Acute Pain Flashcards
(42 cards)
1
Q
What are the factors that increase the risk of developing chronic post-surgical pain?
A
- old age
- previous chronic pain
- type of procedure (mastectomy, thoracotomy, post-amp, CABG)
- depressive disorder
- anxiety disorder
- high catastrophization
- repeat surgery
- increased duration of surgery
- open vs laparascopic surgery
2
Q
Criteria for PSPS?
A
- surgical intervention
- greater than 2 months after surgery
- not due to pre-existing condition
- no other cause for pain
3
Q
What are the components of the opioid risk tool?
A
- history or pre-adolescent sexual abuse
- psychiatric disorders (MDD, OCD, Bipolar, ADHD, schizophrenia)
- family history
- personal history
- age
- female (more points)
4
Q
Anticoagulation guidelines for time of stopping of medications prior to high and intermediate pain procedures:
- ASA
- NSAIDs
- Aspirin
- Clopidogrel
A
NSAIDs
- Ketorolac/ibuprofen/diclofenac - 1 day
- Indomethacin - 2d
- naproxen/meloxicam - 4 days
Clopidogrel - 7 days; restart 12-24 hours
ASA
- Primary prevention 6 days,
- 2ndary prevention - shared assessment and risk start; restart 24hrs
Ticagelor - 5 days; restart
5
Q
Anticoagulation guidelines for time of stopping of medications prior to high and intermediate pain procedures:
- Warfarin
- Dabigatran
- Apixiban/rivaroxiban
- IV Heparin
- SC Heparin
- LMWH
A
- Warfarin - 5 days, a normal INR; restart 6 hours
- Dabigatran - 4 days (renal impairment 5-6d); restart 24 hours
- Apixiban/rivaroxiban - 3 days; restart 24 hours
- IV Heparin - 6h (high); 6h (med); 6h (low); restart 6h except low risk is 2h
- SC Heparin - 24h (high); 6h (med); 6h (low); restart 6h except low risk is 2h
- LMWH:
- Enoxaparin (prophylaxtic) - 12h (high); 12h (med); 12h (low); restart 12-24h except low risk is 4h
- Enoxaparin (therapeutic)/Dalteparin - 24h (high); 24h (med); 24h (low); ;restart 12-24h except low risk is 4h
6
Q
Indications for PCA?
A
- moderate to severe pain
- post-op pain
- burns/trauma
- Sickle cell/ pancreatitis/ painful med conditions
- cancer pain
7
Q
Preventative analgesia is?
A
- antinociceptive treatment that attenuates pain from high intensity noxious stimuli before, during and after the insult.
- goal is at attenuate afferent input produced by the peripheral NS that can alter the peripheral or central processing. (ie. central sensitization and CPSP)
8
Q
Indications for PCA?
A
- relief of moderate to severe pain
- post-op pain
- burns and truama
- sickle cell crisis/pancreatitis/painful med conditions
- cancer related pain
9
Q
Adjuncts for PCA?
A
- NSAIDs
- clonidine
- Precedex
- acetaminophen
- NMDA antagonists
10
Q
QTc prolonging medications used for analgesia?
A
- NSAIDS
- ketorolac (COX-1)
- celecoxib (COX-2)
- diclofenac (COX-2)
- Opioids
- methadone
- buprenorphine
- oxycodone
- tramadol
- meperidine
- Antidepressants
- SSRI
- TCAs
- Trazadone
- Venlafaxine
- AEDs
- gabapentin
- lamotrigine
- topiramate
- Muscle relaxants
- tizanidine
11
Q
What are 5 parameters of the PCA that you can set?
A
- loading dose
- demand or bolus dose
- dosing interval or lockout
- time-based cumulative dose
- background or basal infusion
12
Q
A
13
Q
Morphine PCA prescriptions:
- Loading dose?
- PCA dose?
- Lockout?
- Basal rate?
- 1 h limit?
A
- 2-5mg
- 0.5-2.5mg
- 5-10min
- 0.5-1mg
- 8-15mg
14
Q
Hydromorphone PCA prescriptions:
- Loading dose?
- PCA dose?
- Lockout?
- Basal rate?
- 1 h limit?
A
- 0.4-0.8
- 0.1-0.4
- 5-10min
- 0.1-0.4mg
- 1.2-2.4mg
15
Q
Fentanil PCA prescriptions:
- Loading dose?
- PCA dose?
- Lockout?
- Basal rate?
- 1 h limit?
A
- 0.02mg
- 0.025-0.05mg
- 5-10min
- 0.01-0.05mg
- 0.080-0.2mg
16
Q
Patients for which SC PCA would be appropriate?
A
pediatric
elderly
palliative
end-stage medical conditions
17
Q
SC PCA preferred sites?
A
infraclavicular area
abdomen
lateral aspect of thigh
flexor aspect of forearm
*sites rotated every 5 days or sooner
18
Q
The epidural space is between what two structures horizontally?
What are the most superior and inferior borders of the epidural space?
A
- dura and ligamentum flavum
- foramen magnum, sacrococcygeal ligament
19
Q
Compare and contrast the spinal anatomy at the cervical, thoracic and lumbar levels
A
- cervical
- very thin ligamentum flavum (LF)
- C7 most prominent cervical spine
- lamina are narrow triangles
- marked negative pressure (esp if seated)
- thoracic
- very narrow epidural space
- LF thicker than cervical but thinner than mid lumbar
- spinal cord narrowest
- marked negative pressure (esp if seated)
- lumbar
- widest epidural space
- SC ends about L1-2 in adults
- LF thickest
- spinous processes least angulated
- very prominent lateral epidural veins
20
Q
What are most common local anesthetics used in a epidural infusion?
