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PTX Exam 2 > Acute Pain > Flashcards

Acute Pain Flashcards

(55 cards)

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1
Q

Define acute pain. How is it different from chronic pain?

A

Sudden onset with a short duration (3-6 months)

Usually linked to a specific event

Can have signs/symptoms like tachycardia, hypertension, etc whereas chronic pain usually does not

More commonly it is nociceptive pain rather than neuropathic

Can develop INTO chronic pain if it is untreated or undertreated!

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2
Q

Does dependence and tolerance usually occur in acute pain?

A

It’s unusual for this to occur in acute pain but is common in chronic pain

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3
Q

Is there a psychological component to acute pain?

A

Psychological component usually not present in acute pain, but it is often a major problem in chronic pain

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4
Q

What role does environmental/family issues play in acute pain?

A

Small role in acute pain; it’s significant in chronic pain

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5
Q

What is the treatment goal for acute pain vs chronic pain?

A

Acute pain = goal is to cure

Chronic pain = goal is to renew functionality

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6
Q

Define multi modal approach

A

There are numerous targets and ways to inhibit pain transmission; target more than one for a multi modal approach

Use pharmacologic interventions, non-pharmacologic interventions, and regional interventions

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7
Q

What are the common CV adverse consequences of uncontrolled pain?

A 
Tachycardia
Hypertension
Increased peripheral vascular resistance
Increased myocardial oxygen consumption
Myocardial ischemia
Altered regional blood flow
DVT
Pulmonary embolism
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8
Q

What are the common respiratory adverse consequences of uncontrolled pain?

A 
Reduced lung volumes
Atelectasis
Decreased cough
Sputum rete.tion
Infection
Hypoxemia
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9
Q

What are the common gastrointestinal adverse consequences of uncontrolled pain?

A

Decreased gastric and bowel motility

Increased risk of bacterial transgression of bowel wall

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10
Q

What are the common genitourinary adverse consequences of uncontrolled pain?

A

Urinary retention

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11
Q

What are the common neuroendocrine/metabolic adverse consequences of uncontrolled pain?

A

Increased catabolic hormones (breakdown): Glucagon, growth hormone, vasopressin, aldosterone, renin, angiotensin

Decreased anabolic hormones: Insulin, testosterone

Catabolic state leads to hyperglycemia, increased protein background, negative nitrogen balance –> all leads to impaired wound healing and muscle wasting

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12
Q

What are the common musculoskeletal adverse consequences of uncontrolled pain?

A

Muscle spasm
Immobility (increased risk for DVT)
Muscle wasting
Leads to prolonged recovery of function

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13
Q

What are the common psychological adverse consequences of uncontrolled pain?

A 
Anxiety
Fear
Helplessness
Sleep deprivation
Leads to increased pain
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14
Q

What are the common psychological adverse consequences of uncontrolled pain?

A 
Anxiety
Fear
Helplessness
Sleep deprivation
(all leeds to increased pain)
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15
Q

What are the common CNS adverse consequences of uncontrolled pain?

A

Chronic persistent pain due to central sensitization

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16
Q

What is the cornerstone of pain management?

A

Pharmacologic intervention

Right agent (Based on type and severity of pain and patient assessment)
Right dose (What controls pain with fewest side effects)
Right route (Oral when possible)
Right schedule
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17
Q

What is the indication for IV Acetaminophen? Dosage? How is it administered?

A

Indication: Management of mild to moderate pain and moderate to severe pain with adjunctive opioid therapy

Dosage: 1000 mg IV every 6 hours or 650 mg IV every 4 hours
(Max dose 4000 mg per day, minimum interval 4 hours)

Administered as 15 min IV infusion; 1g/100 mL single-use glass vial, has to be used within 6 hours of opening

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18
Q

Risks/benefit with IV APAP instead of Oral?

A

IV is pregnancy category C, oral is B

Oral is way cheaper

IV APAP reduces post-op morphine requirements by 20%

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19
Q

Ketorolac: Administration? Dose? Onset? Duration?

A

Admin oral or injectable
Dose 15-30 mg IV/IM q6h
Onset is 30 mins, peak at 1-2 hours, lasts 4-6 hours

DO NOT GIVE FOR MORE THAN 5 DAYS
DO NOT GIVE PERI-OPERATIVELY (increases bleeding risk)
HIGH RISK OF GI BLEED

Also can be given intranasal (1 spray q6-8h, max 4 doses per day. Discard bottle within 24 hours of opening)

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20
Q

IV Ibuprofen: Dose? How to make? How to administer?

A

400-800 mg IV q6h
Dilute in 100-200mL NS, D5W, or LR (4mg/mL)
Infuse over 30 mins
Can be given for more than 5 days

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21
Q

Diclofenac injectable: Indication? Dosage? Max? Contraindications?

A

For mild to moderate or moderate to severe pain alone or in combination with opioids

37.5 via IV bolus over 15 seconds every 6 hours as needed

Maximum dose 150 mg/day

Contraindicated in renal insufficiency in perioperative period and in patients at risk for volume depletion

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22
Q

What co-analgesics are available under the multipurpose classes?

A

Corticosteroids (dexamethasone, prednisone)

Antidepressants (desipramine, duloxetine, bupropion, venlafaxine (SR), nortriptyline)

Alpha-2 adrenergic agonists (Tizanidine)

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23
Q

What co-analgesics are available to be used for neuropathic pain?

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A

Anticonvulsants (Gabapentin, pregabalin)

GABA Agonists (Clonazepam)

24
Q

What co-analgesics are available to be used for bone pain?

