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Year 2 C&M Clinical Symposia > Pain 2 > Flashcards

Pain 2 Flashcards

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1
Q

What are the 2 types of pain as classified by duration?

A

1) Acute

2) Chronic

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2
Q

What are the 2 types of pain as classified by pathophysiology?

A

1) Nociceptive

2) Neuropathic

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3
Q

What are the main differences between acute and chronic pain?

A

Acute pain is associated with injury and resolves with healing of the underlying injury, it serves a protective function and assists wound repair
Chronic pain persists beyond the normal type of healing and is dissociated from tissue damage, it ceases to perform a protective function and is associated with considerable suffering

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4
Q

What is nociceptive pain?

A

Pain which is caused by actual tissue damage and painful stimuli at nociceptors

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5
Q

How is nociceptive pain regulated?

A

By the opioidergic system

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6
Q

Is it possible to get chronic nociceptive pain?

A

Yes - for example osteoarthritis, but chronic nociceptive pain may lead to neuropathic and mixed pain

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7
Q

What are the 2 main beneficial aspects of acute pain?

A

1) protective - avoid further damage
2) Learning experience
It is part of the trauma response

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8
Q

What are the 4 main adverse effects of acute pain?

A

1) Humanitarian issue
2) Cardiovascular stress
3) Respiratory compromise
4) Hypercoagulation

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9
Q

For what 2 reasons is it very difficult to measure pain?

A

1) It is a synthesis of several observations eg. intensity, quality etc
2) How it is perceived is relative to distress of person eg. acid reflux in normal 43 year old compared to in a 43 yr old with strong family history of IHD may be perceived as more severe in latter

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10
Q

What are the 5 factors associated with changes in pain perception?

A

1) Anxiety
2) Depressed affect - if depressed pain is felt more strongly
3) Gender - socialisation/gonadotrophins
4) Circadian variation - pain worse in middle of night
5) Climatic conditions - MSK pain thought to be worse in cold

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11
Q

How can pain be assessed in patients?

A

Self reported - visual analogue score

Assess at rest and during movement

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12
Q

What are the 3 main steps in the analgesic ladder, when do you progress through the ladder?

A

Start at the bottom and progress if pain persists or is increasing

1) Non-opioid +/- adjuvant
2) Opioid for mild to moderate pain + non opioid +/- adjuvant
3) Opioid for moderate to severe pain + non opioid +/- adjuvant

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13
Q

Name 4 non opioid drugs?

A

1) Acetaminophen
2) Aspirin
3) NSAIDs
4) Cox-2 inhibitors

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14
Q

Name 3 opioids for mild to moderate pain?

A

1) Codeine
2) Dihydrocodeine
3) Tramadol

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15
Q

Name 5 opioids for moderate to severe pain?

A

1) Morphine
2) Fentanyl
3) Hydromorphone
4) Buprenorphine
5) Methadone

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16
Q

In what way do opioids act at 2 sites in the spinal cord?

A

1) Presynaptically pain signal transmission is reduced

2) Post synaptic membrane is hyperpolarised, decreasing the probability of an action potential being generated

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17
Q

NSAIDs and COX-2 inhibitors act mainly peripherally, which non opioid has central acitivity?

A

Paracetemol

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18
Q

What is the mode of action of NSAIDs?

A

Inhibition of cyclo-oxygenase - prostaglandin synthesis decreases

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19
Q

What are the 4 main side effects of NSAIDs?

A

1) GI irritation/bleeding
2) Renal toxicity
3) Potential drug-drug interactions
4) CV side effects (COX2)

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20
Q

What is the efficacy of NSAIDs?

A

Mainly act on nociceptive pain

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21
Q

What is the efficacy of opioids?

A

Mainly nociceptive pain - less effective in chronic states, only partially effective in neuropathic pain

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22
Q

What is the efficacy of paracetemol?

A

Analgesic and antipyretic effects, no anti inflammatory action

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23
Q

What is the mode of action of paracetamol?

A

Not fully understood - inhibits central prostaglandin synthesis

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24
Q

What is the main side effect of paracetamol?

