Pain Flashcards
(40 cards)
1
Q
What is acute pain?
A
- Caused by tissue damage– it is a protective response
- Peripheral nociceptive neuron is stimulated by intense noxious stimuli which sends a signal to the CNS
- CNS: brain and spinal cord process the afferent input and this results in sensation of pain
2
Q
What is chronic pain?
A
- Neural dysfunction in the peripheral and/or CNS pain pathways
- extends beyond the expected 3-6 months healing period and often has no identifiable cause
- serves no purpose
3
Q
What are the consequences of pain?
A
- Activation of stress response- SNS and adrenocortical stimulation
- elevated blood sugar
- immunosuppression
- urinary retention
- altered coagulation
- psychosocial- anxiety, depression, impact of relationships and productivity
4
Q
What makes pain assessment difficult?
A
- It is difficult because it is subjective and each patient’s experience of pain is unique
- Pain can be influenced by:
- unique physiology (PNS and CNS circuitry)
- pathophysiology
- personality
- previous life experience
- cultural and religious background
- age
- Healthcare providers may undertreat pain if:
- they dont believe the pt
- they dont understand the science behind it
5
Q
What should you assess regarding the history of pain?
A
- existence of pain
- assess each type of pain/pain problem separately
- previous injuries
- Adjunctive therapies
- acupuncture, TENS, injection therapy, SCS
- Coexisting psychological disease/physical disease
6
Q
What are the elements of a pain assessment?
A
- P- precipitating events
- Q- quality
- R- Region/radiation
- S- severity
- T- Temporal relationship/Timing
-
A- associated symptoms
- functional impairment
- previous treatment
- inflammation
- Pain goals
7
Q
What is the benefit of behavioral pain scales?
A
- provides a means for consistent evaluation of pain in non-verbal patients
- pediatric pts
- pts with cognitive impairment
- critically ill patients
8
Q
What pain scale would be appropriate for a pediatric patient >3 yrs old?
A
- Wong-Baker FACES scale
9
Q
What is the Payen Behavioral pain scale?
A
- It was developed for critically ill intubated ICU patients
- Is reliable and valid and correlates to NPI ratings, even in patients who are on sedation
- uses a 0-12 pain rating scale
10
Q
For what patients would you use the FLACC score?
A
2 months to 7 years
11
Q
For what patients would you use the CRIES pain scale?
A
0-6 month olds
12
Q
What else should you assess in a patient with chronic pain?
A
- General medical history- comorbidities contributing to complex pain condition
- How does pain effect:
- sleep?
- physical functions?
- ability to work?
- your mood?
- family/social life?
- What treatments have you received? Effects? adverse effects?
- Are you depressed
13
Q
What should you assess on the physical exam of pain?
A
- General physical examination
- affected area
- neurological exam
- musculoskeletal system
- ROM
- muscle wasting
- skin- redness, wounds, edema, changes
- assessment of psychological factors: un-kept personal hygiene
14
Q
What are some specific diagnostic studies that can be done?
A
- Quantitative sensory testing for pain thresholds and pain tolerance
- diagnostic nerve blocks
- pharmacologic tests
- conventional radiography, tomography, MRI, ultrasound imaging
- Electromyography nerve test (EMG)- assess nerve impulses into muscle
- Nerve conduction velocity test (NCV)- to see how rapid an impulse comes through a nerve
- bone scans- cancer pain
- blood test- looking for comorbidites
15
Q
How can you test for different types of allodyna?
A
- “poor man’s sensory testing”
- Cold allodynia- cold water in a glass tube
- heat allodynia- glass tube with warm water
- dynamic mechanical allodynia- cotton wool and artist’s brush
- hyperalgesia- blunt needle
16
Q
What is the neuroendocrine response that is caused by acute pain?
A
An SNS response, release of cortisol and Renin
17
Q
What may be a predictor of chronic pain?
A
Poorly controlled acute pain
18
Q
What ways may cancer cause pain?
A
- By the cancer
- tumor invading bone (most common)
- tumor compressing peripheral nerves
- Pain due to treatment
- Physical effects- pain can worsen due to loss of sleep, appetite, nausea, and vomiting
- Psychological- pain can worsen with heightened anxiety, feelings of loss, low self-esteem, changes in life goals, disfigurement
19
Q
Why is it important to manage post-operative pain?
A
- Reduces stress response
- shorter times to extubation, shorter ICU stay
- improved respiratory function
- earlier return of bowel function
- early mobilization, decreased risk of DVTs
- early discharge
- patient satisfaction
- reduction in sensitization, neuroplasticity, wind-up phenomenon and transition to chronic pain
20
Q
What is the wind-up phenomenon?
A
- The idea that pain will increase when a stimulus is delivered repeatedly above a critical rate
- Caused by repeated stimulation of C fibers
21
Q
What is preemptive analgesia?
A
- Blockade of response to noxious stimuli and extending this block into the postoperative period
- Reduced post-op pain and accelerates recovery
- Thought to stop peripheral and central sensitization and hyperexcitability to pain and therefore the development of chronic pain
22
Q
What is the principle of the multimodal approach?
