Principles 2 Fall 2025 > Acute pain > Flashcards

Acute pain Flashcards

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1
Q

Why is acute pain a main concern for us?

A

It has effect on everybody system & it’s a pt’s top concern

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2
Q

T/F: the more severe acute pain is the more exaggerated response as we get on body systems

A

T

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3
Q

what are the 2 types of pain? What are the sub categories within those pains? (2-2) Describe them

A
  1. Somatic
    -superficial: skin, subcutaneous tissues, mucus membranes
    -deep: muscle, tendons, joints, bones
  2. Visceral
    -parietal: localized to the area around the organ; sharp, stabbing
    -referred: migrational pain
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4
Q

What are the goals of pain control? (4) How do we attain these goals? (3)

A
  1. Optimal pt comfort
  2. Attenuation of adverse physiological responses
  3. Prevention of chronic pain development
  4. Control anxiety/agitation

How to attain goals:
1. Preemptive/prevent preventative analgesia
2. Multimodal anesthesia
3. Opioid free anesthesia

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5
Q

What are the 3 phases of pain in order?

A
  1. Acute pain –>
  2. Chronic nociceptive pain –>
  3. Neuropathic pain
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6
Q

Which disease pathology can skip the acute and chronic phases of pain?

A

Diabetic neuropathy – it can start at neuropathic pain

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7
Q

What are the diseases that can cause pain? (12)

A
  1. Degenerative joint disease
  2. Degenerative disc disease
  3. Spinal stenosis
  4. DM
  5. Cerebral vascular disease
  6. Osteoporosis
  7. Cancer
  8. Heart disease
  9. Polymyalgia rheumatica
  10. Wounds
  11. PAD
  12. End of life
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8
Q

Pain can be caused by ________ dt loss of functional status caused by ________ (9)

A

Immobility

  1. Dementia
  2. CVD
  3. Degenerative joint disease
  4. Fx
  5. Sx
  6. Amputation
  7. Neuropathy
  8. Peripheral vascular disease
  9. Edema
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9
Q

T/F: mobility may be a solution to help Tx pain

A

T

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10
Q

What are red flags w/ pain? (8)

A
  1. Constitutional symptoms
  2. Pain that wakes pt up
  3. Immunosuppression
  4. Severe/progressive neurological deficit
  5. Cold, pale, model, synthetic limb
  6. New bowel/bladder dysfunction
  7. Severe abdominal pain
  8. Signs of shock/peritonitis
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11
Q

Pain on body system: cardiovascular (3)

A
  1. Tachycardia
  2. HTN
  3. Increase cardiac workload
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12
Q

Pain on body system: pulmonary (5)

A
  1. Respiratory muscle spasm (splinting)
  2. Decrease in VC
  3. Atelectasis
  4. Hypoxia
  5. Increased risk of pulmonary infection
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13
Q

Pain on body system: GI

A

Postop Ileus

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14
Q

Pain on body system: Renal (2)

A
  1. Increase risk of oliguria
  2. Urinary retention
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15
Q

Pain on body system: coagulation

A

Increased risk of thromboemboli

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16
Q

Pain on body system: immunologic

A

Impaired immune function

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17
Q

Pain on body system: muscular (2)

A
  1. Muscle weakness/fatigue
  2. Limited mobility –> increase risk of thromboembolism
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18
Q

Pain on body system: physiological (3)

A
  1. Anxiety
  2. Fear
  3. Frustration –> poor pt satisfaction
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19
Q

Define the specificity theory of pain

A

Suggested that intensity of pain is directly rt the amount & degree of pain associated w/ tissue injury

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20
Q

Define the intensity theory of pain

A

Define pain as an emotional experience rather than a sensory one

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21
Q

Define the gate control theory of pain

A

First cohesive explanation for the emergent complexities of pain phenomena, particularly chronic pain

States that pain transmission is modulated by a balance of impulses transmitted to the spinal cord & these fibers terminate & inhibitory enter neurons in the substantia gelatinosa & the cells in this area function as a regulating transmission of impulses to the CNS

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22
Q

During surgery, what are the inflammatory mediators released from surgical incision/tissue injury? (4)

A
  1. Histamine
  2. Bradykinin (peptides)
  3. Prostaglandins (lipids)
  4. Serotonin (neurotransmitters)
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23
Q

In the pain pathway, the 1st order neurons start in the _______ & end in the _______. describe this pathway.

