ANESTHESIA TECHNIQUES| Acute Pain

Question 1

In order for PREVENTIVE analgesia to be successful, three critical principles must be adhered to:

A. The depth of analgesia must be adequate to block all nociceptive input during surgery

B. The analgesic technique must be extensive enough to include the entire surgical field

C. The duration of analgesia must include both the surgical and postsurgical periods

D. All of the above

Answer 1

D. All of the above

Question 2

TRUE or FALSE

The opioid receptors are members of a G protein–coupled (guanosine triphosphate regulatory proteins) receptor family, which signals via a second messenger such as cyclic adenosine monophosphate or an ion channel.

Answer 2

TRUE

Question 3

TRUE or FALSE

A typical patient-controlled analgesia (PCA) regimen in an otherwise healthy adult would be an incremental dose of 1 to 2 mg of morphine with an 8- to 10- minute lockout

Answer 3

TRUE

Question 4

The pain assessment tool FLACC is appropriate for which age group?

A. 2 month old to 7 years old

B. 5 to 10 years old

C. 2 to 18 years old

D. 6 month to 10 years old

Answer 4

A. 2 month old to 7 years old

Question 5

The pain assessment tool VAS or visual analog scale is appropriate for which age group?

A. 6 - 18 years old

B. 10 - 18 years old

C. 15 years old and up

D. 2 - 18 years old

Answer 5

A. 6 - 18 years old

Question 6

In general, acute pain resolves within:

A. 1 month

B. 6 months

C. 1 year

D. 12 weeks

Answer 6

A. 1 month

Question 7

Acute pain–induced change in the central nervous system is known as ___________

Answer 7

NEURONAL PLASTICITY

Acute pain–induced change in the central nervous system is known as neuronal plasticity.

This can cause sensitization of the nervous system, resulting in allodynia and
hyperalgesia

Question 8

Nociceptors are free nerve endings located in skin, muscle, bone, and connective tissue with cell bodies located in:

A. Dorsal root ganglia

B. Ventral root ganglia

Answer 8

A. Dorsal root ganglia

Question 9

This nerve fiber transmits “second pain,” which is more diffuse in nature and is associated with the affective and motivational aspects of pain.

A. Polymodal C fibers

B. A delta fibers

C. A beta fibers

D. B fibers

Answer 9

A. Polymodal C fibers

Question 10

Which nerve fibers transmit “first pain,” which is described as sharp or stinging in nature and is WELL LOCALIZED?

A. Polymodal C fibers

B. A delta fibers

C. A beta fibers

D. B fibers

Answer 10

B. A delta fibers

Aδ fibers transmit “first pain,” which is
described as sharp or stinging in nature and is well localized.

Polymodal C
fibers transmit “second pain,” which is more diffuse in nature and is
associated with the affective and motivational aspects of pain.

Question 11

Nociceptive-specific neurons respond only to noxious stimuli, and are thought to be
involved in the sensory-discriminative aspects of pain. This is located on which lamina based on Rexed Laminae (Grey Matter):

A. Lamina I

B. Lamina III

C. Lamina VI

D. Lamina X

Answer 11

A. Lamina I

NOXIOUS STIMULI –> Lamina I –> Sensory-discriminative aspects of pain.

Question 12

True or False

WDR neurons are predominately located in laminae IV, V, and VI, respond to both non-noxious and noxious input, and are involved with the affective–motivational
component of pain

Answer 12

TRUE

WDR neurons = L456

Question 13

TRUE or FALSE

Nociceptive input is not passively transmitted from the periphery to the brain

Answer 13

TRUE

NOT PASSIVELY TRANSMITTED.

Question 14

This phenomenon is defined as exaggerated pain response to a normally painful stimulus

A. Hyperalgesia

B. Allodynia

C. Central sensitization

D. Withdrawal

Answer 14

A. Hyperalgesia

Question 15

This is defined as a painful response to a typically nonpainful stimulus.

A. Hyperalgesia

B. Allodynia

C. Central sensitization

D. Withdrawal

Answer 15

B. Allodynia

Question 16

One of the four elements of pain processing event whereby noxious thermal, chemical, or
mechanical stimuli are CONVERTED into an action potential

A. Transduction

B. Transmission

C. Modulation

D. Perception

Answer 16

A. Transduction

Stimuli —> Action Potential = TRANSDUCTION.