A
- Control postoperative pain and attenuate the perioperative stress response through the use of regional anesthetic techniques and a combination of analgesic agents (multimodal analgesia)
- It is an extension of “clinical pathways” into effective postoperative rehabilitation pathways
23
Q
What are the ERAS protocols regarding pain?
A
- Early Recovery After Surgery
- Pre-hospital: make a pain management plan
- Pre-op: initiation of multimodal medications and regional block placement
- Intra-op: short-acting, opioid-sparing medications; multimodal medications; regional
- Post-op: regional analgesia, non-opioid analgesics/NSAIDS
24
Q
What are the different modes of drug administration?
A
- IV- preferred
- SC
- IM
- Oral
- SL
- PR
- Buccal
- intranasal
- transdermal patch
- *ketamine nebulizers or gargles- have a systemic effect
25
Opioids
how do they work?
advantages
disadvantages
* *Were* the standart in pain managment
* Work by affecting mu and kappa opioid receptors in the CNS
* Adv: no analgesic ceiling
* Disadv: side effects
* **respiratory depression**
* hypotension
* N/V
* sedation
* pruritus
* urinary retention
* dependence
26
How do NSAIDS work?
When is it used?
* Analgesic effect achieved through inhibition of cyclooxygenase (COX), preventing the synthesis of prostaglandins
* results in the attenuation of the nociceptive response to inflammatory mediators
* peripherally and in the spinal cord
* Used in mild to moderate pain and pain related to inflammatory conditions
* useful in adjunct to opioids
27
Side effects of NSAIDS?
* Renal dysfunction
* GI hemorrhage
* effects on bone healing/osteogenesis
* liver dysfunction
* decreased homeostasis
* platelet dysfunction
* inhibition of thyromboxane A2
28
What are some NSAIDS?
* **Ketorolac**
* piroxicam (Feldane)
* Nabumatone (Relafen)
* Indomethacin (Indocin)
* Celecoxib (Celebrex)
* Parecoxib
* Caldolor (ibuprophen)
29
What are some adjubant drugs that can help treat pain?
* Ketamine- IV, gargled, nebulized
* Nalbuphine (nubain)- IV
* Lortab elixir (hydrocodone and acetaminophen)- PO
* Gabapentin (Neurontin)- PO
* Mag sulfate- PO, IV
* Lidocaine lollipops
* lidocaine infusions
* Beta blockers
* Corticosteroids
30
What are the benefits of peripheral nerve blocks?
* Single injection or continuous infuison
* can be used intraoperatively or as an adjunct to postoperative analgesia
* limits the path of nociceptive impulses
* superior analgesia
* few side effects
* can have analgesia for up to 24 hours after singel injection
31
What are the benefits of neuraxil analgesia?
* provide superior analgesia compared with systemic opioids
* reduced stress response
* facilitates return of GI motility
* decreased incidence of pulmonary complications
* decreased incidence of coagulation-related adverse events
32
Neuraxial opioids:
Difference between hydrophilic and lipophilic opioids
* Hydrophilic opioids:
* morphine and dilaudid
* tend to remain within the CSF
* delayed onset of action
* longer duration
* extensive CSF spread
* high incidence of side effects
* Lipophilic opioids
* Fentanyl and sufentanyl
* Rapid onset of action
* shorter duration
* minimal CSF spread due to segmental analgesic effect
* less side effects
33
What do you need to consider regarding Continuous epidural analgesia?
* Choice and dose of analgesic agents
* location of catheter placement
* onset and duration of perioperative use
* side effects and risks
* availability of pain management personnel
34
Regarding Analgesic agents for epidural:
LAs only
Opioids only
LAs combine with Opioids
* LAs only
* high failure rate
* high incidence of motor blockade- d/t density required to have effect
* hypotension common
* Opioids only
* Avoids motor block
* less hypotension
* side effects: resp dep, pruritis
* Combined LA and opioids
* Better choice for epidural
* limits regression of sensory block
* less motor block
* decreases total dose of LA
* great choice for abdominal, pelvic, thoracic, orthopedic procedures of lower extremeties
35
What are some of the epidural drugs?
* LAs
* lidocaine
* bupivicaine
* ropivacaine
* Opioids
* morphine
* dilaudid
* fentanyl
* sufentanyl
36
What are some adjuvant neuraxil drugs?
how do they work?
limits?
* Clonidine
* selective alpha 2 agonist
* prolongs duration of block
* limited by side effects:
* hypotension, bradycardia, sedation
* Epinephrine and Neosynephrine
* prolongs duration and intensity of block
37
Medication related side effects of neuraxial analgesia
* Hypotension
* motor blockade
* N/V
* pruritis
* respiratory depression
* urinary retention
38
What are the risks of epidural analgesia?
* complications with placement
* epidural hematoma
* abscess
* neurologic injury
* Intravenous, entrathecal, or subcutaneous injection of medications
* anticoagulants:
* post-op surgical anticoagulants
39
What are some adjunct treatments for acute pain?
* Ice
* surgical
* local infiltration
* intra-articular analgesia
* pain pumps
* TENS
* acupuncture
* psychological approaches
* hypnosis
* distraction
* relaxation
* imagery
* music
40
What are the advantages of a PCA?
* cost-effective
* higher degree of patient satisfaction
* total drug consumption is less
* harder to overmedicate self
* prevents the pain-no pain cycle
