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182 Cards in this Set
- Front
- Back
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what is nociception
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the detection, transduction and transmission of noxious stimuli
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what are nociceptors
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free afferent nerve endings of a delta and c fibers
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are a delta fibers myelinated or unmyelinated
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MYELINATED
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are c fibers myelinated or unmyelinated
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UNMYELINATED
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how are nocioceptors activated
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by mechanical, chemical or thermal stimuli
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nociceptors are in close approximation to what in which they operate as a functional unit with
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*small blood vessels
*mast cells |
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with first order neurons the cell body is located where
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dorsal root ganglion
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with first order neurons axons project to what
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dorsal horn and other areas
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first order neurons synapse with what
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2nd order neurons
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with 2nd order neurons the cell body is where
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in dorsal horn
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with 2nd order neurons axons project where
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to contralateral hemisphere of spinal cord and ascend in spinothalamic tract to thalamus
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2nd order neurons synapse with what
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3rd order neurons
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3rd order neurons do what
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send axonal projections into sensory cortex
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modulation of nociception may occur where
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*in the periphery
*at any synapse in the ascending AFFERENT pathway *via descending EFFERENT inhibitory pathways originating at brainstem level |
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peripheral modulation of nociception occurs how
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either by release of or elimination of endogenous mediators of inflammation in the vicinity of the nocioceptor
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regarding peripheral modulation of nociceptors tissue injury causes release of what that directly activate nociceptors
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*glutamate
*substance P |
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the analgesic effects of ASA, NSAIDs and COX-2 inhibitors result from what
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*inhibition of prostaglandin synthesis
*reduction of PGE1 and PGE2 mediated sensitization of peripheral nocioceptors |
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excitatory ion channels of peripheral nocioceptors are involved in what
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*pain sensation
*hypersensitivity to noxious stimuli |
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excitatory ion channels of peripheral nociceptors modulate what following inflammation
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pain hyperexcitability
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spinal modulation of nociception results from what
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*action of NT in the dorsal horn
*spinal reflexes which convey efferent impulses back to the peripheral nociceptors |
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what are the EXCITATORY pain modulating NT
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*glutamate
*aspartate *VIP *cholecystokinin *angiotensin *substance P |
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what are the INHIBITIORY pain modulating NT
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*endorphins
*enkephalins *somatostatin *substance P |
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regarding pain modulation via spinal reflexes AFFERENT impulses directly evoke what
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*somatic EFFERENT impulses
*sympathetic EFFERENT impulses |
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regarding pain modulation via spinal reflexes sympathetic efferent impulses are from where
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cell bodies in the intermediolateral column of spinal cord
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regarding pain modulatin via spinal reflexes sympathetic efferent impulses produces what
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smooth muscle spasm, vasoconstriction & release of NE in vicinity of wound resulting in more pain
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dynamic modulation neuroplasticity is more accurately described as what
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neural activity-dependent plasticity
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regarding primary hyperalgesia peripheral nociceptors are sensitized by what
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locally released mediators or injury/inflammation
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what are locally released mediators of injury/inflammation
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*prostaglandins
*bradykinin *K+ ions |
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with secondary hyperalgesia exaggeration of impulse conduction in first order neurons by axonal release of substance P produces what
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*vasodilation
*mast cell degragranulation releasing histamine & serotonin |
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increased peripheral nerve firing does what
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*produces changes in the excitability of neurons in the spinal cord
*alters response of spinal cord neurons to AFFERENT impulses |
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changes in the excitability of neurons in the spinal cord does what
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makes reduced gradient b/t the resting and critical threshold potential for firing
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once stimulus frequency reaches a critical threshold second order neurons do what in regards to action potentials
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produce bursts of action potentials rather than a single AP
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WINDUP does what
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*results in AP lasting up to 60 sec after a stimulus removed
*produces changes in spinal cord processing lasting 1-3 hrs |
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AFFERENT axons release what EXCITATORY neurotransmitters
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*glutamate
*substance P *neurokinin A |
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synaptic potentials of A-delta and C fibers are what kind of onset
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SLOW
