1
Q
Pain is difficult to assess because it is subjective and each patient’s experience of pain is unique. What factors have an influence over this?
A
- Unique physiology (peripheral and central nervous system circuitry)
- Pathophysiology (not one injury is exactly the same)
- Personality
- Previous life experience
- Cultural and religious background
- Age
2
Q
What goes into ascertaining a patient’s history of pain?
A
- Existence of pain
- Previous injuries
- Adjunctive therapies (acupuncture, TENS, injection therapy, SCS (what are they doing for the pain?)
- Coexisting psychological/physical diseases
- Assess other factors which may influence pain history: social, cultural, and spiritual factors
3
Q
Elements of a Pain Assessment
A
- P = Precipitating events
- Q = Quality
- R = Region/ Radiation
- S = Severity
- T = Temporal relationship/ Timing
- A = Associated symptoms:
- Functional impairment
- Previous treatment
- Inflammation
- Pain Goals
4
Q
Appropriate population for Wong-Baker FACES
A
3 years old and up; “younger and/or not as verbal”
5
Q
Purpose of Behavioral Pain Scales
A
- Provide a means for consistent evaluation of pain in non-verbal pt populations
- Allows pts who cannot self report pain a method for pain assessment
- Pediatric patients, neonates, babies
- Pts w/ cognitive impairment
- Critically ill patients
6
Q
Appropriate population for the Checklist of Non-verbal Pain Indicators (CNPI)
A
Adults
7
Q
Appropriate population for the Payen Behavior Pain Scale
A
- Developed for critically ill, intubated ICU pts
- Has reliability &validity & correlates to NPI ratings (even in sedated pts)
- Uses a 0 to 12 pain rating scale (3-12???)
8
Q
Appropriate population for FLACC
A
2 months – 7 years
Face/Legs/Activity/Cry/Consolability
(scale = 0-10)
9
Q
Appropriate population for CRIES Pain Scale
A
0-6 months old
Crying
Requires O2 for SaO2 less than 95%
Increased vitals (BP/HR)
Expression
Sleepless
(scale = 0-10)
10
Q
Considerations in Methods to Relieve Pain
A
- Duration of pain relief (shorter vs longer acting)
- Acute vs Chronic pain?
- Patient history
- Goals of management
11
Q
Nonpharmacologic pain treatment modalities
A
- PT/ rolling
- Heat/cold
- Acupuncture
- Relaxation behaviors
- Massage
- Positioning
- Immobilization
- TENS
12
Q
Pain Treatment Modalities: Medications
A
- Types:
- Opioids
- Non-steroidals
- Corticosteroids
- Local anesthetics
- Ketamine
- Alpha 2 Adrenergic Agonists
- Antidepressants
- Anticonvulsants
- Prescription or OTC
- Continuous or PRN
13
Q
Physical Exam
A
- General physical examination
- Examine affected area
- Neurological exam
- Musculoskeletal system examination (ROM; muscle wasting)
- Skin (redness, wounds, edema, temp changes)
- Assessment of psychological factors: un-kept personal hygiene
- Vital signs
14
Q
Specific Diagnostic Studies
A
- Quantitative sensory testing (QST) for pain thresholds and pain tolerance
- “Poor man’s sensory testing”
- Diagnostic nerve blocks
- Pharmacologic tests
- X-rays, CT, MRI, ultrasound
- EMG (Electromyography nerve test)
- NCV (Nerve Conduction Velocity test)
- Bone scans
- Blood tests: looking for co-conditions (RA, chronic inflammation)
15
Q
What is acute pain?
A
- Pain caused by noxious stimulation d/t injury, trauma, an acute disease process, or abnormal function of muscle or viscera.
- Almost always nociceptive pain
- Results in a neuroendocrine response
16
Q
Why manage pain?
A
- Control of postop pain allows for:
- Reduction of the stress response
- Shorter times to extubation, shorter ICU stay
- Improved respiratory function
- Earlier return of bowel function
- Early mobilization = decreased risk DVTs
- Early discharge
- Reduction in sensitization, neuroplasticity, wind-up phenomenon, and transition to chronic pain
17
Q
What is the “poor man’s sensory testing”?
A
- Cold water in a glass tube (cold allodynia)
- Warm water in a glass tube (heat allodynia)
- Cotton wool and artist’s brush (dynamic mechanical allodynia)
- Blunt needle (hyperalgesia)
18
Q
Methods to relieve pain intra-op
A
- Preemptive Analgesia- best postop pain management begins preop.
