Postop Pain Management Flashcards
(115 cards)
1
Q
Pain is considered the
A
5th vital sign
2
Q
Pain is defined as an
A
unpleasant sensory and emotional experience associated with actual or potential tissue damage
3
Q
In 2001, JCAHO identified responsibilities including
A
assessment of pain in all patients
educate about pain management strategies
orient staff to be competent to assess pain
record assessments and reassessment of pain
4
Q
The categories of pain include
A
acute: primarily due to nociception
chronic: may be due to nociception but also affected by psychological and behavioral factors
5
Q
Nociception refers to the
A
detection, transduction, and transmission of noxious stimuli
6
Q
Acute pain is
A
of short duration (<6 weeks)
cause usually known
temporary and located in area of trauma or damage
Resolves spontaneously with healing
7
Q
Chronic pain is
A
persists beyond normal duration of recovery from acute injury or disease
cause may not be identifiable
affects patients self image and sense of well being
8
Q
Procedures with high incidence of chronic pain include:
A
thoracotomy, sternotomy, mastectomy, hysterectomy, inguinal hernia repair
9
Q
Pain can be classified by:
A
etiology: postoperative, cancer
pathophysiology: nociceptive, neuropathic, idiopathic, psychogenic
affected area
10
Q
Psychogenic pain is
A
sustained by psychological factors
11
Q
Idiopathic pain is
A
not attributable to identifiable causes
12
Q
Nociceptive pain is
A
the appropriate response to identifiable tissue damage
13
Q
Nociceptive pain is due to the
A
activation or sensitization of peripheral nociceptors that transduse noxious stimuli
the result of four processes: transduction, transmission, modulation, and perception
14
Q
Transduction is
A
stimuli translated into electrical energy at the site
15
Q
Transmission is
A
propagation of the impulse through the nervous system
16
Q
Modulation is
A
alteration of the stimuli that can be amplified or attenuated
17
Q
Perception is
A
based on the psychological framework of the patient
18
Q
Subtypes of nociceptive pain include:
A
Somatic & visceral pain
19
Q
Somatic pain can be
A
superficial: arises from skin, subcutaneous tissues, or mucous membranes
characterized as well-localized, sharp, pricking, throbbing, or burning
Deep somatic pain: arises from muscles, tendons, joints or bones
dull, aching quality that is less well-localized
20
Q
Visceral pain is due to
A
disease process or abnormal function of internal organ
may be localized or referred
21
Q
Neuropathic pain is the result of
A
injury or acquired abnormalities of peripheral or central neural structures
22
Q
Neuropathic subtypes include
A
Central generator: central pain due to injury to brain or spinal cord; phantom pain
Peripheral generator: originates in nerve root, plexus, or nerve; polyneuropathies, mononeuropathies
23
Q
Idiopathic pain is perceived to be
A
excessive for the extent of the pathology
24
Q
Allodynia is the
A
perception of an ordinarily non-noxious stimuli as pain
25
Analgesia is the
absence of pain perception
26
Anesthesia is the
absence of all sensation
27
Hyperalgesia is the
exaggerated response to noxious stimuli
28
Neuralgia is
pain in nerve distribution
29
Paresthesia is an
abnormal sensation perceived without stimulus
30
Radiculopathy is the
functional abnormality of one or more nerve roots
31
Peripheral nerve afferent fibers are categorized into three groups based on
size, degree of myelination, speed of conduction, and distribution of fibers
32
The three groups of afferent nerve fibers include:
Class A- alpha, beta, delta, gamma
Class B
Class C
33
Class A peripheral nerve fibers are
large, myelinated fibers
have low threshold for activation
1-20 micrograms in diameter
34
Class A delta fibers
mediates pain sensation- transmits fast or first pain
sharp, stinging, pricking type pain
conducts impulses at 5-25 m/s
35
Class A alpha fibers
transmits motor and proprioceptive impulses
| 60-120 m/s
36
Class A Beta fibers
cutaneous touch and pressure
| 60-120 m/s
37
Class A gamma fibers:
cutaneous touch and pressure
| 15-35 m/s
38
Class B peripheral nerve fibers are
medium sized myelinated fibers
conduction speed 3-14 m/s
diameter less than 3 micrometers
have higher threshold (lower excitability) than Class A fibers
Lower threshold than Class C fibers
Postganglionic sympathetic and visceral afferents are class B
39
Class C peripheral nerve fibers are
unmyelinated or thinly myelinated
conduction speeds of 0.5-2 m/s
Diameter 0.4-1.2 micrometers
Preganglionic autonomic fibers and pain fibers are Class C- transmits slow or second pain; burning, persistent, aching, throbbing pain
40
A-Delta Fibers transmit
"First" or "Fast" pain
it is well localized; sharp, stinging, pricking
duration of pain coincides with painful stimulus
pain from parietal peritoneum carried here
41
The major neurotransmitter involved in A-Delta fibers is
glutamate and binds to NMDA and AMPA receptors on postsynaptic membrae
42
C Fibers transmit
"Second" or "slow" pain
| diffused and persistent; burning, aching, throbbing; duration exceeds stimulus; pain from viscera is carried here
43
The major neurotransmitter involved in C Fibers is
substance P which bids to NK-1 receptors on the postsynaptic membrane
44
Pain is modulated in the
descending dorsolateral spinal tract
45
IV opioids act primarily at other sites in the brain including
the limbic system, hypothalamus, and thalamus; this supraspinal analgesia is mediated by Mu-1 receptors
46
IV opioids can also produce
spinal analgesia by working in the periventricular/periaqueductal gray where they stimulate Mu-2 receptors
47
Neuraxial opioids work at the same receptor site as
enkephalin; their mechanism of action is to decrease the release of Substance P by binding to Mu-2 receptors; this is known as spinal anesthesia