Question 17

This is when the action potential is conducted through the nervous system via
the first-, second-, and third-order neurons, which have cell bodies located
in the dorsal root ganglion, dorsal horn, and thalamus, respectively.

A. Transduction

B. Transmission

C. Modulation

D. Perception

Answer 17

B. Transmission

Question 18

This involves altering afferent neural transmission along the pain pathway and the dorsal horn of the spinal cord is the most common site

A. Transduction

B. Transmission

C. Modulation

D. Perception

Answer 18

C. Modulation

Question 19

Examples of inhibitory spinal modulation:

A. Release of inhibitory
neurotransmitters such as γ-amino butyric acid (GABA) and glycine by
intrinsic spinal neurons

B. Activation of Ascending efferent neuronal
pathways from the motor cortex, hypothalamus, periaqueductal gray matter,
and the nucleus raphe magnus, which results in the release of norepinephrine,
serotonin, and endorphins in the dorsal horn.

Answer 19

A. Release of inhibitory
neurotransmitters such as γ-amino butyric acid (GABA) and glycine by
intrinsic spinal neurons

AND

Activation of DESCENDING efferent neuronal
pathways from the motor cortex, hypothalamus, periaqueductal gray matter,
and the nucleus raphe magnus.

RESULTING in the release of NE, Serotonin and Endorphins in the DORSAL HORN.

Question 20

TRUE or FALSE

In general, traditional analgesic therapies have only targeted pain perception.

Answer 20

TRUE

In general, traditional analgesic therapies have only targeted pain perception.

A multimodal approach to pain therapy should target ALL FOUR ELEMENTS of the
pain-processing pathway.

Question 21

This is a specific example of central plasticity that results from repetitive C-fiber stimulation of WDR neurons in the dorsal horn:

A. ‘Wind up’

B. OIH

C. Tolerance

D. Allodynia

Answer 21

A. ‘Wind up’

Question 22

An exaggerated response to pain at
the site of injury:

A. Primary hyperalgesia

B. Tolerance

C. Allodynia

D. Spinal modulation

Answer 22

A. Primary hyperalgesia

Peripheral sensitization of
polymodal C fibers and high-threshold mechanoreceptors by these chemicals
leads to primary hyperalgesia, which is an exaggerated response to pain at
the site of injury.

Question 23

Which of the following compound is INHIBITORY?

A. Glycine

B. Substance P

C. Neurokinin A

D. Glutamate

Answer 23

A. Glycine

Three classes of transmitter compounds integral to pain transmission include

(1) the excitatory amino acids glutamate and aspartate

(2) the excitatory neuropeptides substance P and neurokinin A

(3) the inhibitory amino acids glycine and GABA

Question 24

Which of the following compound is EXCITATORY?

A. Glycine

B. GABA-A

C. Endorphin

D. GABA-2

Question 25

This allogenic substance is produced from PLATELET: A. Serotonin B. TNF C. Interleukin D. Bradykinin

Answer 25

A. Serotonin

Question 26

This allogenic substance is produced from MACROPHAGES: A. Serotonin B. Glutamate C. Adenosine D. Bradykinin

Answer 26

D. Bradykinin

Question 27

Prolonged depolarizations of second-order neurons leads to: A. Primary hyperalgesia B. Tolerance C. Allodynia D. Spinal modulation

Question 28

This is an increased pain response evoked by stimuli OUTSIDE the area of injury: A. Secondary hyperalgesia B. Primary hyperalgesia C. Allodynia D. Spinal modulation

Answer 28

A. Secondary hyperalgesia Repetitive C-fiber stimulation of WDR neurons in the dorsal horn at intervals of 0.5 to 1 Hz can precipitate the occurrence of windup and central sensitization. This leads to secondary hyperalgesia, which, by definition, is an increased pain response evoked by stimuli outside the area of injury.

Question 29

TRUE or FALSE Postoperative pain and the surgical stress response are not the same.