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A

Pamidronate
Zoledronic acid
Denosumab

(All osteoclast inhibitors)

25
What co-analgesics can be used for bowel obstruction?
``` Anticholinergic drugs (Glycopyrrolate) Somatostatin analogue (Octreotide) ```
26
What factors affect opioid response?
Intrinsic to opioid: - Pharmacokinetics (Route, t1/2, absorption, metabolism, elimination) - Pharmacodynamics Intrinsic to the patient - Pain-related factors - Pharmacokinetic (unusual t1/2) - Pharmacodynamic (Extent of tolerance) - Pharmacogenetics - Age - Gender
27
What route of admin should be avoided in pain control?
Intramuscular
28
What is central regional analgesia?
Neuroaxial analgesia Administered via epidural/intrathecal route
29
Which common IV opioids are metabolized in the liver?
Glucuronidation: Hydromorphone, Morphine CYP3A4: Fentanyl
30
Which common IV opioid has active metabolites?
Morphine Fentanyl and Hydromorphine have none
31
Which IV opioid has less hypotension risk than morphine?
Fentanyl
32
What routes of admin are available for morphine? Fentanyl? Hydromorphine?
Morphine: IV, PO, Rectal Fentanyl: IV, Transdermal (no PO) Hydromorphine: IV, PO, Rectal
33
Which common IV opioid causes the most histamine release?
Morphine
34
Why do we do opioid rotations?
Switching the opioid a patient is receiving to another opioid to reduce limiting adverse effects and/or increase analgesia
35
How should we reduce the dose when doing opioid rotations?
Reduce dose by 25-50% based on patient age/pain intensity and renal/hepatic dysfunction Reduce by 75% when treating frail, elderly patients or in patients who have: - Moderate pain - Major organ dysfunction - History of adverse reactions to opioids
36
How are rescue doses determined?
5-15% of 24 hour oral dose (1/8 total 24 hour dose) Administer orally every 1-2 hours as needed Administer parenteral every 15-60 minutes as needed
37
What is PCA?
Patient controlled analgesia Interactive method of pain management that allows patients to manage their pain by self-administering doses of analgesia, usually opioids
38
Are there risks with PCA's?
PCA errors represent a 4 fold higher risk than other reported medication errors
39
What are the criteria for a pt to be eligible for PCA?
Moderate to severe pain Unable to swallow Unable to tolerate side effects of oral medications Rectal route not convenient, appropriate, or acceptable Erratic GI absorption of medications (ie bowel obstruction) Pain not well controlled w/ oral medications after multiple upward titrations and maximal use of adjuvants Transdermal pain medications with breakthrough medications are not effective or appropriate
40
What is the demand dose?
Dose provided each time the patient presses the buttom
41
What is the basal rate?
Amount for continuous infusion NOT FOR OPIOID NAIVE PTS
42
What is lock-out?
Time between administrations, usually 6-15 mins (10 mins standard)
43
What is hour limit?
The total amount a patient can receive in 1 or 4 hours by both PCA demand dose and basal rate Prevents opioid overdose regardless of how many times a PCA button is used
44
What specific groups are not good candidates for PCA?
Infants Young children (less than 5) Cognitively impaired patients
45
What specific groups should PCA be used with great caution?
Asthmatics, sleep apnea, severe obesity | Concurrent use of CNS depressant therapy
46
What opioids are available for PCA?
Morphine (gold standard unless renal impairment) Hydromorphine Fentanyl Methadone - opioid tolerant only NOT meperidine
47
What is the standard fentanyl conc for PCA? Loading bolus?
10 mcg/mL Loading: 20 mcg/mL
48
What is the standard hydromorphine conc for PCA? Loading bolus?
0.2 mg/mL Loading: 0.4 mg
49
What is the standard morphine conc for PCA? Loading bolus?
1 mg/mL Loading: 2 mg
50
How is basal rate determined for initiating PCA?
Opioid tolerant: Basal rate determined by dividing total opioid dose required and divide by 24 hours (tolerant ONLY) PCA dose is 30-50% of hourly basal rate (use 0.3) Lock-out for morphine, hydromorphone: 10 mins Lock-out for fentanyl: 5 mins
51
What respiratory rate should trigger concern?
Less than 8 breaths per minute
52
What are risk factors for opioid-induced respiratory depression?
``` Opioid naive Concurrent use of benzodiazepines History of obstructive sleep apnea/COPD Obesity Night-time Age over 65 Basal/continous infusion (for opioid naive) PCA by proxy smh Inadequate sedation monitoring ```
53
What are the adverse reactions that require monitoring in opioid use?
Constipation (monitor bowel movement frequency and consistency) Sedation, N/V (will decrease over time) Tolerance (Chronic use) Dependence (Chronic use) Addiction/abuse (seldom a problem with acute pain) Monitor these 2 with regular efficacy monitoring Histamine release (monitor for uticaria, pruritus, bronchospasm) Increase in sphincter tone (monitor for biliary spasm, urinary retention) Hypogonadism (Monitor fatigue, depression, sexual dysfunction, amenorrhea) - problem with chronic use
54
What are important history points to obtain from PCA pumps?
History points: PCA attempts (number of times a patient presses the PCA button), PCA injections (number of times pt has successfully administered a PCA dose), and volume given and volume remaining in reservoir
55
How are intraspinal opioid doses different from IV or PO?
Much lower bc it is much more direct Morphine: 1-6 mg Hydromorphine: 0.8-1.5 Fentanyl: 0.025-0.1 Sufentanil: 0.01-0.06

PTX Exam 2 (8 decks)

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