Pain Scales
What age can patients accurately assess their pain severity?
Patients aged 3 and older can accurately assess severity of pain
Whats the problem with 8 hr NPO?
Can lead to hypovolemia -> (+ the induction of anesthesia) will lead to hypotension -> vasoconstrictive response -> poor tissue perfusion (which are bad for flaps)
Risk of colloid administration
Volume expansion -> endothelial damage 0> pulm edema and orange damage
How does regional anesthesia help with ERAS? (3)
multimodal approach -> better pain control -> faster mobility, decreased hospital stay, increased patient satisfaction
What is the leading cause of unanticipated admission for outpatient procedures?
PONV which causes more cost
Defense and Veterans Pain Rating Scale combines whihc assessment tools
Numeric Rating Scale, FACES, and Visual analog in the form of stop light colors with green (no pain) to red (worst pain)
-Adds phrases to anchor pain rating with perceptual limitation that the pain imposes upon their funcitonal ability
True or False: Under the ERAS protocol, encourage the usage of red gatorade up to 2 hrs before surgery
How do you initiate goal directed fluid therapy?
4-2-1 rule + insensible 3rd space loss 1-15 mL/kg
4 ml/kg (1st 10 kg) + 2 ml/kg (2nd 10 kg) + 1 ml/kg (rest of kg of weight)
6 postoperative interventions of the ERAS pathway
Allow PO intake when tolerated to replace IVF
Advance diet as tolerated
PONV prophylaxis and treatment
Schedule non-opioid pain meds
Non-pharmacological pain management (ice pack)
Encourage mobility as tolerated
FLACC stands for...
Face
Legs
Activity
Cry
Consolability
Scored 0-2 (up to 10)
What are 4 behavioral domains of the critical care pain observation tool?
Facial expression, Movement, muscle tension, ventilator compliance
-Each section is from 0-2 (Total = 8)
Non-opioid analgesia (gabapentin, pregabalin acetaminophen, celebrex), antiemetics (scopolamine, flexeril, decadron), regional anesthesia (Peripheral nerve block, neuraxial)
How should you replete blood loss with crystalloid, colloid, and blood products?
Crystalloids should be 3 L of crystalloid for every 1 L of blood loss
Colloid and Blood products are 1:1
Interventions of Post discharge?
Reinforce expectations related to pain
Encourage mobility
Consider scheduled non-opioid pain management
How do you perform a defense and veterans pain rating scale?
1. Ask patient to rate their pain on NRS scale (0-10)
2. Grab DVPRS printout
3. Point to number corresponding to what they said
4. Ask patient if functional descriptors match their pain level or if their pain is better or worse with visual cues
-Ask them if they feel like their pain is "awful and it's hard to do anything" (8/10) or if it just "distracts them occassionally" (4/10)
5. Document new number if there is one
What are 3 behavioral domains for the behavioral pain scale?
Facial expression, upper limbs (movement), compliance with ventilator
-Each section is 1-4 (Total: 12)
High risk PONV patients
Female, non smoker, DM, motion sickness, obesity, pregnancy, full stomach, pain & anxiety, young age
Surgery: ex-laps, mastectomys, ENT, GI procedures, etc
Doage of propofol intraop
50-150 mcg/kg/min IV
GABA receptor and good for PONV
Where can SRNAs find the protocols for RUMC ERAS protocols?
Each institution is different-- inquire at clinical site
Uses of FLACC Scale
babies, young children, adults when BPS or COPT is not used
When used on patients who could self-report, scores from these two assessment tools were found to be lower than the numerical rating scale.
Behavioral Pain Scale and Critical Care Pain Observation Tool
Why is ERAS so important? (6)
-Increase opioid use over past 3 decades
-Majority of drug overdose deaths were from opioid OD
-40% of opioid OD involved prescription opioids
-EACH YEAR, >2 million people have persistent opioid use after elective, ambulatory surgery *
-2.1 million misuse prescription opioids
-10% of opioid-naive patients become chronic opioid users after surgery
Overhydration causes a risk of what? (5)
Poor wound healing from collagen regeneration impairment, wound dehiscence, wound infection, anastomotic leakage, CHF
Postoperative Complications of PONV (4)
Increased pain and changes in vitals (tachycardia, hypertension)
Wound dehiscence
Bleeding
Aspiration
Number 1 and 2 causes of patient dissatisfaction in the hospital
1. Pain
2. PONV