- Opioids and NSAIDs in GA
- Regional blocks
- Local infiltration at surgical site could be used to control acute pain (hernia repair, tonsilar bed.)
- Regional Anesthesia-pts do better overall
19
Q
How do we see patients doing better with regional anesthesia as a method for intra-op pain relief?
A
- Less morbidity
- Less CV failure
- Less infections
- Less urinary cortisol
- >L1 significant effect on the neuroendocrine response to surgery.
- Lower overall post op complication rate
20
Q
Patient Controlled Analgesia (PCA): Advantages and Findings
A
Advantages:
- Cost-effective
- Higher degree of patient satisfaction
- Total drug consumption less than IM
- Harder to over-medicate self
- Prevents the “pain no pain cycle”
Findings:
- Patients consume less drug
- Male use more than female
- Shortens hospital stays
21
Q
Patient Controlled Analgesia (PCA): Features
A
- Reservoir
- Infusion controller
- Pushbutton operated by pt only (not family and visitors)
- Delivers specific dose
- Lockout (minimal intervals b/t doses)
- Basal infusion (background infusion)
22
Q
Patient Controlled Analgesia (PCA): Considerations/Disadvantages
A
- Prescription: Relieve pain before starting PCA.
- Too little each hit discourages pt. If demand dose too much = adverse reactions also discourage pt (distrust)
- Side Effects: Onset of respiratory depression parallels analgesia and is more rapid with lipophilic opioids.
- N/V constipation, pruritis. Nearly all overdoses have been d/t errors in programming parameters.
23
Q
Principle behind Multimodal Approach
A
- Control postop pain and attenuate periop stress response through use of regional anesthetic techniques and combo of analgesic agents (multimodal analgesia)
- An extension of “clinical pathways” into effective postop rehabilitation pathways
24
Q
ERAS Protocols
A
- Early Recovery After Surgery
- Pre-hospital:
- pain management plan
- Pre-op:
- initiate multimodal meds
- regional block placement
- Intra-op:
- short-acting
- opioid-sparing meds
- multimodal meds
- regional anesthesia/analgesia
- Post-op:
- non-opioid analgesics/NSAIDS
- regional anesthesia
- Pre-hospital:
25
Peripheral Nerve Blocks
* **Single injection or continuous infusion** of LA applied at a peripheral nerve site
* Can add opioid and/or steroids to mixture
* Can be used for **intraop anesthesia or adjunct** to postop analgesia
* **Limits path of nociceptive impulses**
* Superior analgesia
* Few side effects
* Can have analgesia for up to 24 hrs after single injection
26
Exparel®️
* Bupivicaine liposome injectable suspension
* Approved for single-dose local infiltration and interscalene brachial plexus nerve blocks
* Lasts up to 96 hrs post-infiltration and 120 hrs post-p.n.block
* Side effects: N/V, fever
27
What is the recommended dose of EXPAREL for local infiltration in adults?
Up to a max dose of **266 mg (20 mL)**
28
What is the recommended dose of EXPAREL for interscalene brachial plexus nerve block in adults?
**133 mg (10 mL)**
29
_Neuraxial (Spinal/Epidural) Analgesia_: Benefits
* Provide **superior analgesia** compared w/ systemic opioids
* Facilitates return of **GI motility**
* ↓ **stress response**
* **↓** incidence of **pulmonary complications**
* **↓** incidence of **coagulation-related adverse events**
30
_Neuraxial (Spinal/Epidural) Analgesia:_ Disadvantages
* Cannot be used w/ anticoagulants
* Infection
31
Single-Dose Neuraxial (Spinal/Epidural) Opioids
* Sole or adjuvant analgesic
* Intrathecal (spinal) or epidural
* Opioid selection depends on degree of lipophilicity vs hydrophilicity
32
Adjunct Treatments for Acute Pain Management
1. Ice
2. Surgical
* Local infiltration
* Intra-articular analgesia
* Pain pumps (onQ)
3. TENS
4. Acupuncture
5. Psychological Approaches
* Hypnosis
* Distraction, relaxation, imagery, music
33
Subpopulations w/ Special Considerations
* Ambulatory *(pts are going home, so consider short-acting and control of PONV)*
* Pediatric *(assessment; PO/rectal pre-meds)*
* Elderly *(sensitive; regional might be better)*
* Obesity *(pulmonary considerations)*
* Obstructive Sleep Apnea (OSA) *(pulmonary considerations)*