Answer 29

TRUE Although similar, postoperative pain and the surgical stress response are not the same. Surgical stress causes release of cytokines (e.g., interleukin-1, interleukin-6, and tumor necrosis factor-α) and precipitates adverse neuroendocrine and sympathoadrenal responses, resulting in detrimental physiologic responses, particularly in high-risk patient. The increased secretion of catabolic hormones such as cortisol, glucagon, growth hormone, and catecholamines and the decreased secretion of anabolic hormones such as insulin and testosterone characterize the neuroendocrine response.

Question 30

Preventive analgesia includes any antinociceptive regimen delivered at ANY TIME during the perioperative period that will attenuate pain-induced sensitization.

Answer 30

TRUE

Question 31

The GOAL of preventive analgesia is to block the development of sustained pain.

Answer 31

TRUE The goal of preventive analgesia is to block the development of sustained pain. Theoretically, this occurs by preventing NMDA receptor activation in the dorsal horn that is associated with wind-up, facilitation, central sensitization expansion of receptive fields, and long-term potentiation, all of which can lead to a chronic pain state.

Question 32

Three critical principles for PREVENTIVE ANALGESIA to be successful:

Answer 32

(1) the depth of analgesia must be adequate enough to block all nociceptive input during surgery (2) the analgesic technique must be extensive enough to include the entire surgical field (3) the duration of analgesia must include both the surgical and postsurgical periods

Question 33

Which surgical procedure has a relatively high risk for neuropathic pain: A. Cesarean Section B. Inguinal Hernia repair C. ORIF of upper limb D. Tonsillectomy and Adenoid surgery

Answer 33

B. Inguinal Hernia repair Neuropathic pain is a result of accidental nerve injury secondary to cutting, traction, compression, or entrapment. Clinical features may include continuous burning, paroxysmal shooting, or electric pain with associated allodynia, hyperalgesia, and dysesthesias. There can be a delay in the onset of the pain, and it can follow a non-dermatomal distribution. Surgical procedures that are a relatively high risk for neuropathic pain include limb amputations, breast surgery, gallbladder surgery, thoracic surgery, and inguinal hernia repair.

Question 34

Nociceptive pain BEST responds to: A. NMDA receptor antagonists B. α2-agonists C. α2–δ subunit calcium channel ligands D. NSAIDS

Answer 34

D. Nsaids Nociceptive pain responds best to opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), para-aminophenol agents, and regional anesthesia techniques. Neuropathic pain, on the other hand, may benefit from the addition of the nonopioid analgesic adjuvants such as the NMDA receptor antagonists, α2-agonists, and the α2–δ subunit calcium channel ligands

Question 35

True of PROTEIN BINDING: A. FREE and BOUND fraction of the drug readily cross cell membranes B. Acidic drugs bind to A1-acid glycoprotein C. Basic drugs bind to ALBUMIN D. It is the FREE FRACTION that determines the concentration of bound drug on the receptor

Answer 35

D. It is the FREE FRACTION that determines the concentration of bound drug on the receptor FREE and UNBOUND - not bound is readily crossing the cell membranes ACIDIC drugs - ALBUMIN BASIC - alpha1-glycoprotein Remember, Free fraction determines the concentration!

Question 36

Pain that escalates above a persistent background pain: A. Hyperalgesia B. Breakthrough pain C. Intermittent background pain D. Allydonia

Answer 36

B. Breakthrough pain Acute pain may be viewed as breakthrough, intermittent, or background in nature.

Question 37

Which of the following are correctly paired with respect to opioid receptors: A. Morphine - Mu1 and Kappa partial-antagonist B. Meperidine - ORL1 antagonist C. Fentanyl - Kappa partial antagonist D. Methadone - Mu1 antagonist E. Buprenorphine - Mu agonist & Kappa antagonist

Answer 37

E. Buprenorphine - Mu agonist & Kappa antagonist The main opioid receptors: mu (μ), delta (δ) kappa (κ) opioid receptor-like 1 (ORL1). The opioid receptors are members of a G protein–coupled (guanosine triphosphate regulatory proteins) receptor family, which signals via a second messenger such as cyclic adenosine monophosphate or an ion channel.