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synaptic potentials of A-delta and C fibers are what kind of duration
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LONG
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accumulation of EXCITATORY neurotransmitters results in what occuring
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summation of these slow AP and prolonged depolarization
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descending EFFERENT INHIBITORY pathways originate where
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at brainstem level
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descending EFFERENT INHIBITORY pathways synapse where
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in substansia gelantinosa of dorsal horn
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opioid INHIBITORY pathway releases what
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*endorphins
*enkephalins |
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monoamine or a-adrenergic INHIBITORY pathway releases what
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NE
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hyperpolarization of nerves does what
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prevents transmission of AP and NT release
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opioid and a2 receptors are _______ coupled
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G protein
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regarding supraspinal modulation receptor binding does what to the a subunit
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cleaves it
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regarding suprasupinal modulation hydrolysis of GTP produces what
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activation of alpha subunit to alpha`
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regarding supraspinal modulation alpha` binds and opens K channel producing what
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hyperpolarization of membrane
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regarding supraspinal modulation hyperpolarization of the membrane does what
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prevents transmission of action potential
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effective post-op analgesia is essential to what
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reducing the deleterious effects of pain on organ systems and post-op recovery
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regarding the surgical stress response hyperglycemial is d/t what
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*insulin resistance
*gluconeogenesis (epi, cortisol, glucagon) |
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regarding the surgical stress response negative nitrogen balance is d/t what
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protein catabolism as a substrate for gluconeogenesis
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regarding the surgical stress response increased peripheral & pulmonary extravascular fluid is d/t what
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*sodium and water retention
(aldosterone, cortisol, ADH) |
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regarding the surgical stress response increased pain sensation is d/t what
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sensitization of peripheral nocioceptors
(catecholamines) |
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what are the CV effects secondary to the surgical stress response
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*myocardial ischemia d/t increased o2 demand
*coronary vasoconstriction *hypercoagulability *CHF |
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what are the responses that are produces secondary to myocardial ischemia with surgical stress response
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*HTN
*tachycardia *dysrhythmias (cathecholamines, angiotension II) |
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CHF from the surgical stress response is caused by what
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*salt and water retention
(aldosterone, cortisol, ADH) *above combined with effects of catecholamines |
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with surgical stress response there is reflex inhibition of GI function d/t what
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pain induced sympathetic hyperactivity
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the surgical stress response may result in what with regards to GI function
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post-op ileus
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with GI and surgical stress response failure to resume early enteral feeding may contribute to what
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post-op morbidity including:
*septic complications *abnormal wound healing |
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with the surgical stress response what may may be see with the gentitourinary system
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urinary retention d/t reflex inhibition of visceral smooth muscle including urinary bladder tone
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pain related stress response suppresses both cellular and humoral immune function resulting in what
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*lymphopenia
*leukocytosis *depression of RES |
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regarding the surgical stress response how can anesthesia affect neutrophils
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can cause an anesthetic induced reduction in chemotaxis
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many known mediators of the stress response are potent what
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immunosuppressants
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what may play a role in post-op infection
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surgical stress response affect on immunologic system
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stress induced promotion of a hypercoagulable state causes what
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*increased plt adhesiveness
*decreased fibrinolysis *increased blood viscosity |
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stress induced promotion of a hypercoagulable state combined with immobility predispose the post-op pt to what
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thromboembolic events
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interrruption & limitation of central sensitation should focus on what
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PREVENTATIVE rather than therapeutic measures
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preemptive analgesia has the greatest impact when
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*in pts with limited physiolgic reserve
*in procedures involving more extensive surgical trauma |
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general anesthesia does or does not effectively attenuate the neuroendocrine stress response
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does NOT
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what tech with general anesthesia may inhibit some components of the stress resonse
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high dose opioid
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what MAC of inhalational agent reduces intra-op catecholamine release but has NO effect on post-op catecholamine release
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1.5 MAC
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regional anesthesia and analgesia does what to AFFERENT impulses reaching the spinal cord
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decreases the intensity
