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Pharmacology > Pain Management Part I > Flashcards

Pain Management Part I Flashcards

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1
Q

Describe general anesthetics

A
  • used for major surgeries
  • induces a reversible state of unconsciousness
  • provides amnesia
  • often used in conjunction
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2
Q

Describe the ideal anesthetic

A
  • Rapid onset
  • Loss of consciousness & sensation
  • Amnesia
  • Skeletal muscle relaxation
  • Inhibition of sensory & autonomic reflexes
  • Easy dose adjustment
  • Minimum toxic side effects
  • Recovery rapid & uneventful
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3
Q

What are the stages of anesthesia

A
  • Stage I Analgesia: still conscious, somewhat aware, loss of sensation
  • Stage II Excitement: unconscious, amnesiac, appears agitated & restless
  • Stage III Surgical Anesthesia: ideal level for surgery, regular & deep respirations
  • Stage IV Medullary Paralysis: should be avoided, cessation of spontaneous respirations, cardiovascular collapse
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4
Q

Routes of administration for anesthetics

A
  • Inhalation: gases/volatile liquids; longer onset to stage III; easier to adjust dose & maintain anesthesia
  • Intravenous (IV): several categories of CNS depressants; rapid onset to stage III; risk of over medication
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5
Q

Describe inhalation anesthetics

A
  • Gases: Nitrous oxide, used for short procedures
  • Volatile liquids: several chemically similar agents available; Desflurane or Sevoflurane are preferred due to rapid onset, faster recovery, & better anesthesia control
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6
Q

Describe intravenous (IV) anesthetics

A
  • Barbiturates: induction of anesthesia, fast onset, relatively safe
  • Benzodiazepines: induction & maintain of anesthesia
  • Opiod analgesics: induction & maintain of anesthesia
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7
Q

Describe Ketamine

A
  • dissociative anesthesia
  • pt appears detached from surroundings
  • awake but sedated & unable to recall events
  • useful for short procedures
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8
Q

Adverse effects and advantages of Ketamine

A
  • Adverse effects: hallucinations, strange dreams, & other psychotic reactions
  • Advantages: less respiratory adverse effects & less cardiac dysfunction
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9
Q

Describe Propofol (IV anesthesia)

A
  • Short acting hypnotic
  • Rapid onset
  • Induction & maintenance
  • Rapid recovery
  • Continuous infusion: sedation of mechanically ventilated patients
  • Rare adverse effect: Propofol related infusion syndrome (PRIS)
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10
Q

Describe Etomidate (IV anesthesia)

A
  • Hypnotic like drug
  • Rapid onset
  • Short duration
  • Quick recovery
  • Minimal cardiopulmonary side effects
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11
Q

Describe Dexmedetomidine (IV anesthesia)

A
  • Alpha 2 agonist
  • No respiratory depression
  • Adjunct during surgery
  • Short term sedation for mechanically ventilated patients
  • Hypotension
  • Bradycardia
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12
Q

Describe anesthesia pharmacokinetics

A
  • widely and uniformly distributed
  • high degree of lipid solubility
  • stored in adipose tissue: slow washout, longer based on duration of anesthesia or patient weight
  • Elimination: excretion from the lungs, biotransformation in the liver
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13
Q

Describe the mechanism of action for anesthesia

A
  • Inhibit neuronal activity in the CNS: sedation, hypnosis, amnesia
  • Inhibit neuronal function in spinal cord: immobility, inhibiting motor response to painful stimuli
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14
Q

Describe neuromuscular blockers

A
  • Adjunct to general anesthesia
  • Skeletal muscle paralysis
  • Does not provide anesthesia, sedation, analgesia, or amnesia (DO NOT USE ALONE)
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15
Q

Neuromuscular blockers mechanism of action

A
  • block transmission of nerve impulses (depolarizing or non-depolarizing)
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16
Q

Adverse effects of neuromuscular blockers

A
  • Tachycardia
  • Increased histamine release
  • Hyperkalemia
  • Residual muscle pain & weakness
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17
Q

