Acute pain.

Question 1

What is nociceptive pain?

Answer 1

response to injury or pathology.

Question 2

Are we best using one, or a number of drugs to manage acute main?

Answer 2

multi-modal of low does drugs from different categories is best.

Question 3

What is an analgesic corridor?

Answer 3

Blood levels of drugs should be maintained within this.

Question 4

When taking a pain history, apart from socrates what should we ask patients about?

Answer 4

impact on function, sleeping and eating.
effectiveness of analgesia
previous/current therapy.

Question 5

Where do high pain patients e.g. post op start on the pain ladder?

Answer 5

At the top and work their way back.

Question 6

What are rules for prescribing to pain in renal failure?

Answer 6

Best to avoid NSAIDS.
Some drugs have minimal active metabolites e.g paracetamol or fentanyl so wont accumulate.
Most other analgesics can be used but dosage needs to be reduced to allow for decreased clearance.

Question 7

What are the two key issues we need to think about when prescribing pain meds to people with renal failure?

Answer 7

Further damage to renal function

Accumulation of active metabolites

Question 8

What should we think when prescribing in vomiting?

Answer 8

probably not oral route.

Question 9

How does paracetamol work?

Answer 9

Inhibits prostaglandin synthesis in the CNS

Question 10

What prescribing factors must we remember with paracetamol?

Answer 10

Remember to reduce dose if weight <50kg

Question 11

What do NSAIDs do?

Answer 11

inhibit the enzyme cyclo-oxygenase [cox]

Question 12

What are the contraindications for NSAIDs?

Answer 12

Gastrointestinal bleeding [old or new] or active peptic ulceration
Coagulopathy
Renal impairment
Aspirin/NSAID allergy

Question 13

What are the cautions for NSAIDs?

Answer 13

Elderly
Dehydration
Asthmatics [ask about sensitivity to NSAIDS]
Certain types of surgery, e.g. - plastic or eye surgery, some orthopaedic surgery
Cardiac failure
Pregnancy
Concurrent medication e.g. anticoagulants

Question 14

How do you manage opioid resp depression?

Answer 14

Give oxygen
Adjust dose or stop delivery of opioid until situation satisfactory
If necessary give naloxone titrate to effect
Respiratory depression may be delayed after intrathecal or epidural opioids.

Question 15

What are the strong opioids?

Answer 15

Morphine, Diamorphine, Oxycodone, Fentanyl, Methadone

Question 16

What are the weak opioids?

Answer 16

Codeine, Tramadol

Question 17

How is morphine metabolised and excreted?

Answer 17

Metabolised in the liver to M6G and M3G - these have longer half-lives than morphine and are excreted via the kidney

Question 18

What is oxycodone?

Answer 18

Synthetic opioid

Question 19

What is the onset of oxycodone?

Answer 19

Good oral bioavailability

Fast onset and short time to steady state

Question 20

What is tramadol and where/how does it work?

Answer 20

Centrally acting synthetic analgesic: mu opioid receptor activity + inhibits the uptake of noradrenaline and serotonin

Question 21

What are the advantages of tramadol?

Answer 21

said to be absence of tolerance, lower abuse potential, less respiratory depression, less constipation - nausea, vomiting and sedation may still occur

Question 22

When should we avoid tramadol?

Answer 22

epileptics as reduces threshold.

Question 23

What are contraindications to PCA?

Answer 23

Patient inability to comprehend the technique e.g. extremes of age
Patients inability to press the button e.g. severe rheumatoid
Patient rejection
Ward staff must be trained appropriately

Question 24

If we need to give an IV top up for PCA pain control, what drugs should be used?

Answer 24

same drug as in the PCA.

Question 25

What are the different N and V drugs we use, plus class?

Answer 25

Antihistamines e.g. Cyclizine
5HT3 antagonists e.g. Ondansetron
Antidopaminergic e.g. Prochlorperazine, Metoclopramide
Anticholinergic e.g. Hyoscine

Question 26

When scoring pain, what do we need to ensure?

Answer 26

We add a movement component e.g. cough.

Question 27

What pain scores need intervention?

Answer 27

2 and 3

Question 28

How do we assess respiratory depression on opioids?

Answer 28

0= None (patient alert)
1= Mild (occasionally drowsy; easy to rouse)
2= Moderate (frequently drowsy; easy to rouse)
3= Severe (somnolent; difficult to rouse)
S= Sleep (normal sleep; easy to rouse)

Question 29

How do we chart N and V on opioids?

Answer 29

0= None
1= Mild (no treatment required)
2= Moderate (helped by treatment)
3= Severe (despite treatment)

Question 30

How long do fentanyl patches take to kick in?

Answer 30

12 hours

Question 31

What analgesics are good for renal impairment?

Answer 31

fentanyl
alfentanil
oxycodone

Question 32

What type of drug is clonidine?

Answer 32

antihypertensive used as an analgesic in specialist settings

Question 33

What does clonidine do?

Answer 33

reduces norepininephrine release and so inhibits sympathetic nervous synstem

Question 34

What are the side effects of clonidine?

Answer 34

hypotension
bradycardia
sedation

Question 35

What is a good treatment for limb ischaemia and why?

Answer 35

nerve block as causes vasodilation

Question 36

When does pain become chronic?

Answer 36

after 3 months or after healing should have normally been completed.

Question 37

What are the three main categories of pain?

Answer 37

nociceptive
neuropathic
cancer

(acute or chronic of any)