A

Periphery

Dorsal horn of the Spinal cord

Synapse w/ 2nd order neurons in the dorsal horn of the spinal cord

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24
Q

In the pain pathway, the 2nd order neurons start in the _______ & ends _______. describe this pathway.

A

Dorsal horn of the spinal cord

above the thalamus

After synapse w/ 1st order in dorsal horn of spinal cord –> crosses to the contralateral side of spinal cord –> ascends in the spinothalamic tract towards the brain –> terminates above the thalamus

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25
In the pain pathway, the 3rd order neurons starts _______ & end in the _______ of the ________. describe this pathway.
above the thalamus Post central gyrus Cerebral cortex Starts above thalamus --> internal capsule --> Post central gyrus of the Cerebral cortex
26
Describe the difference between the 2 main pain transmission fibers
A-delta = fast pain -Myelinated -large -fast C fiber = slow pain -Nonmyelinated -small -slow
27
What are the 4 elements of pain processing in order? Describe them
1. Transduction: stimuli converted into AP 2. Transmission: AP conducted through nervous system 3. Modulation: pain transmission alters afferent neural transmission 4. Perception: integration of painful input into the somatic sensory & limbic cortex
28
Define allodynia
Pain from a stimulus that does not normally evoke pain
29
Define hyperalgesia. What are the 2 different types? What are the difference between them?
Exaggerated response to a normal painful stimulus 1. Primary: augmented sensitivity or allodynia misinterpretation 2. Secondary: increase excitability of neurons in the CNS dt NMDA-receptors
30
__________ medication can cause hyperalgesia, therefore it should never be given without ________
Remifentanil Ketamine
31
The pain sensitivity curve shifts to the ______ with hyperalgesia/allodynia from the normal pain curve.
Left
32
neuropathic pain is complete innovation of a body part that results in _________ which is called a _______ symptom.
Numbness Negative
33
Aging has ______ effects on absorption. There is _________ GI mobility/blood flow, gastric acid secretions are _________ & gastric pH is ________.
Minimum Reduced Decrease Increase
34
T/F: With aging, increased use of medications alter pH
T
35
With aging & distribution, the proportion relates to the amount of the drug in the body to the ________ measured in the _________
Concentration Biological fluid
36
How does aging affect distribution? (4)
1. Decrease muscle mass 2. Increase proportion of body fat 3. Decrease total body water (affects water soluble drugs) 4. Decrease albumin (affects protein bound drugs)
37
The _____ is the primary organ for metabolism. What does it do?
Liver Convert substances believed to be harmful into a form that can easily be eliminated
38
How does aging affect the liver? (3)
1. Reduced hepatic blood flow 2. Reduced liver mass 3. Reduced intrinsic metabolic activity
39
The ______ is the primary organ for excretion/elimination
Kidney
40
How does aging affect the kidney? (4)
1. Decreased renal blood flow 2. Decreased renal mass 3. Decreased # a functioning nephrons 4. Decrease GFR (glomerular filtration rate)
41
What is the most important renal change with aging?
Decrease GFR (glomerular filtration rate)
42
According to the WHO "Pain relief ladder" what is the 1st step treating pain? What is the takeaway from this?
1st step: non–opioid adjuvant After a non-opioid intervention --> opioid But continue with the non-opioid intervention as well.
43
Opioids act ________ and their adverse effects include _________ (3). What other considerations should I have with these? (4)