Question 38

Which of the following opioid is considered 'BROAD-spectrum' opioid? A. Nalbuphine B. Methadone C. Remifentanil D. Oxycodone E. Morphine

Answer 38

B. Methadone The “broadspectrum” opioid, methadone, also has NMDA receptor antagonist properties and inhibits the reuptake of serotonin and norepinephrine, which may make it useful in the treatment of neuropathic pain.

Question 39

One of the unique property of this opioid is it inhibits the reuptake of serotonin and norepinephrine, which may make it useful in the treatment of NEUROPATHIC PAIN: A. Gabapentinoids B. Hydromorphone C. Fentanyl D. Oxycodone E. Methadone

Answer 39

Methadone The “broadspectrum” opioid, methadone, also has NMDA receptor antagonist properties and inhibits the reuptake of serotonin and norepinephrine, which may make it useful in the treatment of neuropathic pain.

Question 40

True of the GI adverse effects of OPIOID: A. Tolerance rarely develops to the constipating effects of the opioids B. Diarrhea is a major concern among opioid-naive patient C. Spasm of the GI smooth muscle is non-existent and negligible D. Biliary colic is rare

Answer 40

A. Tolerance rarely develops to the constipating effects of the opioids Numerous different pharmacologic approaches have been developed to combat OIC, which includes prolonged-release formulations that contain naloxone, tapentadol, and the peripherally acting MOR antagonists methylnaltrexone and alvimopan. The benefit of the addition of naloxone to long-acting opioids such as oxycodone is the reduced risk of diversion, given that the opioid is immediately antagonized if the tablet is crushed and injected or snorted.

Question 41

True or False Respiratory depression in opioid is usually preceded by sedation?

Answer 41

TRUE

Question 42

A phenomenon whereby patients who are receiving opioids suddenly and paradoxically become more sensitive to pain despite continued treatment with opioids: A. OIH (opioid-induced hyperalgesia) B. Tolerance C. Dependence D. Allodynia

Answer 42

A. OIH (opioid-induced hyperalgesia) Evidence suggests that OIH is more likely to develop following high doses of phenanthrene opioids such as morphine. Changing the opioid to a phenyl piperidine derivative such as fentanyl may thwart OIH. There is also evidence that coadministration of an NMDA receptor antagonist can abolish opioid-induced tolerance and OIH.]

Question 43

Which is NOT an immunomodulatory effects of OPIOID: A. Inhibition of cellular and humoral immune functions B. Depressed natural killer cell activity C. Inhibition of angiogenesis D. Inhibition of apoptosis

Answer 43

C. Inhibition of angiogenesis - FALSE statement because PROMOTION OF ANGIOGENESIS is one of the immuno-modulatory effect of OPIOID Opioid analgesics have profound immunomodulatory effects, which include inhibition of cellular and humoral immune functions, depressed natural killer cell activity, promotion of angiogenesis, and inhibition of apoptosis. Such effects can be beneficial or deleterious depending upon the clinical situation

Question 44

A patient presents with low back pain, biceps femoris weakness, and urinary incontinence after continuous spinal anesthesia. Which among the following is associated in this case? A. Use of a large-bore spinal catheter B. Maldistribution of LA C. Addition of epinephrine D. Use of chlorhexidine solution

Answer 44

B. Maldistribution of LA KEYWORD concept: * complications of SPINAL ANESTHESIA

Question 45

The cauda equina may be more susceptible to chemical injury more than the proximal roots for what reason: A. The percentage of nerve volume to dural sac volume is DECREASED B. The cauda equina is not covered by meninges C. The cauda equina is covered only by the PIA matter D. CSF movement is unidirectional at this level

Answer 45

C. The cauda equina is covered only by the PIA matter Key concept: The anatomical relevance of cauda equina The meninges and their role in neuraxial anesthesia Movement of CSF is not unidirectional The catch here is which one is a TRUE statement.

Question 46

Which of the following statement is FALSE regarding acute pain assessment: A. Visual analogue scale is equally effective as numeric rating scale and verbal categorical rating scale (VRS). B. Faces pain scale is well validated C. Assessment of pain during mobilization is more effective for pain control than at rest D. Mechanical allodynia is assessed by von-frey filaments.