48
Pain management is important because
effective intraoperative and postoperative pain relief is vital to your patient's outcome
Prompt treatment can help prevent the development of negative sequelae that pain can precipitate
Pain is not just an unpleasant experience; it causes a multitude of systemic effects
49
The cardiovascular surgical stress response includes
HTN, tachycardia, enhanced myocardial irritability, increased SVR (angiotensin II), CO increases except in patients with compromised left ventricular function
May result in increased myocardial O2 demand and precipitate ischemia
50
The respiratory surgical stress response includes
increase in total body O2 consumption and CO2 production causes increase in minute ventilation
increases work of breathing
pain may decrease chest expansion and result in atelectasis, intra-pulmonary shunting, hypoxemia, and hypoventilation
increases in skeletal muscle tension that results from pain impulses may lead to V/Q mismatch
51
The endocrine surgical stress response includes
hyperglycemia- secondary to increased glucagon, increased epinephrine, and decreased insulin
Vasoconstriction, increased myocardial contractility, tachycardia- secondary to increased cortisol, increased catecholamines, activation of renin-angiotensin system
Salt & water retention (increased aldosterone & ADH) may lead to CHF
52
The gastrointestinal surgical stress response includes
increased sphincter tone with decreased smooth muscle tone that may lead to formation of ileus and lead to PONV
decreased oral intake is associated with septic complications and delayed wound healing- hypersecretion of gastric acid promotes stress ulcers; abdominal distension further aggravates loss of lung volume and pulmonary dysfunction
53
The immunological surgical stress response
produces leukocytosis with lymphopenia & depresses the reticuloendothelial system predisposing patients to infection
54
The hematological surgical stress reponse
increases platelet adhesiveness and diminished fibrinolysis promotes a hypercoagulable state; immobility exacerbates this problem
55
Describe the impact that general anesthesia has on the surgical stress response:
not effective in attenuating the response except with high dose narcotic technique
56
Describe the impact that regional anesthesia has on the surgical stress response:
diminishes the intensity of afferent impulses getting to the spinal cord
reduces catecholamine and other stress hormone responses during perioperative period
57
Pain management points:
effective pain program is based on an understanding of pain
pain management requires patient evaluation preoperatively, postoperatively and thru discharge
education of the patient is key to pain management
pain management is geared at balancing the advantages, disadvantages, and patient considerations
58
A pain assessment involves
history of current and persistent pain
physical examination
pain attributes- intensity, onset, duration, location, descriptors of what exacerbates or relieves pain
behavioral manifestations
impact of pain on ADLs
current & past treatments
are the patient's expectations for pain relief realistic
59
Postoperative pain intensity is rate the highest in
orthopedic/trauma on extremities
60
These surgeries are ranked among 25 with highest pain intensity:
appendectomy, cholecystectomy, hemorrhoidectomy, tonsillectomy
some laparoscopic procedures are ranked unexpectedly high
61
Opioids are the ____and can be given___
mainstay for postoperative analgesia; may be given IV, PO, IM, subQ, PCA, or neuraxial
62
Opioids are safe and effective in treating
moderate to severe pain
63
Opioids should be administered via
the most effective route and limiting side effects
64
Side effects of opioids include
N/V, constipation, lethargy, sedation, and respiratory depression
65
The minimum effective analgesic concentration is the
analgesic blood level at which the patient experiences analgesia and the severity of pain rapidly diminishes
66
Opioids can lead to opioid-induced
hyperalgesia; patients receiving opioids may exhibit diminished pain threshold and enhanced pain sensitivity
-escalating opioids worsens pain perception
67
The mechanism for opioid-induced hyperalgesia is possibly due to
enhanced release of neurotransmitters
sensitization of primary and secondary afferents
upregulation of spinal and supraspinal pathways- critical component is activation of excitatory NMDA receptor & central glutamatergic system
Demonstrated in patients receiving high-dose intraoperative opioids such as fentanyl and remifentanil
68
Pain perception can be decreased by using
analgesics capable of inhibiting CNS sensitization before painful stimulus occurs
clinical role of preemptive analgesia still uncertain and much debated
69
Drug options for preemptive analgesia include
NSAIDs, opioids, local anesthetics, NMDA antagonists, alpha-2 agonists
70
A multi-modal approach is
use of different agents allows reduced dosages of each thus, reduced side effects
may include more than 1 route of administration
71
The synergistic effects between drug classes enhances
analgesic effects of each drug
72
Multi-modal approach is effective in patients at risk of
side effects from large doses of opioids such as obstructive sleep apnea, chronic pain, and frail elderly
73
NSAIDs are effective in treating
mild to moderate pain
74
Adverse effects of NSAIDs include
GI bleeding, ARF, and hepatotoxicity
75
NSAIDs should be avoided in patients with
hypersensitivity, significant renal compromise, & PUD
76
NSAIDs should be used in caution in
elderly patients due to increased risk for renal impairment
77
Ketamine is a
NMDA receptor antagonist
78
Ketamine dosage is
0.5 mg/kg bolus followed with infusion at 4 mcg/kg/min.