Physical therapy considerations with neuromuscular blockers varying washout period

A
  • Increased confusion
  • Disorientation
  • Lethargy
  • Delirium
  • Muscle weakness
  • Bronchial secretions
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18
Q

Describe local anesthetics (LA)

A
  • Loss of sensation in a specific area
  • Used prior to minor surgical procedures
  • Rapid recovery with minimal side effects
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19
Q

Non- surgical use of local anesthesia (LA)

A
  • Short term pain relief: musculoskeletal & joint pain
  • Chronic pain: cancer, complex regional pain syndrome
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20
Q

How can a PT deliver local anesthesia (LA)

A
  • phonophoresis
  • iontophoresis
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21
Q

What factors go into the selection of local anesthetics (LA)

A
  • Operative site
  • Nature of procedure
  • Type of regional anesthesia
  • Anesthetic duration
  • Patient characteristics
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22
Q

Describe the pharmokinetics of local anesthetics (LA)

A
  • Drug to remain at administration site: trigeminal nerve for dental procedure; spinal cord (epidural, spinal)
  • Commonly used with vasoconstrictor: epinephrine prevents “washout” from site; prevent from reaching the bloodstream (decreases systemic side effects)
  • Eliminated by hydrolysis
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23
Q

Clinical uses of local anesthetics (LA)

A
  • Topical
  • Transdermal
  • Infiltration
  • Peripheral nerve block
  • Central nerve blockade
  • Sympathetic blockade
  • Intravenous (IV) regional anesthesia
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24
Q

Describe topical local anesthetics (LA)

