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72 Cards in this Set
- Front
- Back
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What 5 aspects of Pain are in the multidimensional phenomenom?
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Social
Functional Physical Emotional Spiritual |
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What is pain defined as?
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"An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage"
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When were the AHRQ guidelines initally set out?
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1992
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What are the AHRQ priniciple guidelines?
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Reduce the incidence and severity of pain
Educate patients about unrelieved pain Enhance patient comfort and satisfaction Contribute to fewer post-op complications Contribute to shorter lengths of stay |
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What factors are involved in measured pain?
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High reliability
High validity Assign numbers Objective Comprehensive Independent variables Uncontrolled variables are omitted, limited |
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What factors are involved in assessed pain?
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Moderate reliability
Moderate validity Rank low->high Subjective Individualized Factors interrelated Uncontrolled variables accepted |
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What are the 3 indices of pain?
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Cognitive Indicators
Behavioral Indicators Physiological Indicators |
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What scale would you use to measure cognitive indicators?
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McGill Survey-
1 Flickering Quivering Pulsing Throbbing Beating Pounding 2 Jumping Flashing Shooting 3 Pricking Boring Drilling Stabbing Lancinating 4 Sharp Cutting Lacerating |
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What are Behavioral Indicators?
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Body movements
Facial expressions Vocalizations Health-seeking Taking medications |
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What are physiological Indicators?
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Respiratory rate
Heart rate Blood pressure Temperature Skin moistness Chemical releases |
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When would you use the visual analogue scale (VAS), like could you use it on a blind person, ;)
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No you can't, you would obviously use it on someone who could see, duh. Scale from no pain to worst pain
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What are VAS measurement issues?
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Unable to understand 56%
Visual Impairment 17% Physical Restriction 12% Refused 7% Reason not documented 6% Hearing Impairment 2% |
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What is specificity in Pain theories?
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Specific types of cutaneous receptors relay information along specific nerve pathways to defined areas of the brain
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What is pattern related to pain theories?
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All types of cutaneous receptors were potentially interested in all forms of stimuli
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What is the Gate Control Theory?
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Suggests that when you block the afferent impulse it won't get to the brain to be synthesized and it will not be sent back down the efferents.
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Where does pain originate from in the body in post op setting?
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Peripheral activation of nociceptors in injured tissues
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What is somatic pain?
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Pain that has an identifiable locus and follows distribution of a somatic nerve
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What is visceral pain?
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Associated with distention of an organ capsule or obstruction of a hollow viscus
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What is/describe neuropathic pain.
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Described as burning, tingling, shock-like. Can be generated peripherally or centrally, difficult to treat
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What events occur in body after pain stimulus?
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Biochemical Events
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What are the neurotransmitters responsible for pain modulation?
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Substance P
Bradykinin Serotonin Mnemonic- BSS |
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What is the best known neurotransmitter related to pain?
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Substance P
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What is responsible for lare release of endogenous biochemicals when pain stimulation occurs?
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Arachidonic Cascade
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Describe how BSS chemicals work?
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Generate action potential stimulating peripheral nerve receptors causing;
Nociception and sympathetic reflex response |
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How does pain information impulse transmit?
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Via ascending tracts to supraspinal sites
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What are the supraspinal sites that process pain?
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Cerebral Cortex
Hypothalamus Peraqueductal gray Matter |
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How does Arachidonic Acid become what it is?
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From cell membranes- with Phospholipase A action.
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What does Arachidonic Acid create?
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Cyclooxygenase
Lipooxygenase |
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What does cyclooxygenase turn into?
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Endoperoxides
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What causes free radical formation in cascade?
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Endoperoxides and Lipooxygenase
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What are the prostaglandins in arachidonic acid cascade?
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Prostacycline
PGE2 PGD2 PGF2a Thromoxane |
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What leukotrienes are involved in the Arachidonic acid cascade and what do they do
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A4 B4 C4 D4 E4
They are chemotaxis, cause bronchoconstriction and inflammation |
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What is role of prostacycline?
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Vasodilation Thrombocyte aggregation
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What does PGE2 do?
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Erythema, Edema and fever
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What does PGD2 do?
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Bronchial constriction Inflammation
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What is role of PGf2a?