Answer 46

A. Visual analogue scale is equally effective as numeric rating scale and verbal categorical rating scale (VRS) - FALSE statement. Verbal rating scale is less useful. It should be used only as a coarse screening instrument. Four point VRS instrument underestimates intense pain as compared to VAS. (Breivik EK, Bjornsson GA, Skovland E. A comparison of pain rating scale by sampling from clinical trial data. Clin J Pain. 2000;16:22–8). Faces pain scale is validated for more than 3 years of age. The faces pain scale revised: toward a common metric in paediatric pain measurement. Von frey filaments are made up of nylon hairs, of the same length but will different diameters to provide different range of forces especially from 0.008 gms force up to 300 gms force.

Question 47

Which of the following pain modulating neurotransmitter is INHIBITORY? A. Glutamate B. Aspartate C. Vasoactive intestinal polypeptide D. Cholecystokinin E. Enkephalins

Answer 47

E. Enkephalins The rest of the choices are EXCITATORY neurotransmitters.:) Tatlo lang INHIBITORY according kay Miller: Enkephalins Somatostatin Endorphins

Question 48

In PCA (patient-controlled analgesia), the minimum time interval that must elapse between dose administrations is known as: A. Lockout Interval B. Half-life C. ED50 D. Intermittent Bolus Per Interval Time

Answer 48

A. Lockout Interval

Question 49

This is clinically defined as a rightward shift of the dose–response curve and is “a state in which an increased dosage of a psychoactive substance is needed to produce a desired effect.” A. Tolerance B. Withdrawal C. Dependence D. Withdrawal Syndrome

Answer 49

A. Tolerance

Question 50

This commonly occurs in patients who are receiving chronic opioids, and this puts them at an increased risk for adverse consequences, particularly respiratory depression. A. Differential tolerance B. Innate Tolerance C. Dependence D. Withdrawal Syndrome

Answer 50

A. Differential tolerance

Question 51

While doing a preoperative evaluation, you elicited in the history that the patient is currently taking oral morphine amounting to >60mg/day. This patient can be labeled as: A. Opioid-naive B. Opioid-exposed C. Opioid-tolerant D. Opioid-addict

Answer 51

C. Opioid-tolerant The opioid-tolerant patient is defined as having received >60 mg/d oral morphine equivalent in the 7 days prior to surgery. Opioid-tolerant patients have a greater likelihood of a complicated hospital course, which may manifest through delayed wound healing, increased surgical reintervention, prolonged hospital stays, higher readmission rates, greater health care costs, and increased mortality.

Question 52

An OPIOID-NAIVE patient is: A. a patient who did no received opioid in the past 4 weeks B. a patient who did no received opioid in the previous 90 days C. a patient who did no received opioid in the previous 30 days D. a patient who did no received opioid in the previous 3 months

Answer 52

B. a patient who did no received opioid in the previous 90 days The opioid-naive patient is defined as having received NO opioids in the previous 90 days.

Question 53

An OPIOID-EXPOSED patient is: A. a patient who did no received opioid in the past 4 weeks B. A patient with a history of opioid equivalent to monthly fentanyl patch of >10mg/day C. A patient with a history of <60 mg/day oral morphine equivalent in the previous 30 days. D. A patient with a history of <60 mg/day oral morphine equivalent in the previous 90 days.

Answer 53

The opioid-exposed patient has a history of <60 mg/d oral morphine equivalent in the previous 90 days.

Question 54

Naltrexone is used in both alcohol- and opioid-dependent patients who are highly motivated to remain abstinent. Perioperatively, holding the oral formulation for 3 days prior to surgery is employed and scheduling surgery for at least 4 weeks after the last dose is done. The clinical significance of this preoperative advice is due to: A. These patients can experience opioid receptor upregulation due to chronic opioid antagonism with naltrexone B. These patients can experience opioid receptor downregulation due to chronic opioid antagonism with naltrexone C. These patient will have an opioid plateau which will require higher dose of opioid agonists D. These patient will have an opioid plateau which will require lower dose of opioid agonists

Answer 54

A. These patients can experience opioid receptor upregulation due to chronic opioid antagonism with naltrexone

Question 55

A patient taking Naltrexone will have to be on hold for how long prior to a surgery? A. 1 week B. 3 days C. 24 hours D. 6 hours

Answer 55

B. 3 days