Centrally 1. Sedation 2. Respiratory depression 3. Constipation Other considerations: 1. Can develop addiction, dependence, tolerance 2. Schedule II, III controlled drugs 3. No anti-inflammatory effects 4. No ceiling effects
44
Non-opioids act ________ and their adverse effects include _________ (3). What other considerations should I have with these?
Peripherally 1. Gastric irritation 2. Bleeding 3. Renal toxicity Other considerations: 1. Non-habit forming 2. Anti-inflammatory effects 3. Ceiling effect
45
What does ceiling effect mean? Which medication medications have these?
Increase dose does not equal increase analgesia but does increase SE Non-opioids
46
Which opioid receptor is the least devastating? What does it affect only?
Delta Analgesia
47
How are the Mu & Kappa receptors the same?
Both affect respiratory depression & analgesia
48
What differs the Mu (u) receptor? (3)
1. Euphoria 2. Reduced GI motility 3. Bradycardia
49
What differ the Kappa receptor? (4)
1. Dysphoria 2. Psychosis 3. Delusion/delirium 4. Miosis
50
T/F: Opioids reduce pain
F Opioids reduce the PERCEPTION of pain Non-opioids reduce pain
51
How many opioid receptors are there? Name them
4 Mu Mu-2 Delta Kappa
52
Opioids trade names: Codeine
Tylenol #3
53
Opioids trade names: Fentanyl
Duragesic patch
54
Opioids trade names: hydrocodone (2)
Lortab Vicodin
55
Opioids trade names: hydromorphone
Dilaudid
56
Opioids trade names: methadone
Dolophine
57
Opioids trade names: morphine (3)
MSIR MsContin Kadian
58
Opioids trade names: oxycodone (4)
OxyIR Percocet Percodan Oxycontin
59
__________ is more reliably absorbed overly than morphine. What is the scientific name for this?
Codeine 3-methoxymorphine
60
What population do we want to avoid codeine in? Why?
Children < 12yo They lack maturity of the P450 enzyme CYP2D6 & can experience SE w/o analgesia
61
How is codeine metabolized?
Hepatic P450 enzyme CYP2D6
62
Drug dose: codeine (Adult/peds/max)
Adult: 15 - 60 mg q 4hr max = 360 mg/day Peds: 0.5 - 1 mg/kg max = 60 mg/dose !!!!!!
63
Analgesia effect of 60mg of codeine = ______ aspirin
650 mg
64
Tramadol is an analogue of _______ & _______. What receptors does it work on? (3) What does it oppose?
Morphine Codeine Mostly all the opioid receptors (Mu, kappa, delta) Opposes serotonin reuptake
65
How is Tramadol metabolized? What is its metabolite? Describe it.
Hepatic P-450 enzymes **CYP2D6 & CYP3A4** O-desmethyltramadol 2-4 x more potent than tramadol
66
Tramadol is _______ potency of morphine. What is its onset?
1/5 - 1/10 potency Onset = 1-2 hrs PO
67
What is tramadol's contraindications?
Seizure disorders
68
What are the benefits of tramadol? (3) Cons?
Benefits: 1. Minimal respiratory effects 2. Not associated with/ dependence, tolerance, addict addiction 3. Minimal incidents of constipation Cons: 1. High incidence of N/V
69
With morphine the oral dose requirement is about ______ the IM/PO dose
3x
70
What receptors does morphine primarily act at? (2)
1. Mu-1 2. Mu-2
71
How is morphine metabolized? What are its metabolites? (2) Describe them
Conjugation w/ glucuronic acid in the hepatic & extra hepatic sites 1. Morphine-6-glucuronide = analgesia 2. Morphine-3-glucuronide = neurotoxicity & hyperalgesia
72
T/F: morphine dosing is dependent on the form of administration & is highly variable
T
73
Morphine has _______ analgesic potency & _____ speed of offset in women
Greater Slower (It works better in women)
74
What type of patient should we avoid morphine in? Why?
Pts w/ renal impairment dt metabolite Morphine-3-glucuronide can accumulate --> respiratory depression
75
What abnormal SE do most opioids have? (2)
1. Histamine release (itchiness) 2. Euphoria (Mu-1)
76
What is the most used opioid in the world? What is it normally used for? (2)