79
Ketamine is able to reduce
morphine consumption and pain intensity up to 6 weeks following spine surgery
80
Methadone is a
D-isomer NMDA receptor antagonist
81
The dose of methadone is
0.2 mg/kg
82
Methadone results in a
50% reduction in post-op opioid consumption and pain scores at 48 hours after complex spine surgery
83
Anticonvulsants include
pregabalin & gabapentin
84
Anticonvulsants are used to manage
spontaneous firing of sensory neurons associated with neuropathic pain
-attenuate neuronal sensitization response
85
Anticonvulsants are able to reduce the incidence of
chronic postoperative pain syndrome- decrease opioid consumption and neuropathic pain 3-6 months following total knee replacement
86
Alpha 2 agonists include _____ and the risk associated with these drugs is
dexmedetomidine & clonidine
| hypotension & bradycardia
87
Dexmedetomidine is particularly useful in reducing
morphine consumption 2-14 hours post-op; decreased PONV
| significantly reduces opioid consumption in obese population
88
Clonidine results in
reduced morphine consumption 12-24 hours post-op; also decreased PONV
89
Additional drugs that can be administered in a multi-modal approach include
acetaminophen and magnesium
90
Infiltration of local anesthetic can be done
by the surgeon at the end of the case
| ilioinguinal and femoral nerve blocks can be placed by the anesthetist
91
Glucocorticoids are
potent anti-inflammatory agents that play a role in reducing postop pain and can help to manage PONV
92
Side effects of neuraxial opioids include:
itching (most common)
| nausea, urinary retention, respiratory depression (early & late), sedation, CNS excitation, neonatal morbidity
93
Regional anesthesia is preferred to provide
postoperative pain control to a specific part of the body
94
Benefits of regional anesthesia include
eliminating the need for IV pain medications and early discharge of ambulatory patients
95
Disadvantages of regional anesthesia include
block failure, bleeding, hematoma, & neurological injury
96
Central neuraxial blocks include
spinal & epidural
97
Peripheral nerve blocks include
lumbar plexus blocks & interscalene nerve blocks
98
Intrathecal placement of neuraxial opioids can lead to
LATE respiratory depression (6-12 hours) due to rostral spread
early respiratory depression does not occur because uptake by systemic circulation is minimal
99
Epidural placement of neuraxial opioids can lead to
EARLY respiratory depression (within 2 hours) may occur since systemic uptake is greater then with intrathecal placement
late respiratory depression is more likely due to rostral spread in CSF
100
Hydrophilic opioids onset of analgesia
is slow, duration, prolonged
101
With lipophilic opioids the onset of analgesia is
rapid with short duration
EARLY respiratory depression occurs due to significant systemic uptake with both intrathecal & epidural placement
-respiratory depression is most pronounced after epidural placement
102
Discuss lipophilic opioids and late respiratory depression.
Late respiratory depression DOES NOT occur because diffusion of lipophilic opioids out of the CSF is substantial, therefore rostral spread is minimal
103
Distraction can be used
as an adjunct to analgesic interventions
can include music or imagery
requires patient cooperation
104
The maximal benefit of distraction is when
it is introduced preoperatively
105
Hypnosis is a
state of focused attention combined with decrease in external awareness
106
Hypnosis may not be as frequently used because
it may not work on all patients
social stigma
conflicting data on efficacy
107
Heat is used to
decrease joint stiffness and increase blood flow
| easy to use
108
Cold is used to
alter pain threshold, reduce swelling, and decrease tissue metabolism
easy to use
109
Cold is contraindicated in patients with
decreased circulatory states such as Raynaud's
110
Transcutaneous electrical nerve stimulation (TENS) is thought to
produce analgesia by stimulating large afferent fibers
| gate theory of pain suggests that the afferent input from large fibers competes with that from smaller pain fibers
111
With a TENS unit,
electrodes are applied to the same dermatome as the pain
| requires professional to instruct in use
112
The benefit of using a TENS unit is that there is an
absence of significant side effects
113
Immobilization can include
healing process as well (i.e. casting)
114
Positioning can be done
every two hours
| improves blood flow and prevents decubitus ulcer development
115
Exercise can assist in the
CPM, ambulation, physical therapy
| assists with edema and DVT formation