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what type of anesthesia/analgesia has been shown to reduce peri-op release of catecholamine and other hormones for certain sx
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REGIONAL
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with regional anesthesia/analgesia blockade of cortisol response is greatest with what type of procedures
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*lower abd
*lower extremity |
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regional anesthesia and post-op analgesia have the greatest benefit when
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in pts at highest risk of complication
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what are the cardiac benefits are regional anesthesia/analgesia
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may reduce myocardial work and o2 consumption
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how are myocardial work and o2 consumption reduced with regional anesthesia/analgesia
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d/t reductions in:
*HR *BP *L vent contractility |
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with a thoracic epidural there is reduced incidence of what in high risk populations
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*myocardial ischemia
*dysrhythmias |
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with a thoracic epidural there are sig reductions in CV morbidity following what sxs
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*thoracic
*abd *vascular |
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in animal models epidural local anesthetics improved what blood flow ratios
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endocardial to epicardial
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what are the resp benefits of regional anesthesia and analgesia
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*improved post-op diaphramatic fxn
*reduced work of breathing *enhanced ability to cough *facilitation of chest physiotherapy |
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with regional anesthesia and analgesia there is what in high-risk pts following thoracic and upper abd sx
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reduction in incidence of post-op pneumonia & resp failure
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regarding coagulation epidural anesthesia/analgesia does what
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*enhances fibronolytic activity
*speeds return of antithrombin III to normal level *attenuates post-op increase in plt adhesiveness |
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what is the likely mech for the changes in coagulation with epidural anesthesia/analgesia
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*block of sympathetic EFFERENT nerves
*reduction in circulating catecholamines *anticoagulant properties of systemically absorpbed LA |
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with regional anesthesia/analgesia there is a reduced incidence of what following lower extremity revascularization
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vascular graft occulusion
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with regional anesthesia/analgesia there is what benefit following total hip arthroplasty
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reduced incidence os DVT and PE
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the benefits seen with regional anesthesia/analgesia and total hip arthroplasty are possibly related to what
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*inhibitory effect on plt aggregation
*improved lower extremity blood flow |
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regarding coagulation regional anesthesia/analgesia is of most protective value in what pts
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pts at high risk for vaso-occulusive events such as those with atherosclerotic vascular dz or a predisposition to hypercoagulability
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opioids produce their effects by interacting with receptors that are what
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*saturatable
*membrane bound *non-uniformly distributed throughout the CNS |
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in addition to the CNS opioid receptors are also present in what nerves
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PERIPHERAL
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peripheral opioid effect is more profound in what type of tissue
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chronically inflammed
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what opioid receptors appear to be transported to and activated on primary AFFERENT neurons in response to inflammation
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opioid receptors produced in dorsal root ganglia
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application of opioid in the periphery (at the nerve terminal) may produce what in terms of analgesia
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long lasting analgesia of similar potency as the local anesthetics
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is there an analgesic ceiling with opioids
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NO
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analgesic effect limited by what
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tolerance and side effects
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what is the primary mech of action for NSAIDs
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inhibition of COX therefore inhibition of prostaglandin synthesis
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NSAIDs act primarily where
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peripherally but also through inhibition of spinal COX
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COX-1 is constitutive or inducible
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CONSTITUITIVE
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what are the fxns of COX-1
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*plt aggregation
*hemostasis *gastric mucosal protection |
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COX-2 is constituitive or inducible
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INDUCIBLE
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what are the fxns of COX-2
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*pain
*inflammation *fever |
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NSAIDs as a sole analgesic is typically effective for what type of pain
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mild to moderate
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the benefits of using NSAIDs as an adjunct pain medication are what
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*reduce opioid dosage and s/e
*provide an economic benefit to pt and hospital |
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what are the potential s/e of NSAID usage
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*decreased hemostasis
*renal dysfunction *interference with bone healing & spinal fusion *increased incidence of GI bleeding *bronchospasm |
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how can NSAIDs cause decreased hemostasis
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*causing plt dysfunction
*inhibition of thromboxane a2 |
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how can NSAIDs cause increased incidence of GI bleeding
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by COX-1 inhibition reducing synthesis of cytoprotective gastric mucosal prostaglandins
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what are the benefits of selective COX-2 inhibitors