A
  • Applied directly to produce analgesia: skin, mucous membranes, cornea
  • Used for minor surface irritation or injury: burns, abrasions, inflammation
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25
Describe transdermal local anesthetics (LA)
- Applied to skin surface - Enhanced with electrical current (iontophoresis) and/or ultrasound (phonophoresis) - Used in dermatologic & minor surgical procedures - Transdermal patch: musculoskeletal pain, neuropathic pain
26
Describe infiltration anesthesia (LA)
- Injection directly into selected tissue - Diffuse sensory nerve endings - Used for performing surgical repair
27
Describe peripheral nerve block local anesthetics (LA)
- Injected close to nerve trunk - Interrupt transmission along the nerve - Used in dental procedures - Minor nerve black: single peripheral nerve - Major nerve block: several nerves or nerve plexus
28
Describe central nerve blockade (LA)
- Injected in spaces surrounding the spinal cord - Epidural nerve blockade: injected into the space b/w the bony vertebral column & the dura mater - Caudal block: injected into lumbar epidural space via sacral hiatus - Spinal nerve blockade: injected into subarachnoid space
29
Describe sympathetic blockade (LA)
- Selective interruption of sympathetic efferent discharge - Used for complex regional pain syndrome (CRPS) - Injected into area surrounding the sympathetic chain ganglion innervating the limb: usually involves a series of 5 injections; goal is decreased sympathetic outflow not analgesia
30
Describe intravenous regional anesthesia (LA)
- Injected into peripheral vein in selected extremity - Local vessels carry anesthetic to the nerves in that extremity - Requires use of a tourniquet to localize the medication - Used for short surgical procedures or to treat CRPS
31
What is the mechanism of action (MOA) of local anesthetics (LA)
- Inhibit opening of sodium channels on nerve membranes - Blocks action potential along neuronal axons - Only 2-3 nodes of Ranvier in a myelinated neuron need to be affected to block the action potential
32
Describe differential nerve block
- Local anesthetics block specific nerve fiber groups depending on their size & myelination - Smallest fibers first then progressively larger fibers - Different diameter fibers transmit different information: Smallest (type C) transmit pain & Largest (Type A-alpha) transmit impulses to skeletal muscle
33
Systemic effects of local anesthetics (LA)
- Temperature - Local Anesthetic Systemic Toxicity (LAST): early symptoms include ringing in the ears, agitation, restlessness, decreased sensation in the tongue, around the mouth, & areas of the skin
34
CNS and cardiac effects of local anesthetic systemic toxicity (LAST)
- CNS: somnolence, confusion, agitation, excitation, seizures, impaired respiratory function - Cardiac: decreased cardiac excitation, HR, & force contraction
35
PT considerations with local anesthetics (LA)
- PTs may be involved in administration of LAs to treat musculoskeletal pain: iontophoresis and phonophoresis - Working with patients post anesthesia: decreased sensation below the blockade, risk of damage during exercise due to analgesia, impaired motor function - Working with CRPS patients: schedule PT right after administration of LA
36
What is chronic pain linked to
- Restrictions in mobility - Dependence on opioids - Anxiety and depression - Poor perceived health or quality of life
37
Describe the pain ladder
- Step 1: non-opioids +/- adjuvants - Step 2: opioids from mild to moderate pain +/- non-opioids +/- adjuvants - Step 3: opioids from moderate to severe pain +/- non-opioids +/- adjuvants - Step 4: invasive and minimally invasive treatments
38
What are the pharmacologic properties of NSAIDs (non-steroidal anti-inflammatory drugs)
- Anti-inflammatory: reduces inflammation - Analgesic: relieves pain - Antipyretic: reduces fever - Anticoagulant: inhibits platelet aggregation
39
NSAIDs history
- Aspirin (ASA) considered the original NSAID - Newer NSAIDs compared to ASA: efficacy and safety - Acetaminophen (APAP) lacks anti-inflammatory & anticoagulant effects (not true NSAID, though blocks COX in CNS)
40
Describe eicosanoids
- Eicosa: 20-carbon - Enoic: containing double bonds - Prostanoid: specific eiconsanoids (Prostaglandins, thromboxanes, & prostacyclins) - Prostaglandins: group of lipid like compounds that regulate cell function (produced in every cell except RBC; thromboxanes & leukotrienes derived from same precursor)
41
Effects of excessive prostaglandins
- Inflammation - Pain - Fever - Dysmenorrhea - Thrombus formation - Other pathologies
42
Describe COX-1 (cyclooxygenase)
- synthesizes beneficial prostaglandins - maintains cellular hemostasis - most NSAIDs are nonselective - inhibition may cause stomach & kidney issues
43
Describe COX-2 (cyclooxygenase)
- produces prostaglandins in response to injury - selective NSAIDs inhibit only COX-2: less GI adverse effects; risk of HTN, heart failure, & infarction - Celecoxib
44
Adverse effects of NSAIDs
- GI damage - Cardiovascular problems - Kidney damage - Hepatotoxicity - Hypersensitivity - Reye syndrome
45
PT considerations related to NSAIDs
- NSAID use is common - Effective for mild to moderate pain & inflammation w/o cognitive side effects - Use with caution in people with GI problems, liver damage, kidney damage, heart failure, & diabetes - May increase bleeding
