is an

A

absence of significant side effects

113
Q

Immobilization can include

A

healing process as well (i.e. casting)

114
Q

Positioning can be done

A

every two hours

improves blood flow and prevents decubitus ulcer development

115
Q

Exercise can assist in the

A

CPM, ambulation, physical therapy

assists with edema and DVT formation

N928 Basic Principles of Anesthesia (16 decks)

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