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Anaethetics 2 > Peri-operative Pain Management > Flashcards

Peri-operative Pain Management Flashcards

1
Q

Nociception?

A

Detection, transduction and transmission of a noxious stimulus, associated with tissue damage and/or inflammation

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2
Q

What is acute pain?

A

Recent onset

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3
Q

Chronic pain?

A

Persists beyond usual course of an acute illness or injury
>3 months
Outlasts the potential for healing

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4
Q

What is a nociceptor?

A

Potential harmful
Thermal
Chemical
Mechanical stimuli activate free nerve endings = nociceptors

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5
Q

How is pain felt?

A

Activation threshold is reached
Depolarization
Propagation of an impulse from the nociceptors to the dorsal horn of the spinal cord

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6
Q

What type of pain do A (delta) and C fibers transmit?

A

A (delta)fibers- sharp well localized pain

C fibers- dull persistent pain

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7
Q

What is hyperalgesia and how does it occur?

A

Increased sensitivity to pain

Release of inflam mediators (K, serotonin, sub P, histamine, cytokines, NO, and prostaglandins) lowers firing threshold of receptors in injured area = zone of primary hyeralgesia

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8
Q

What is pain?

A

Unpleasant sensation and emotional experience associated with actual or potential tissue damage

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9
Q

How is pain transmitted?

A

1st order neurons synapse with 2nd in dorsal horn
Impulses then crosses midline and ascending in ant and lateral spinothalamic tracts to thalamus
Then synapses with 3rd –> axonal projections to sensory cortex, limbic system, cerebellum, peri-aquedal grey matter and reticular formation

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10
Q

What neurotransmitters are released?

A

Glutamate, subs P, neurokin A+B, GABA, and glycine

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11
Q

Where are the most NB points of pain modulation?

A

Horsal horn 1 and 2 neurons synapse

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12
Q

How is nociceptive transmission dampened?

A

Efferent neurons in the BRAINSTEM send impulses to the other layers of the dorsal horn, where release of neurotransmitter substances (endorphins, enkephalins, noradrenaline, serotonin and GABA) dampen nociceptive transmission.

They do so by making post-synaptic membranes more difficult to depolarize or by impairing the release of nociceptive neurotransmitters

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13
Q

What is the multi-modal approach to pain and why is it important?

A

Based on the knowledge that there are many different receptors and transmitters involved in nociception

Use several different class of drugs to act at different points in the pain pathway will give a more effect analgesia and the SYNERGISTIC action of the different classes will reduce total doses and side effects

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14
Q

What is the stepwise approach to treating pain?

A

Mild pain: simple analgesia (paracetamol), NSAIDS, and codeine (weak opioids)

Moderate pain: higher doses of codeine or tramadol

Severe pain: stronger opioids (morphine and fentanyl)

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15
Q

What is the mechanism of action of paracetamol?

A

Acts centrally and peripherally and has an anti-prostaglandin effect via a COX 3 enzyme

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16
Q

Where is paracetamol used?

A

Has mild analgesic properties

Can be used alone for minor surgery or with other stronger analgesics for major surgey

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17
Q

What properties does paracetamol have?

A

No anti-inflammatory

Anti-pyretic properties

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18
Q

What are the side effects of paracetamol?

A

Only overdose causing fulminant hepatic necrosis and failure

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19
Q

How is paracetamol overdose treated?

A

With N-acetylcysteine

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20
Q

What is the dose of paracetamol and what is is onset and duration time?

A

1g orally or rectally 6hourly

MAX= 4g in 24 hours

Onset- 30mins
Duration 2-5hours

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21
Q

What is IV paracetamol called and what is its dosage and advantages?

A

Pefalgan

Improved bio-availability and faster onset of time 5-10 minutes

1g IV 6hourly (4doses)

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22
Q

How do NSAIDS work?

A

Inhibit COX and inhibits production of PG and thromboxanes from membrane phospholipids

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23
Q

How does aspirin work?

A

Aspirin binds irreversibly to COX

NSAIDs cause reversible enzyme inhibition with an antipyretic action via inhibition of central PG.