A
bupivicaine and ropivicaine
Bupivicaine has been assocaited with significant cardiotoxicity and motor block
21
Q
What are the most common side effect of local anesthetics used in a epidural infusion?
A
- hypotension (from epidural induced sympathectomy; treatment - increase intravascular volume with cystalloid or colloid)
- motor block (switch to BUP)
- numbness (reduce concentration)
22
Q
Mechanism of action of opioids in epidural infusions?
A
penetration of opioid into the CSF through the dura
23
Q
Site of action of local anesthetics in epidural infusions?
A
spinal nerve roots and dural cuff regions
24
Q
Side effects of opioid epidural infusions?
A
nausea (tx: Zofran, prochlorperazine, low-dose naloxone)
pruritis (antihistamine, low dose naloxone)
resp depression (Naloxone, in small 0.04mg doses)
sedation (naloxone)
neuraxial effects (dysphoria?)
*avoid opioid epidurals in pts with OSA, use LA only
25
Name two additives for epidural infusions that can result in improved analgesia?
- clonidine
- epinephrine
26
What equipment is necessary for placing an epidural catheter (or ESI)?
cardiovascular monitoring
airway support equipment
caridopulmonary support equipment
Sterile kits
27
For epidural placement, when do you use a midline approach vs a paramedian approach?
midline - lumbar
paramedian - thoracic, esp. T5-T9
28
What is the optimal distance for threading the epidural catheter once it enters the epidural space?
3-5cm
29
What is the test dose of lidocaine with epi that use administer once you haev placed the epidural catheter?
3ml of 1.5-2% lido (45-60mg) with epi (5-10mcg)
if intravasc - will see immediate HR increase by 15-20
if intrathecal will get full motor and sensory block (small enough dose that it will not cause a high spinal)
30
Name 5 complication of placing an epidural catheter
1. headache (1-2% from dural puncture)
2. backache
3. sympathetic blockade (may cause significant hypotension)
4. high blockade
1. resp distress (intercostal block)
2. bradycardia (high thoracic block)
3. unconscious (total spinal block)
4. numbness in fingers or arms
5. Horner's syndrome
5. Nerve damage
6. Abcess
7. Hematoma
31
Compare and contrast epidural hematoma vs abcess.
* Abcess
* insidious and slow - hours to days
* starts with LBP; tenderness to percussion
* weakness progressing over hours to days ending abruptly in cauda equina syndrome
* fever, high WBC
* B&B dysfunction
* Dx: MRI with Gad
* Tx: surgical decompression and Abx
* Hematoma
* Acute and abrupt - minutes to hours
* starts with LBP; tenderness to percussion
* weakness progressing very rapidly to cauda equina syndrome or paresis
* Dx: MRI with Gad
* Tx: surgical decompression
32
What are the benefits of peripheral nerve blocks in acute pain management?
* less opioid use
* decreased incidence of PONV
* improved hemodynamic stability
* reduced time to discharge
33
Contraindications to peripheral nerve blocks?
* patient refusal
* localized infection
* Relative contraindications:
* pre-existing neurological deficit
* coagulopathy
* bacteremia
34
Risks of perpheral nerve block for acute pain?
* LAST
* nerve damage
* bleeding
* infection
* failed/inadequate block
35
What are three ways to minmize intraneural injections?
1. use a stimulating needle with appropriate current
2. use a blunt tipped needle
3. ultrasound guidance
36
What are four upper extremity regional block techniques?
1. Interscalene
2. supraclavicular
3. infraclavicular
4. axillary
37
Name the motor and sensory distribution of the following nerves:
1. Musculocutaneous
2. Median
3. Ulnar
4. Radial
1. Sensory - lateral forearm; motor - flexion of the upper arm at the shoulder and elbow
2. Sensory - lateral aspect of the palm, and the digital cutaneous branch, which innervates the lateral three and a half fingers on the anterior (palmar) surface of the hand; motor - lateral deviation of wrist, pincer grip of thumb, 2nd and 3rd digits,
3. Sensory - medial aspect of the hand (4th and 5th digits) on palmar and dorsal surface; motor - ulnar deviation and grip with 4th and 5th digits.
4. Sensory - extensor surfaces of hand and arm; motor - arm, wrist and finger extension
38
Intrascalene block is indicated for?
And what are the potential complications?
- shoulder surgery
poor coverage of inferior trunk so not good for forearm or hand surgery
Risks - diaphragmatic paralysis, Horner syndrome, recurrent larygneal nerve block (temp vocal cord paralysis), pneumothorax, seizures, high spinal (from epidura/intrathecal injection)
39
Indications for supra and infraclavicular blocks?
- surgeries distal to the midhumerus
40
Indications for axillary blocks?
surgeries distal to the elbow
41
Name the motor and sensory distributions for the following nerves:
1. Femoral
2. LCNT
3. Obturator
4. Tibial
5. Common peroneal
6. Sural
1. Sensory - Ant thigh and knee, medial aspect of lower leg (by saphenous); motor - leg extension
2. Sensory - lateral thigh; motor - none
3. Sensory - medial distal thigh; motor - hip adductors
4. Sensory - heel and plantar foor; motor - plantar flexion and inversion
5. Sensory - dorsal foot; motor - dorsiflexion; motor - dorsiflexion and eversion
6. Sensory - lateral foot; motor - none
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