* Opioid-tolerant Patients *(alcohol users; chronic pain pt that might require more meds in acute setting)*
34
Chronic Pain Management: Pharmacology
* **N**SAIDS/Acetaminophen
* **O**pioids
* **T**ramadol
* **A**ntidepressant Drugs
* **C**orticosteroids
* **O**thers
* **M**uscle Relaxants
* **A**nticonvulsant Drugs
35
Tricyclic Antidepressants
* Block reuptake of serotonin and NE at neuronal membrane
* **Elevate mood**, help w/ **sleep**
* **Potentiate narcotic** analgesics
* Use **smaller doses** than indicated for depression
* **Monitor** drug levels
* **Anticholinergic side effects**
* Dry mouth, sedation, fatigue, orthostatic hypotension, arrhythmias
* _Examples_: Amitriptyline, Doxepin
36
Anticonvulsant Drugs
* Alter ion channels along nerve fiber = blocking pain stimuli by blocking action potential
* Used for tx **neuropathic pain** resulting from lesions to peripheral (DM, herpes) or CNS (stroke)
* **Side effects**: sedation, dizziness, ataxia
* _Examples_: carbamazepine, clonazempan, phenytoin, gabapentin
37
Corticosteriods
* Reduce inflammation and swelling
* Reduce inflammatory mediators
* Prevent release of prostaglandins
* _Example_: Dexamethasone
38
Adjuvant: Muscle Relaxants
* Reduction of muscle spasms
* Analgesia
* ? Mechanism *(release of muscle tension)*
* _Examples_: baclofen, cyclobenzaprine, carisoprodol, skelaxin
39
Adjuvant: NMDA receptor antagonists example
Ketamine
40
Adjuvant: Alpha-2 adrenergic agonists
* Work pre- and post-synaptically within dorsal horn to inhibit neuron firing
* Also works centrally by inhibiting release of substance P (Precedex)
* _Examples_: Clonidine, Dexmedetomidine (Precedex)
41
Nerve Blocks
* **Trigger Point** injections
* **Epidural steroid** injections
* Provide **high dose** of steroid at level of pathology to:
* Reduce swelling of nerve root
* Block C-fibers
* Stabilize nerve membranes
* Decrease ectopic discharges from inflamed tissue
42
Neurolytic Blocks
* **Permanent destruction** of nerve
* Most common neurolytic blocks are:
* Lumbar sympathetic chain
* Celiac plexus
* Hypogastric plexus
* Ganglion impar (retroperitoneal plexus)
* Also intercostal blocks
* Alcohol and Phenol
43
Spinal Cord Stimulation
* **Stimulating electrodes in epidural space** surrounding entry level of noxious input into spinal cord
* Activation of **descending modulating system** and therefore inhibit sympathetic outflow
* Used with:
* phantom limb pain
* ischemic pain
* PVD
* spinal cord lesions
44
TENS
* Transcutaneous electrical nerve stimulation
* Hyperstimulation of nervous system drowns out pain
45
Radiofrequency Ablation
* Radio frequency ablation (RFA) is procedure where **dysfunctional tissue is ablated using microwave energy**
* **Cryoneurolysis** with cold-freeze
46
Cancer Pain
* 70-90% of CA pain can be effectively treated w/ pharmacotherapy alone & 40-50% of pts experiencing CA-related pain do not receive effective analgesia
* Pain caused by cancer
* Most common cause: **Tumor invasion of bone**
* 2nd most common cause: **Tumor compression** of peripheral nerves
* Pain d/t treatment
* Physical effects—worse d/t loss of sleep, appetite, N/V
* Psychological—heightened anxiety, feelings of loss, low self-esteem, changes in life goals, disfigurement
47
Cancer Pain Management
* Treat disease
* Assessment of pain
* Onset & duration of pain
* Aggravating and relieving factors
* Past treatment
* Impact of pain in overall suffering
* Physical and neurologic/psychological exam
* Multi-disciplinary team
48
WHO Analgesic Ladder
Therapeutic Ladder for Pain Management in Terminally Ill Patients:
1. Step _One_, Mild Pain: **Non-opioid analgesics**
2. Step _Two_, Mild-Moderate Pain: **Weak oral opioids**
3. Step _Three_, Moderate-Severe Pain: **Potent parenteral opioids**
4. Step _Four_, Intractable Pain: **Invasive** Therapy
49
What is Inadequate Pain Relief Related to?
* Poor pain assessment
* Poor pain treatment plans
* Lack of knowledge of analgesics available
* Fear of addiction
* Fear of respiratory depression
* Side effects of pain treatment
Coexisting
flashcards
Decks in class (5)
# Cards