The inhibition of thromboxane production results in reduced plt aggregation and risks of bleeding

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24
Q

How many COD enzymes are there and why are they important?

A

3 COX enzymes

COX-1 is constitutive and helps maintain normal physiology with NB roles in renal blood flow, haemostatic function and mucosal integrity

COX-2 is inducible and expressed in response to tissue damage

NSAIDs are non- selective (COX 1&2)
Or selective (COX 2)
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25
Q

What are NB side effects of NSAIDS?

A

Gastric irritation, bronchospasm, renal dysfunction, plt dysfunction, hepatotoxicity, and MI

NSAIDs can be given orally, rectally, intravenously and IM

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26
Q

What is the dose of aspirin?

A

10-15mgkg

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27
Q

What is the dose of ibuprofen?

A

Adults: 200-400mg orally 8hourly

Children: 5-10mgkg orally 8hourly

28
Q

Dose of diclofenac?

A

Adult: 50mg orally 8-12hourly

Children: 1mgkg orally or 1-2mgkg rectally

29
Q

Indomethacine dosages?

A 
Adults: 25-50mg orally 8hourly,
             100mg rectally (12hourly)

Children: 0,5-1mgkg (8hourly)

30
Q

What is ketorolac and dosage?

A

It is a opioid sparing agent, decreased the amount of opioids needed

Adults: 10mg orally (4-6hourly)
0,6mgkg IM stat, then 0,2-0,4mgkg 6hourly

Oral onset: 30-60mins
IM: 10mins
IV: 5mins

31
Q

Celecoxib dosage?

A

Adult: 100mg (12hourly) or 200mg daily

Onset: 30-60mins
Duration 8-10hours

32
Q

Parecoxib dosage?

A

Adults: 40mg IV or IM followed by 20-40mg (6-12hourly)

Onset of action= 5mins IV and 30mins IM
Duration of action 8-10hours

33
Q

What are endogenous agonists and how do they work?

A

B-endorphins and enkephalins

Work with opioids act by reducing neuronal cell excitability

34
Q

When endogenous agonist receptor are stimulated what are the effects?

A

Analgesia, drowsiness, change in mood, nausea, bradycardia, resp depression, miosis, pruritis and inhibition of gut motility with constipation

They are selective for pain and don’t interfere with other sensory modalities

35
Q

Common side effects of opioids?

A

Nausea, vomiting, ictching, constipation and urinary retention

More serious by less common- reduced LOC, resp depression and mm rigidity

36
Q

Codeine dosage?

A

Adults: oral 30-60mg 4-6hourly

37
Q

What is Panadeine?

A

Paracetaml 500mg, and codeine 8mg

10% is metabolism to morophine

38
Q

Tramadol?

A

Adults: oral IV 50-100mg 4-6hourly
Duration: 2-5hours

39
Q

What dose tramadol do?

A

It is agonist at the opioid receptors.

Also has an added mechanism of preventing the reuptake of noradrenaline and 5-hydroxytrytamine at the pre-synaptic nerve endings; and stimulates pre-synaptic 5-HTrelease.

Particularly important in the descending inhibitory pathways

It’s produces less constipation, and resp depression but more nausea

40
Q

Which other drugs interact with tramadol?

A

Selective serotonin reuptake inhibitors SSRIs and noradrenaline re-uptake inhibitors can result in seizures and serotonin syndrome

41
Q

What is Tramacet?

A

325mg paracetamol and 37,5mg tramadol

42
Q

What are some of the side effects of pethidine?

A

Anti- cholinergic causing dry mouth and tachycardia

If given with MAOI:
   Convulsions
   Hyperpyrexia 
   Coma
    Labile circulation
43
Q

Morphine dosage?

A

Adults and children: 0,1-0,2mgkg 4-6hourly IV and MI

44
Q

How is morphine used intra-op?

A

It is titrated to effect with bolus of 1-5mg IV

45
Q

What is morphines effect in RA?

A

In epidural and spinals it enhances the analgesic effect of LA

BUT causes resp depression and needs monitoring

46
Q

Patient controlled analgesia?