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*lower incidence of GI complications
*produce mininal plt inhibition *may not impair bone healing |
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ketamine is useful as an adjunct in pain management d/t what
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antagonism of NMDA
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antagonism of NDMA does what
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*reduces central sensitization
*may attenuate opioid tolerance |
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what are the benefits of a low dose infusion of ketamine for pain control
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*doesnt seem to cause cognitive impairment or hallucinations
*s/e comparable to those seen with opioids |
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what is the dosage for a lose dose infusion of ketamine for pain control
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20mcg/kg/min
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when should you AVOID ketamine for pain control b/c concerns for neurotoxicity exist
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central neuraxis
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what are the DISADVANTAGES to oral delivery of pain control in acute post-op pain
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*lack of titratibility
*prolonged onset & time to peak effect *require a functioning GI system |
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transdermal fentanyl takes how long to reach peak effect
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several hrs
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what are the problems with transdermal fentanyl
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*titratibility
*unpredictability of absorption |
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transdermal fentanyl in combination with a PCA does what
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*reduces number of demand doses
*has no change in total opioid requirements or s/e |
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is transmucosal opioid delivery method indicated for post-op pain
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NO
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what are the benefits to PCA use
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*provides superior analgesia
*improves pt satisfaction *decreases risk of pulm complications *has no increase in total opioid dose or s/e |
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what is the "typical" demand dose for opioid naive pts for morphine
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1 mg
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what is the "typical" demand dose for opioid naive pts for fentanyl
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10-20 mcg
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what is the lockout interval for PCA
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typically 5-10 min
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what are factors associated with resp depression during PCA use
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*use of background infusion
*advanced age *concurrent admin of sedative/hypnotic drugs *coexisting pulm dz *OSA |
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with use of PCA noctural hypoxemia may be reduced how
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with the use of supplemental o2
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for hydrophylic opioids the site of action is where
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SPINAL
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what are the hydrophylic opioids
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*MS
*hydromorphone |
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which opiod remains in the CSF and produces a delayed onset but longer duration of analgesia
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HYDROMORPHONE
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which opioid has a higher incidence of side effects d/t cephalad spread within the CSF
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HYDROMORPHONE
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what is the site of action for lipophylic opioids
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UNCLEAR
(spinal vs systemic) |
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what are the lipophylic opioids
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*fentanyl
*sufentanil |
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which opioid b/c of its rapid onset and rapid clearance from CSF limits its cephalad spread
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SUFENTANIL
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with local anesthestics the site of action is potentially where with epidural
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*spinal nerve roots
*dorsl root ganglion *spinal cord |
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what are the benefits of local anesthetic + opioid used together in epidural
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*improved post-op analgesia
*slower regression of sensory block *decreased dose (concentration) of LA required |
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for an epidural with continuous infusion what type of LA drug is prefered
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drugs that produce more SENSORY than motor block
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for an epidural with continuous infusion what SPECIFIC drugs are preferred
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*bupivicaine </= 0.125%
*levobupivacaine </= 0.125% *ropivicaine </= 0.2% |
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with an epidural with continuous infusion what type of opioids are preferred
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LIPOPHYLICS
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with an epidural with continuous infusion what LIPOPHYLIC drugs are used
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*fentanyl 2-5 mcg/ml
*sufentanil 0.5-1 mcg/ml |
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with an epidural with a continous infusion what HYDROPHYLIC drugs are used
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*morphine 0.05-0.1 mg/ml
*hydromorphone 0.01-0.05 mg/ml |
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what are adjuvant drugs used for epidural pain management
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*clonidine
*epi *ketamine |
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what is the dosage of clonidine used in epidural for pain management
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5-20 mcg/hr
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clonidine in an epidural acts via what
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descending noradrenergic pathway
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what are the s/e of clonidine in and epidural
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SIGNIGFICANT
*hypotension *bradycardia *sedation |
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what is the dosage of epi used in an epidural for pain management
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2-5 mcg/ml
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what drug used with epidurals for pain management may improve the density of the block
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EPI
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what is the management for a motor block with pain management
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*lower concentration of appropropriate LA
*catheter-incision congruent placement |