A

Risk of toxic liver damage

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25
What is the mode of action of opioid analgesics?
- Activate the endogenous analgesic system - Stimulate receptors in the limbic system to eliminate the subjective feeling of pain - Affect descending pathways that modulate pain perception - Reduce ascending pain signal transmission in the spinal cord
26
What is the problem with large bolus analgesia?
Narrow range in which get analgesia without side effects - when only given as a large bolus then the plasma level fluctuates from pain to a level at which side effects occur rather than staying constantly within the plasma level range which has only analgesic effects
27
Name a method of avoiding large bolus analgesia and maintaining opioids within the optimum therapeutic range?
Patient controlled analgesia - small bolus and 5 minute lockout
28
What are the 6 main side effects of opioids?
1) Nausea 2) Vomiting 3) Constipation 4) Dizziness or vertigo 5) Somnolence 6) Dry skin, pruritus
29
What is the most serious potential adverse affect of systemic opioid analgesia?
Respiratory depression and hypoxia
30
What is the best early warning sign of respiratory depression with systemic opioids?
Progressive sedation | - not respiratory rate, not SpO2
31
What 2 opioids should not be used in patients with renal failure and why?
Morphine or codeine Sedative metabolites accumulate (Fentanyl or oxycodone are OK)
32
In patients with a history of substance abuse how should opioids be used?
Give what is required - use balanced analgesia
33
What is epidural anaesthesia?
Drugs administered directly into the epidural space
34
What are the 3 common uses of epidural anaesthesia?
1) Postoperatively: thoracic, abdominal, groin/perineal, lower limb surgery 2) Labour pain 3) Chronic pain
35
What are the 6 benefits of epidural anaesthesia?
1) High quality pain relief 2) Improved pulmonary function 3) Reduced sepsis and chest infection 4) Reduced cardiac morbidity 5) Reduced vascular graft failure 6) Reduced incidence of DVT
36
Where is the epidural space?
Between dura mater and the wall of the vertebral canal
37
What are the 5 areas of block in epidural anaesthesia?
1) High thoracic - upper chest 2) Low thoracic - middle trunk 3) Low thoracic/high lumbar - lower trunk and groin area 4) Lumbar - legs 5) Caudal - saddle region
38
What percentage of people with advanced cancer experience pain?
75%
39
What percentage of cancer patients control their pain with oral or sub cut opioids?
90% -the other 10% require complex management
40
What are the rough guidelines for use of morphine correctly?
1) begin with regular immediate release morphine (provide access morphine for breakthrough pain) 2) Review regular requirement by incorporating breakthrough dose into new 4 hourly dose 3) When stable convert to sustained release morphine (but still provide for breakthrough pain)
41
What type of cancer is a celiac plexus block used in?
Pancreatic carcinoma and upper abdominal neoplasia
42
At what part of the spinal cord do spinal opioids act at?
Dorsal horn of the cord
43
Which type of spinal opioid reaches the brainstem?
Lipophobic morphine
44
Which type of spinal opioid remains segmentally localised?
Lipophilic fentanyl
45
In what 5 ways can morphine be administered?
1) PO 2) IV 3) Epidural 4) Intrathecal 5) Intraventricular
46
What is neuropathic pain?
Spontaneous pain and hypersensitivity to pain in association with damage to or a lesion of, the nervous system, it is intense and may be accompanied by another pain phenomenon, often persistent and associated with severe comorbidity and poor quality of life
47
Give 5 examples of conditions which cause neuropathic pain?
1) Post herpetic neuralgia 2) Painful diabetic neuropathy 3) Trigeminal neuralgia 4) Pain after CVA 5) Post traumatic/post operative
48
What is thought to be the spinal mechanism behind neuropathic pain following surgery/ trauma?
Hyperexcitable spinal cord Previously silent nociceptors start signalling following trauma Have an expanded hyperexcitable dorsal horn with ne inputs
49
What is the supraspinal mechanism involved in neuropathic pain following surgery/trauma?
Remapping of the thalamus and cortex - this is associated with more pain Regions of the cortex which prior to the surgery were receiving input and now are not, get confused by this and start manifesting pain
50
WHat are the 7 features suggesting neuropathic pain?
1) Pain different from normal everyday pain 2) Pain in the absence of ongoing tissue damage 3) Pain in an area of sensory loss 4) Paroxysmal or spontaneous pain 5) Allodynia (pain in response to non painful stimuli) 6) Hyperalgesia (increased pain in response to painful stimuli) 7) Dysaesthesia (unpleasant abnormal sensations - eg ants crawling on the skin)
51
What is the prevalence of neuropathic pain?
2-4% of population
52
What 3 psychiatric conditions are associated with neuropathic pain?
1) Depression 2) Anxiety 3) Insomnia
53
Name a questionnaire designed to measure pain quality?
McGill Pain questionnaire
54
What are the 2 advantages and 2 problems with the McGill Pain questionnaire?
``` Advantages = Well validated and quality assessed Problems = Time consuming, Insensitive to small change in intensity ```
55
Which type of pain medication acts on the brain?
Opioids
56
Which 4 types of pain medication act on the dorsal grey horn?
1) Opioids 2) Antidepressants 3) Anticonvulsants 4) Non-opioid analgesics
57
Name 2 types of pain medication which act in the periphery?
1) Topical analgesics | 2) Non-opioid analgesics
58
What are the 5 possible drug therapies for neuropathic pain?
1) Antidepressants 2) Anticonvulsants 3) Opioids 4) Membrane stabilising drugs 5) Topical drugs
59
For what 3 types of pain are antidepressants (TCAs) effective?
1) Neuropathic pain 2) Complex regional pain syndrome 3) Tension headache
60
What is the mode of action of antidepressants - TCAs?
Inhibition of neuronal re-uptake of noradrenaline and serotonin 5-HT
61
What are the 6 side effects of TCAs?
1) Constipation 2) Dry mouth 3) Somnolence 4) Abnormalities in heart rate and rhythm 5) Insomnia 6) Increased appetite
62
Can antidepressants other than tri-cyclic agents be used for neuropathic pain?
No - serotonin uptake inhibitors are relatively ineffective
63
What are the modes of action of the anticonvulsants Gabapentin, Pregabalin, Carbamazepine in the treatment of neuropathic pain?
Gabapentin - binds to pre-synaptic voltage-dependent calcium channels Pregabalin - interacts with special N-type calcium channels Carbamazepine - blocks Na+ and Ca2+ channels
64
What are the 6 main side effects of anticonvulsants?
1) Sedation 2) Dizziness 3) Ataxia 4) Peripheral oedema 5) Nausea 6) Weight gain
65
Does the anticonvulsant Gabapentin work in both nociceptive and neuropathic pain?
Prevents neuropathic but not nociceptive pain in animal models
66
How is the anticonvulsant Gabapentin excreted?
Renally excreted
67
What does operant conditioning have to do with pain?
Whilst nociception may be the origin of a pain behaviour, if that pain behaviour is reinforced it is likely to occur even in the absence of nociception
68
What are the non medical approaches to managing chronic pain?
1) Cognitive behavioural therapy 2) Stress management 3) Attention/ distraction techniques

Year 2 C&M Clinical Symposia (21 decks)

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