A

50mg morphine in 50mg of normal saline in an infusion pump

Each time patient presses buttons 1-2mg bolus is release IV

SAFELY: there is a 5-10min lockout time preventing overdose

47
Q

Fentanyl dose?

A

1-2ug kg IV in adults and kids

48
Q

Fentanyl is …. Potent than …. And 600 times more….. What does this mean?

A

Potent
Morphine
Lipid soluble
Therefore it means it seldom causes delayed resp depression when given epidural or spinal

49
Q

What are some the side effect of fentanyl?

A

Can cause chest wall rigidity and bradycardia

50
Q

How is fentanyl used as a co-induction?

A

It is given at induction IV and aims to reduce dose of induction agent needed with a synergistic effect

Is also depressed laryngeal reflexes which is useful for LMA and ETT intubation and is less likely to cause histamine release

51
Q

What is fentanyl’s onset and duration of action?

A

Onset 3-4mins

Short duration: 30-40mins but up to 6hours at high doses

52
Q

What does sufentanil and alfentanil do? And what are there side effects?

A

They are synergistic opiated and are short acting when used as a bolus

S/E: Cardiovascularly stable, depress laryngeal reflexes and inhibit increase in heart and blood pressure seen in “intubation response”

53
Q

What is the dose and purpose of remifentanil?

A

0,05-0,5ugkgmin

Ultra short acting opiate due to rapid metabolism by non-specific plasma and tissue esterases- not dependent on the liver metabolism or renal excretion

Controls HR and BP during intubation and stimulating periods of surgery

54
Q

What are the side effects of remifentanil?

A

Hypotension, bradycardia, chest wall rigidity, and resp depression

55
Q

When must remifentanil be given at the end of a surgery and why?

A

Remifentanil must be given 15-20min before termination of a case as the analgesia wears off rapidly

56
Q

What is naloxone and what is a the dose?

A

Opiate antagonist at u, k and s receptors 1-4 ugkg is given for opiate overdose

Amp=0,4mg in 1ml dilute with 9ml of normal salon into a 10ml syringe and you have 40ugml

It is an antanalgesic and makes you more susceptible to pain

Can cause hypertension, dysrhymias and pul odema

57
Q

What is ketamine?

A

Antagonises glutamate at NMDA Receptors, an agonist at s and k opiate receptors but antagonises at u receptors

Dissociative anaesthesia

58
Q

What are some of the effects of ketamine?

A

Indirect sympathetic stimulation results in hypertension and tachycardia

Produced bronchodilation and airway is often maintained

Salivation and emergence phenomena are a problem

Good analgesia

59
Q

Dose of ketamine?

A

Analgesic: 0,2-0,5mg kg IV 2-4mgkg
INFUSION: 4ugkg min, 5mgkg orally

60
Q

Name two alpha 2 agonists?

A

Clonidine and dexmedetomidine

61
Q

What are the benefits of post-operative analgesia?

A

Patient comfort and satisfaction
Adequate breathing and coughing (decreasing incidence of post-operative lunch infections)
Early mobility (reducing DVT)

62
Q

What is pre-emptive analgesia?

A

You pre-empt the pain by giving the analgesic with the premedication or induction before pain starts

Reduced pain and stress response

63
Q

What is sufficient for minor surgeries?

A

Intra-op: Local infiltration

Post-op: oral paracetamol and codeine

64
Q

Major procedure pain management?

A

IV opioids added to simple analgesics and NSAIDS intra-op

65
Q

Common plan for post-op pain?

A

Morphine 5-10mg IM 4-6hourly or tramadol 50-100mg orally 4-6hourly

Paracetamol 1g orally/rectally 6hourly or combined Panadeine 2tablets 6hourly

NSAIDS
Ibuprofen 400mg 8hourly or
Diclofenac 100mg rectally 12hourly

Anti-emetic with opioids
Prochloroerazine (stemetil) 12,5mg IM 8hourly
Ondansetron (Zofrab) 4mg IV/IM 8hourly

66
Q

Useful for chronic pain?

A

Radiofrequency ablation of nerves last 6months

Anaethetics 2 (10 decks)

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