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Causes smooth muscle contraction
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WHat is role of thromboxane?
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Vasoconstriction, thrombocyte aggregation
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What is most important in management of postoperative pain?
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anticipation of pain, frequent assessments and appropriate treatment
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What pain medications have their effect on peripheral sites?
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NSAIDS
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What site of action do opiod act on?
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Central sites
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What sites would low concentrations of local anesthetics exert their effect on?
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Intermediate sites
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What is preemptive analgesia?
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Surgical pain can be blocked at spinal cord dorsal horn level- either with LA or opioids.
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True or False- There are convincing studies showing that preemptive analgesia has consistent reduction in postop pain.
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FALSE- animal studies are more convincing
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What are local anesthetics?
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Injected into wounds
Peripheral nerve blocks Epidural - Reduction in pain with few side effects |
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Describe opioids
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Highly effective in reducing pain by working in both spinal cord and brain.
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What is an important factor in analgesia with opioids?
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Euphoria
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Where are opiods less selective?
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In the brain.
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At what age would IV opioids be best given by continuous gtt?
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Under 7 y/o
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What is the youngest age when you could consider a PCA?
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7 years or older
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What is the preferred route of opioid administration?
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IV, switch to PO as soon as possible though.
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What is tolerance?
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Higher dose needed to maintain same effect as before
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Describe physiological dependance
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Withdrawal symptoms can happen following abrubt discontinuation
Taper opiods to avoid |
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Describe Precedex
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Dexmedetomidine is a a2 agonist with sedative properties, ICU sedation but not over 24 hour period
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What are some concerns with Precedex?
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Caution with advanced heart block or severe Vent. dysf.
Also- significant episodes of bradycardia and sinus arrest in young healthy volunteers |
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Name adjuvant medications and when they are beneficial
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Beneficial for neuropathic pain-
Tricyclic antidepressants, anticonvulsants, corticosteroids, muscle relaxants, local anesthetics |
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How do anticonvulsants work as an adjuvant?
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alter ion channels along nerve fiber causing and by doing this blocks pain stimulit by blocking action potential
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How do corticosteroids work and when are they used?
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Used in complex pain syndromes, reduce swelling and inflammation, used in cancer patients
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What is concern with corticosteroid use?
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Edema with tumors, reduction of inflammatory mediators- prostaglandins and leukotrienes
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Describe fentanyl
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Lipophilic, faster onset
Often epidurally with local anesth. |
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Describe Morphine
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Hydrophilic, prolonged action
Wide spread through CSF Pruritis and urinary retention |
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What are some concerns with use of morphine in spinal or epidural?
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Prolonged duration of action- respiratory depression can be delayed up to 24 hours
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What are some complications of neuraxial opioids?
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Respiratory depression
Pruritis N/V Urinary Retention |
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Describe the percent of incidence of complications of neuraxial opioids
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Resp. Depression- S 5-7%
E 0.1-2 Pruritis S 60% E 1-100% NV S 20-30 E 20-30 Urinary Ret. S 50 E 15-25 |
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WHat are positive things about a continous infusion for epidural?
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Decreased rostral spread minimizing side effects
Avoids peaks/nadir Use of short-acting drugs, less chance of contamination |
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What are positive things about an intermittent bolus of epidural?
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Simple, and don't need a pump
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What are negative things about intermittent epidural bolusing?
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Higher side effect incidence, limited number of suitable drugs, More difficult to titrate, excludes use of local anesth.
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How do NSAIDS work?
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Inhibit cyclooxygenase and prevention of arachidonic acid to prostaglandins
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What are other locations that NSAIDS work not normally thought of?
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Spinal and supraspinal levels
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When would NSAIDS work best, before, during or after pain elicited?
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Preemptively
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What is Toradol and usual dosing?
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NSAID IV- Under65 30mg q6hr not over 120mg/day
Over 65 or renal impairment under 50- 15mg q6hr not to exceed 60mg/day Pediatrics- 0.5mg/kg 2-4 doses total |
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What is Celebrex and dosage?
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NSAID COX-2 100-200mg po BID 5 days to achieve steady state, and may inhibit lasix, ACE
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What NSAID is now off the market and why?
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Vioxx- incidence of CAD and CVA
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