Oxycodone 1. Neuropathic pain syndrome 2. Acute/chronic pains
77
IR/CR oxycodone is called _______
Oxycontin
78
How was oxycodone metabolized? What is special about its metabolism? What are its metabolites? (2) Describe them.
Hepatic P450 -- CYP2D6 It is a prodrug. When it goes thru the liver, it is activated. 1. Oxymorphone (active) 2. Noroxycodone (inactive)
79
What receptors does oxycodone work on? (2)
1. Mu 2. Kappa
80
T/F: oxycodone has a minimal 1st pass effect
F Has an extensive 1st pass effect
81
What is the onset of oxycodone? DOA?
Onset = < 1hr DOA: IR = 3-4hr CR = 12hrs
82
Drug dose: oxycodone
10 - 15mg (equal to 10mg of morphine)
83
The interactions with ALL opioids have ______ with other drugs that are CNS depressants
Additive effects
84
What is methadone normally used for? Why?
Maintenance drug for opioid addiction dt it's oral bioavailability (60-95%), high potency, & long DOA/half life
85
What type of drug is methadone? (4)
1. Weak non-competitive NMDA receptor antagonist 2. Serotonin reuptake inhibitor 3. Mu-receptor agonist 4. Monoamine transmitter reuptake inhibitor
86
How is methadone metabolized? (3)
Hepatic P450 -- CYP3A4, CYP1A2, CYP2D6
87
The metabolism of methadone is increased by P450 inducer like __________ & reduced by others like ___________ (2)
increased metabolism (goes out of system faster): -**Carbamazepine** Decreased metabolism (stays in system longer): 1. **Anti-retroviral agents** 2. **Grapefruit juice**
88
With methadone, steady state concentrations may take up to _____ to achieve. Why? What can this result in?
10 days dt extensive re-distribution of the drug High plasma concentrations
89
Drug dose: methadone
2.5 - 10 mg PO/IM/SQ q 4-12 hrs
90
What increases the concentration/effect off methadone? (3)
1. Cipro 2. Diazepam 3. Ethanol (acute use)
91
What decreases the concentration/effect off methadone? (5)
1. Amprenavir 2. Phenobarbital 3. Phenytoin 4. Rifampin
92
Fentanyl is structurally related to _______
Meperidine
93
Why do we like fentanyl so much in anesthesia? (3)
1. High potency 2. Rapid onset 3. Short DOA
94
How is fentanyl metabolized? What are its metabolite? (3) Describe them
Metabolized by N-demethylation 1. Norfentanyl 2. Hydroxyproprionyl-fentanyl 3. Hydroxyproprionyl-Norfentanyl Norfentanyl is structurally similar to normeperidine
95
Fentanyl's metabolite _______ can be detected in urine up ______ after a single dose
Norfentanyl 72 hours
96
The ________ serve as a large inactive storage for fentanyl. ____% of the initial dose undergoes _________ which limits the initial amount of drug that reaches the systemic circulation
Lung 75% 1st past pulmonary uptake
97
Hydromorphone is ________ times as potent as morphine when administered PO & ____ times as potent IV
3 - 5x 8.5x
98
How is hydromorphone metabolized? What are its metabolites? Describe it
Hepatic Hydromorphone-3-glucuronide Lacks analgesic effects but potentiate neurotoxic effects such as allodynia, myoclonus, seizures
99
What type of patients should we avoid hydromorphone in? Why?
Pts w/ renal insufficiency dt buildup of Hydromorphone-3-glucuronide --> neurotoxic SE --> allodynia, myoclonus, seizures
100
Drug dose: hydromorphone (IV/unusual IV/unusual PO)
0.2 mg IV q 3 - 5 mins Unusual IV: < 2mg q 4hrs Unusual PO: 2 - 8mgs
101
hydrocodone is a derivative of ______, but it is ______ times more potent
Codeine 6 - 8x
102
hydrocodone is commonly combined with ________. what are the names of these? (3)
Tylenol 1. Norco 2. Vicodin 3. Lortab
103
______ is the 2nd most commonly abused drug behind ___________, which is the 1st.
Hydrocodone Oxycodone
104
How is hydrocodone metabolized? (2) What are its metabolite? (2) Describe them
Hepatic P450 -- CYP2D6 & CYP3A4 1. Hydromorphone (dilaudid-active-CYP2D6) 2. Norhydrocodone (inactive-CYP3A4) -- catalyzed by oxidation