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N/V with blocks and opiods for pain managment is dependent on what
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DOSE
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N/V with blocks and opiods for pain management is less frequent with what type of opioid
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LIPOPHYLIC
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pruritis with blocks for pain management is less with what opioid
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FENTANYL
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what is the mechanism for pruritis with blocks containing opioids for pain management
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not clear but UNRELATED to peripheral histamine release, possibly related to central mechanism
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what epidural medication for epidural use in pain management is associated with reactivation of herpes simplex labilalis
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MORPHINE
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resp depression with blocks for pain management is dependent on what
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DOSE
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what is the mechanism for urinary retention with blocks for pain management
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spinal cord opioid receptors decrease contraction strength of the detrusor muscle
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is urinary retention with blocks for pain managment dose dependent
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NO
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urinary retention with blocks for pain management is treatable how
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with low-dose narcan
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what are the advantages of pt controlled epidural analgesia over continuous epidural analgesia
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*allows indivualization of dose
*reduced total drug use *superior analgesia *improved pt satisfaction |
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what are the GI benefits of epidural anesthesia
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earlier return of GI motility following abd sx
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what are the pulm benefits of epidural anesthesia
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*preserved post-op pulm fxn
*decreased incidence of infection and complications |
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with epidural anesthesia thoraciac but NOT lumbar epidural may decrease the incidence of post-op MI via
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*attenuation of sx stress response and hypercoagulability
*improved analgesia *redistribution of coronary blood flow |
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lidocaine topical patch 5% has an opiod sparing effect via what
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*sodium channel blockade
*modulation of a-delta and c fibers *inhibition of NO expression *inhibition of release of pro-inflammatory cytokines |
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a ALPHA fibers mediate what
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*motor
*proprioception |
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a BETA and GAMMA fibers mediate what
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*cutaneous touch
*pressure |
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a DELTA fibers mediate what
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PAIN
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B fibers mediate what
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*postganglionic sympathetics
*visceral afferents |
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C fibers mediate what
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*pre-ganglionic autonomics
*PAIN |
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are a ALPHA fibers myelinated
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YES
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are a BETA and GAMMA fibers myelinated
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YES
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are a DELTA fibers myelinated
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YES
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are B fibers myelinated
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YES
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are C fibers myelinated
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YES
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what is the velocity of a ALPHA fibers
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5-100 m/sec
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what is the velocity of a BETA and GAMMA fibers
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5-100 m/sec
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what is the velocity of a DELTA fibers
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5-100 m/sec
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what is the velocity of B fibers
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3-14 m/sec
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what is the velocity of C fibers
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0.5-2 m/sec
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if the incision location is thoracic the recommended congruent epidural catheter placement would be where
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T4-8
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if the incision location is upper abd the recommended congruent epidural catheter placement would be where
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T6-8
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if the incision location is middle abd the recommended congruent epidural catheter placement would be where
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T7-10
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if the incision location is lower abd the recommended congruent epidural catheter placement would be where
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T8-11
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if the incision location is upper extremity the recommended congruent epidural catheter placement would be where
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L1-4
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examples of procedures for thoracic incision with congruent epidural cathether placement at T4-8 would be what
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*lung resection
*radical mastectomy *thoracotomy *thymectomy |
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examples of procedures for upper abdominal incision with congruent epidural placement at T6-8 would be what
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*chole
*esophagectomy *gastrectomy *hepatic resection *whipple |
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examples of procedures for middle abdominal incision with congruent epidural placement at T7-10 would be what
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*cystoprostatectomy
*nephrectomy |
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examples of procedures for lower abdominal insicion with congruent epidural placement at T8-11 would be what
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*AAA
*colectomy *radical prostatectomy *TAH |
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examples of procedures for lower extremity incision with congruent epidural placement at L1-4 would be what
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*fem pop
*total hip or total knee replacement |