46
Describe Acetaminophen (Paracetamol)
- Analgesic and antipyretic effects - Lacks anti-inflammatory or anticoagulant effects - Not associated with GI irritation - MOA: inhibition of cyclooxygenase in the CNS
47
Adverse effects of acetaminophen
- Liver toxicity in high doses causing hepatic necrosis and potentiated by pre-existing liver damage & alcohol abuse
48
PT considerations for acetaminophen
- Use is common, often combined with other medications - Effective for mild to moderate pain - Use with caution in people with liver disease - Understand the difference between NSAIDs and acetaminophen
49
Epidemiology of rheumatoid arthritis (RA) and osteoarthritis (OA)
- RA: affects 0.5-1% of population; 3x more likely in women - OA: ~50% of people aged 65; most common joint disease in the U.S.
50
Describe RA
- Characterized by synovitis & destruction of articular tissue - Chronic, systemic disorder - Pain, stiffness, inflammation - Periods of exacerbation & remission - Progressive joint damage and bone erosion
51
Goals for treatment of RA
- Decrease joint inflammation - Arrest progression of the disease
52
Medications that can be used for RA
- NSAIDs: decrease joint inflammation & pain; short term use - Glucocorticoids: decrease joint inflammation & pain; bridge to DMARD or acute flare - Disease-Modifying Antirheumatic Drugs (DMARDs): diverse group of medications; slows RA progression, modifications of immune response
53
Describe glucocorticoids
- decreased joint inflammation & pain - decrease joint erosion & damage (high dose)
54
Significant adverse effects of glucocorticoids
- Increased bone loss - Muscle wasting, weakness - HTN - Aggravation of DM, glaucoma, cataracts - Increased risk of infection
55
Describe DMARDs
- Loosely define cluster of agents - Slow or halt the progression of RA - Early use to control synovitis & erosive changes - Used with NSAIDs and glucocorticoids - Highly effective - Significant adverse effects
56
Traditional (nonbiological) DMARDs
- Antimalarials (Hydroxychloroquine): use in combination with newer DMARDs or pts who cannot tolerate newer agents - Immunosuppressant (Azathioprine): use to treat severe cases not responding to other agents - Gold therapy: no longer available - Leflunomide (Arava): decreases pain, inflammation, & joint effusion; slows formation of bone erosions; works early ~1 mo - Methotrexate: antimetabolite used in cancer tx, decreases synovitis & bone erosion, less narrowing of joint space, used alone or in combination, rapid onset ~2-3 wks
57
Adverse effects of antimalarials (Hydroxychloroquine), immunosuppressant (Azathioprine), Leflunomide (Areva), and Methotrexate
- Antimalarials: high doses = irreversible retinal damage; headache; GI distress - Immunosuppressant: fever/chills, sore throat, fatigue, nausea/vomiting, loss of appetite - Leflunomide: GI distress, allergic reactions (skin rashes), hair loss, pneumonitis - Methotrexate: GI distress (loss of appetite, nausea), long term = pulmonary problems, hematological disorders, liver dysfunction, hair loss
58
Describe tumor necrosis factor (TNF) inhibitors
- Inhibit TNF- α: cytokine released from cells involved in inflammatory response - Slow progression of inflammatory joint disease - Improve symptoms & QOL - Must be administered parenterally
59
Adverse effects of TNF inhibitors
- infections - malignancy - liver disease - heart failure - lupus-like disease - demyelinating disorders
60
Other biologicals
- Abatacept: targets T cell activation; used second line - Anakinra: blocks interleukin-1 on joint tissue; moderately effective - Rituximab: depletes B lymphocytes; beneficial in select patients - Tocilizumab: blocks the interleukin-6 receptor; alternative for select patients
61
Describe osteoarthritis (OA)
- intrinsic defect in remodeling of joint cartilage & bone - progressive degeneration of articular cartilage - degenerative bony changes: thickening of subchondral bone, creation of subchondral bone cysts, & formation of osteophytes - occurs inn large wbing joints & spine
62
Goals of treatment for OA
- manage pain - maintain an active lifestyle
63
Medications for treatment of OA
- NSAIDs: decrease joint inflammation & pain - Acetaminophen: decrease joint pain - Disease Modifying Osteoarthritic Drugs (DMORDs): viscosupplementation, Glucosamine, & Chondroitin sulfate
64
Describe viscosupplementation
- Uses hyaluronan to restore lubricating properties of synovial fluid: reduces pain & improves function - Tx consists of weekly injections - Responders may benefit for 6-12mo - Temporarily attenuates progression - May delay need for invasive Tx
65
Describe Glucosamine & Chondroitin Sulfate
- Key ingredients for production of glycosaminoglycans, proteoglycans, & hyaluronic acid - Proposed benefit of decreased pain & improved function - Inconsistent results in clinical trials - Available OTC (over the counter) as dietary supplement - Well tolerated
66
Physical therapy considerations for RA and OA
- Treatments for RA and OA play a role in optimizing rehabilitation - Be aware of medication regimens: adverse effects should be considered when designing therapy programs - MOADs may have a positive effect on ability to participate in rehabilitatio

Pharmacology (12 decks)

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