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Systems: Specialities AB > Anaesthetics: Essential Pain Management > Flashcards

Anaesthetics: Essential Pain Management Flashcards

1
Q

What is pain?

A

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

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2
Q

What are the physical benefits for the patient if we treat pain?

A
  • Improved sleep, better appetite

- Fewer medical complications (e.g. heart attack, pneumonia)

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3
Q

What are the psychological benefits for the patient if we treat pain?

A
  • Reduced suffering

- Less depression, anxiety

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4
Q

What are the benefits for the family if we treat pain?

A
  • Improved functioning as a family member (e.g. as a father or mother)
  • Able to keep working
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5
Q

What are the benefits for society if we treat pain?

A
  • Lower health costs (e.g. hospital stay)

- Able to contribute to the community

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6
Q

How can pain be classified?

A

Duration

  • Acute
  • Chronic

Cause

  • Cancer
  • Non-cancer

Mechanism

  • Nociceptive
  • Neuropathic
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7
Q

What is acute pain?

A

Pain of recent onset and probable limited duration

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8
Q

What is chronic pain?

A
  • Pain lasting for more than 3 months
  • Pain lasting after normal healing
  • Often no identifiable normal healing
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9
Q

Describe pain from cancer?

A
  • Progressive

- May be a mixture of acute and chronic

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10
Q

Describe non-cancer pain

A
  • Can have many different causes

- Can be acute or chronic

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11
Q

Describe nociceptive pain

A
  • Sharp +/- dull

- Well localised

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12
Q

When does nociceptive pain occur?

A

When there is obvious tissue injury or illness

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13
Q

What does nociceptive pain function as?

A

It has a protective function and is also referred to as inflammatory pain

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14
Q

When does neuropathic pain occur?

A

When there is nervous system damage or abnormality

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15
Q

Describe neuropathic pain

A
  • Burning, shooting +/- numbness, pins and needles

- Not well localised

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16
Q

What are the 4 steps in the physiology of pain?

A
  • Periphery
  • Spinal cord
  • Brain
  • Modulation
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17
Q

What physiology occurs in the periphery during the pain response?

A
  • Tissue injury
  • Release of chemicals e.g. prostaglandins, substance P
  • Stimulation of pain receptors (nociceptors)
  • Signal travels in Aδ or C nerve to spinal cord
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18
Q

What physiology occurs in the spinal cord during the pain response?

A
  • Dorsal horn is the first relay station
  • Aδ or C nerve synapses (connects) with second nerve
  • Second nerve travels up opposite side of spinal cord
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19
Q

What physiology occurs in the brain during the pain response?

A

-Thalamus is the second relay station
Connections to many parts of the brain including cortex, limbic system and brainstem
-Pain perception occurs in the cortex

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20
Q

What physiology occurs during modulation in the pain response?

A
  • Descending pathway from brain to dorsal horn

- Usually decreases pain signal

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21
Q

What is the gate theory?

A

Stimulation by non-noxious input is able to suppress pain by closing the ‘gate’ to painful input preventing pain sensation from travelling to the cortex

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22
Q

Give examples of neuropathic pain

A
  • Nerve trauma, diabetic pain (damage)

- Fibromyalgia, chronic tension headache (dysfunction)

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23
Q

What is the pathology behind neuropathic pain?

A
  • Increased receptor numbers
  • Abnormal sensitisation of nerves (peripheral and central)
  • Chemical changes in the dorsal horn
  • Loss of normal inhibitory modulation
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24
Q

What types of drugs can be used for the treatment of pain?

A
  • Simple analgesics
  • Opioids
  • Other analgesics
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25
Q

Give examples of simple analgesics.

A
  • Paracetamol (acetaminophen)

- Non-steroidal anti-inflammatory drugs

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26
Q

Give examples of opioid drugs

A

Mild
-Codeine, dihydrocodeine

Strong
-Morphine, oxycodone, fentanyl

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27
Q

Other than simple analgesics and opioids, what other drugs can be used for pain?

A
  • Tramadol (mixed opiate and 5HT/NA reuptake inhibitor)
  • Antidepressants (e.g. amitriptyline, duloxetine)
  • Anticonvulsants (e.g. gabapentin)
  • Ketamine (NMDA receptor antagonist)
  • Local anaesthetics
  • Topical agents (e.g. Capsaicin)
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28
Q

What non-drug treatments can be used to act at the periphery?

A
  • Rest
  • Ice
  • Compression
  • Elevation
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29
Q

What drugs can be used to act at the periphery?

A
  • NSAIDs

- Local anaesthetics

30
Q

What non-drug treatments can be used to act at the spinal cord?

A
  • Acupuncture
  • Massage
  • TENS
31
Q

What drugs can be used to act at the spinal cord?

A
  • Local anaesthetics
  • Opioids
  • Ketamine
32
Q

What non-drug treatment can be used to act at the brain?

A

Psychological therapies

33
Q

What drugs can be used to act on the brain?

A
  • Paracetamol
  • Opioids
  • Amitriptyline
  • Clonidine
34
Q

What route of drug delivery is preferred?

