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    <title>061-02 Mechanism-based analgesia, sedation rescue, and anaesthetic physiological safety</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Mechanism-based analgesia and anaesthetic safety">
      <outline text="Goals and pain mechanisms">
        <outline text="Relieve suffering, preserve breathing and thinking"/>
        <outline text="Pain score is one measurement, not the endpoint">
          <outline text="Assess function, sleep, cough, mobilisation"/>
        </outline>
        <outline text="Escalating pain despite analgesia">
          <outline text="Compartment syndrome, ischaemia, perforation"/>
        </outline>
        <outline text="Analgesia enables repeated examination"/>
        <outline text="Nociceptive: somatic and visceral transduction"/>
        <outline text="Neuropathic: somatosensory lesion or disease">
          <outline text="Allodynia, hyperalgesia, burning, numbness"/>
        </outline>
        <outline text="Nociplastic: network amplification"/>
        <outline text="Mechanisms overlap and evolve">
          <outline text="Persistent input sensitises spinal circuits"/>
          <outline text="Fear, sleep loss, depression alter descending control"/>
        </outline>
      </outline>
      <outline text="Multimodal analgesia and the pain plan">
        <outline text="Different targets so no toxicity dominates"/>
        <outline text="Select treatments by mechanism"/>
        <outline text="Opioid-sparing only if replacement is safe">
          <outline text="Stacked sedatives worsen falls and ventilation"/>
        </outline>
        <outline text="Each addition needs benefit and review point"/>
        <outline text="One-page plan: regular, as-required, maximum dose"/>
        <outline text="Reconcile hospital and home medicines at discharge"/>
        <outline text="Follow bowels, delirium, retention, kidney function"/>
        <outline text="Distinguish regular from rescue dosing"/>
      </outline>
      <outline text="Paracetamol and non-steroidal drugs">
        <outline text="Paracetamol has a ceiling effect">
          <outline text="Hidden duplication is a major overdose route"/>
        </outline>
        <outline text="Adjust for low weight, alcohol, liver disease"/>
        <outline text="NSAIDs remove gastric, renal, platelet protection">
          <outline text="Harm amplified by dehydration, heart failure, age"/>
        </outline>
        <outline text="Topical use lowers exposure, absorption not zero"/>
      </outline>
      <outline text="Opioids and ventilation">
        <outline text="Effect depends on receptor, metabolites, clearance"/>
        <outline text="Intravenous boluses titrated in monitored pain"/>
        <outline text="Long-acting accumulation outlasts reassessment"/>
        <outline text="Incomplete cross-tolerance: reduce and retitrate"/>
        <outline text="Morphine metabolites accumulate in kidney failure"/>
        <outline text="Respiratory rate alone misses impairment">
          <outline text="Shallow breaths with rising carbon dioxide"/>
          <outline text="Oxygen preserves saturation"/>
        </outline>
        <outline text="Stimulate, open airway, oxygen, ventilate"/>
        <outline text="Naloxone to adequate breathing, not withdrawal">
          <outline text="Infusion when the opioid lasts longer"/>
        </outline>
        <outline text="Long-term therapy judged by function">
          <outline text="Constipation persists despite tolerance"/>
          <outline text="Abrupt discontinuation: withdrawal, suicide risk"/>
        </outline>
      </outline>
      <outline text="Neuropathic agents and local anaesthetics">
        <outline text="Neuropathic medicines work slowly and partially"/>
        <outline text="Tricyclics: anticholinergic, cardiac, overdose risk"/>
        <outline text="Gabapentinoids: sedation, respiratory synergy"/>
        <outline text="Success may mean better sleep and movement"/>
        <outline text="Local anaesthetics block sodium channels"/>
        <outline text="Vasoconstrictor reduces systemic absorption"/>
        <outline text="Total dose sums every infiltration and block"/>
        <outline text="Toxicity: circumoral numbness, tinnitus, seizure">
          <outline text="Then conduction delay, dysrhythmia, collapse"/>
        </outline>
        <outline text="Stop, help, oxygenate, lipid emulsion"/>
        <outline text="Fractionated injection with aspiration"/>
        <outline text="Protect the numb limb"/>
      </outline>
      <outline text="Pre-anaesthetic assessment">
        <outline text="Predict difficulty in oxygenation and ventilation"/>
        <outline text="No single score excludes a difficult airway"/>
        <outline text="Prepare backup devices and front-of-neck rescue"/>
        <outline text="First priority is oxygen, not intubation"/>
        <outline text="Establish medicines, allergies, last intake"/>
        <outline text="Indiscriminate stopping: withdrawal, thrombosis"/>
        <outline text="Decide continue, withhold, or bridge">
          <outline text="Record who restarts after operation"/>
        </outline>
      </outline>
      <outline text="Induction and general anaesthesia">
        <outline text="Preoxygenation replaces nitrogen with oxygen">
          <outline text="Shorter in pregnancy, obesity, children"/>
        </outline>
        <outline text="Induction removes airway tone and sympathetic support"/>
        <outline text="Positive pressure reduces venous return">
          <outline text="Arrest after successful intubation"/>
        </outline>
        <outline text="No single agent provides all components"/>
        <outline text="Paralysis conceals awareness"/>
        <outline text="Confirm tube by waveform carbon dioxide"/>
        <outline text="Distinguish crises by timing, pressures, skin"/>
      </outline>
      <outline text="Malignant hyperthermia">
        <outline text="Skeletal muscle calcium regulation crisis"/>
        <outline text="Triggered by volatiles or depolarising relaxant"/>
        <outline text="Early carbon dioxide rise, rigidity, hyperkalaemia">
          <outline text="Temperature rise can be late"/>
        </outline>
        <outline text="Stop trigger, oxygen, dantrolene, cooling"/>
        <outline text="Record for later testing and safe anaesthesia"/>
      </outline>
      <outline text="Neuraxial and peripheral blocks">
        <outline text="Sympathetic block causes vasodilation"/>
        <outline text="High block: bradycardia and shock"/>
        <outline text="Spinal haematoma risk from anticoagulant timing">
          <outline text="New back pain or weakness is an emergency"/>
        </outline>
        <outline text="Peripheral block can conceal surgical injury">
          <outline text="Check distribution, circulation, compartment signs"/>
        </outline>
        <outline text="Start oral analgesia before block regresses"/>
      </outline>
      <outline text="Sedation and recovery">
        <outline text="Continuum: response and stimulation vary"/>
        <outline text="Rescue at least one level deeper"/>
        <outline text="Oxygen delays desaturation, masks hypoventilation"/>
        <outline text="Propofol: apnoea, vasodilation, no reversal"/>
        <outline text="Repeat dosing before peak effect deepens sedation"/>
        <outline text="Recovery is a distinct high-risk phase">
          <outline text="Stimulation ends, absorption continues"/>
        </outline>
        <outline text="Written restrictions and return instructions"/>
      </outline>
    </outline>
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