105
Drug dose: hydrocodone
30 mg (equals 10mg morphine)
106
What is the 24hr max of Tylenol?
4g = 4,000mg
107
T/F: magnesium & CCB may decrease hydrocodone effect
F It may increase hydrocodone effect
108
What receptors does Buprenorphine work on? (3) How does it work on them?
1. Partial agonist - Mu 2. Antagonist - Kappa 3. Weak agonist - Delta
109
What is the main usage of Buprenorphine? (2)
1. Tx of cancer 2. Chronic pain
110
How is Buprenorphine metabolize? What is it's metabolite? Describe it
Hepatic P450 -- CYP3A4 1. Norbuprenorphine (by N-dealkylation) Norbuprenorphine is a full agonist at the mu, delta, & ORL-1 opioid receptor & partial agonist at the capital of receptor
111
Drug dose: Buprenorphine (IM, transdermal)
IM: 0.3 mg (equal to 10mg morphine) Transdermal: 5 - 70 mg/hr for 4-7days
112
Why don't we give Buprenorphine PO? How can we bypass this?
Extensive first pass effect Even sublingual will bypass & all other routes of administration
113
The antagonist properties of Buprenorphine can precipitate ____________
Withdrawal symptoms
114
Can patients on Buprenorphine have withdrawal symptoms? Describe them
Yes Develop slower in our less intense than those associated with morphine dt antagonist properties
115
What are the benefits of long-term opioid use? (3)
1. Pain reduction 2. Fewer episodes of severe pain spikes 3. Increase in functionality
116
T/F: you can have worsening enough pain if you're on opioids for a long-term
T This is dt tolerence development
117
What are ways to prevent/treat the side effects of opioids? (4)
1. Choosing the "two-for" method 2. Opioid rotation 3. Pharmacological interventions 4. Non-pharmacological intervention (including pt education)
118
T/F: Non-opioids bind to receptors to decrease inflammation and provide analgesia
F Interfere with the AA cascade & block production/inhibit cyclooxygenase (COX)
119
Why should you take NSAIDs with food?
Prevention of abd SE such as constipation, cramps, developing stomach ulcers
120
Drug dose: Tylenol (starting dose)
500 - 1000mg q 6 hrs
121
Drug dose: ibuprofen (starting dose)
200 mg 3x daily
122
Drug dose: Celecoxib (starting dose)
100 mg daily
123
Drug dose: naproxen (starting dose)
220 mg 2x daily
124
Drug dose: Diclofenac (starting dose)
50 mg 2x daily
125
What is the MOA of antidepressants in the role of adjuncts for pain management? What type of pain does it work best in? How long does it take to work?
Increased transmission in spinal cord to reduce pain signal Nerve pain Does not work right away -- takes 5 - 10 days
125
________ (4) are considered adjuvant medications for pain.
1. Antidepressants 2. Anticonvulsants 3. Skeletal muscle relaxant 4. Topical creams (OTC)
126
Why may counseling be beneficial and treating pain?
With chronic pain a psychological component may have developed
127
What are some barriers to opioid use? (3)
1. Pts has fear of SE, addiction, death 2. Care plan adherence dt functional limitations 3. Not best drug for chronic pain
128
T/F: opioids are a great drug for chronic pain
F
129
What is the order of opioid dosing? (3)
Initial dose --> up-titration --> maximum dose
130
Opioid conversion: morphine IV: 10mg
PO = 30mg
131
Opioid conversion: hydromorphone IV: 1.5mg
PO = 7.5mg
132
Opioid conversion: oxycodone ---
PO = 20 - 30mg
133
Opioid conversion: codeine IV: 130mg
PO = 200mg
134
Opioid conversion: hydrocodone --
PO = 30mg
135
Opioid conversion: methadone IV: 1.5-2.5mg
PO = 3-5mg
136
Opioid conversion: fentanyl IV: 0.1mg
PO = ---
137
What should the pt be on if they are in the hospital and on a PCA? (3)
1. O2 2. SpO2 monitoring 3. Capnography monitoring
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