A

Oral

35
Q

What are the advantages of paracetamol?

A
  • Cheap, safe

- Can be given orally, rectally or intravenously

36
Q

What is the disadvantage of paracetamol?

A

Liver damage in overdose

37
Q

What is paracetamol good for?

A

Mild pain (by itself) or moderate- severe pain (with other drugs)

38
Q

Give examples of NSAIDs

A
  • Aspirin
  • Ibuprofen
  • Diclofenac
39
Q

What are the advantages of NSAIDs?

A
  • Cheap

- Generally safe

40
Q

What is the disadvantage of NSAIDs?

A
  • GI and renal side effects

- Sensitive for asthmatics

41
Q

What are NSAIDs good for?

A

Nociceptive pain

42
Q

What are the advantages of codeine?

A
  • Cheap

- Safe

43
Q

What is codeine good for?

A

Mild to moderate acute nociceptive pain

44
Q

What are the disadvantages of codeine?

A
  • Can cause constipation

- Not good for chronic pain

45
Q

What is tramadol?

A

Painkiller with a weak opioid effect plus inhibitor of serotonin and noradrenaline reuptake (modulation)

46
Q

What are the advantages of tramadol?

A
  • Less respiratory depression
  • Can be used with opioids and simple analgesics
  • Not a controlled drug
47
Q

What are the disadvantages of tramadol?

A

Nausea and vomiting

48
Q

What are the advantages of morphine?

A
  • Cheap, generally safe
  • Can be given IV, IM, SC
  • Effective if given regularly
49
Q

What is morphine good for?

A
  • Moderate to severe nociceptive pain (i.e. post-op pain)

- Chronic cancer pain

50
Q

What are the disadvantages of morphine?

A
  • Constipation
  • Respiratory depression in high dose
  • Misunderstandings about addiction
  • Controlled drug
51
Q

How does the oral dose of morphine differ from the IV/IM/SC dose?

A

Oral dose is 2-3 times that of IV/IM/SC dose

52
Q

What is amitriptyline?

A

Tricyclic antidepressant

53
Q

How does amitriptyline work?

A

Increases descending inhibitory signals

54
Q

What are the advantages of amitriptyline?

A
  • Cheap, safe in low dose
  • Good for neuropathic pain
  • Also treats depression and poor sleep
55
Q

What are the disadvantages of amitriptyline?

A

Anti-cholinergic side effects (i.e. glaucoma, urinary retention)

56
Q

Give examples of anticonvulsants that can be used for pain.

A
  • Carbamazepine (tegretol)
  • Sodium valproate (epilim)
  • Gabapentin (neurotonin)
57
Q

Why are anticonvulsants also known as membrane stabilisers?

A

They reduce abnormal firing of nerves

58
Q

What are anticonvulsants good for?

A

Neuropathic pain

59
Q

How should neuropathic pain be managed?

A

Use alternative analgesics and/or psychological and non-drug treatments

60
Q

What are the steps in the WHO pain ladder?

A

Step 1
-Paracetamol +/- NSAIDs

Step 2
Paracetamol (+/- NSAIDs) + Codeine/alternative

Step 3
Paracetamol (+/-NSAID) + Morphine

61
Q

How should the pain ladder be used for mild pain?

A

Start at bottom of the pain ladder

62
Q

How should the pain ladder be used for moderate pain?

A

Bottom of pain ladder plus the middle rung

63
Q

How should the pain ladder be used for sever pain?

A
  • Bottom of pain ladder plus top of ladder. Miss out the middle
  • It is okay to start at the top of the ladder for sever/unbearable pain
64
Q

How should the pain ladder be used as pain resolves?

A
  • Move down the ladder, passing the middle rung first
  • Move from top to middle of WHO ladder
  • Continue bottom rung drugs at all times
  • Lastly stop NSAIDs, then paracetamol as more adverse side effects with NSAIDs
65
Q

What is the RAT approach?

A
  • Recognise
  • Assess
  • Treat
66
Q

How do you recognise that a patient is in pain?

A

Does the patient have pain?

  • Ask
  • Look (frowning, moving easily, sweating?)

Do other people know the patient has pain?

  • Other health workers
  • Patient’s family
67
Q

How do you assess a patient’s pain?

A

Severity

  • Pain score at rest and on movement
  • How does the pain affect the patient?

Type

  • Acute vs chronic
  • Cancer vs non-cancer
  • Nociceptive vs neuropathic
68
Q

What neuropathic features may pain have?

A
  • Burning or shooting pain
  • Phantom limb pain
  • Other features (pins and needles, numbness)
69
Q

What other factors can influence the severity of a patient’s pain?

A

Physical factors
-Other illnesses

Psychological and social factors

  • Anger, anxiety, depression
  • Lack of social support
70
Q

What drugs are used in neuropathic pain?

A
  • Amitriptyline
  • Gabapentin
  • Duloxetine
71
Q

What should be done after using the RAT algorithm?

A

Reassess the patient to see if the treatment is working and if any other treatments are required

72
Q

What is RICE?

A
  • Rest
  • Ice
  • Compression
  • Elevation

Systems: Specialities AB (19 decks)

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