Chapter 10. Interdisciplinary Pain Management Flashcards
1
Q
763. The second most common cause of pain in the elderly is (A) musculoskeletal (B) cancer (C) temporal arteritis (D) postherpetic neuralgia (E) diabetic neuropathy
A
- (B) Many other studies have verified that the
predominant cause of pain in the elderly is, by
far, musculoskeletal. The second most common
source of pain is caused by cancer. Rheumatologic
diseases are, therefore, important to the pain
practitioner because these diseases are usually
amenable to various treatment modalities. Other
types of pain found commonly in the elderly
include herpes zoster, postherpetic neuralgia,
temporal arteritis, polymyalgia rheumatica,
atherosclerotic and diabetic peripheral vascular
disease, cervical spondylosis, trigeminal neuralgia,
sympathetic dystrophies, and neuropathies
from diabetes mellitus, alcohol abuse, and
malnutrition.
2
Q
- Pain assessment in the elderly is usually more
difficult than in the young because it is often
complicated by
(A) good health status which may confuse
the physician
(B) poor memory
(C) depression, which is only seen in cancer
pain patients
(D) most complains are psychiatric as
opposed to organic
(E) none of the above
A
- (B) Pain assessment in the elderly is usually
more difficult than in the young because it is
often complicated by poor health, poor
memory, psychosocial concerns, depression,
denial, and distress. Caution in not attributing
new pain complaints to preexisting disease
processes is mandatory. Most pain complaints
in the elderly are of organic, not psychiatric,
origin. Nonetheless, concomitant depression is
also usually present among the elderly with
chronic, nonmalignant pain.
3
Q
- Which of the following includes recommendations
by the American Geriatric Society for pain
patients?
(A) Pain and its response to treatment do
not necessarily need to be measured
(B) Nonsteroidal anti-inflammatory drugs
(NSAIDs) are contraindicated in older
patients
(C) Acetaminophen is the drug of choice for
relieving mild to moderate pain
(D) Nonopioid analgesic medications may
be appropriate for some patients with
neuropathic pain and other chronic pain
syndromes
(E) Nonpharmacologic approaches (eg,
patient and caregiver education,
cognitive-behavioral therapy, exercise)
have no role in the management of geriatric
pain
A
- (C) Recommendations from the American Geriatric
Society for the management of patients with
pain are - Pain should be an important part of each
assessment of older patients; along with
efforts to alleviate the underlying cause,
pain itself should be aggressively treated. - Pain and its response to treatment should be
objectively measured, preferably by a validated
pain scale. - NSAIDs should be used with caution. In
older patients, NSAIDs have significant side
effects and are the most common cause of
adverse drug reactions. - Acetaminophen is the drug of choice for
relieving mild to moderate musculoskeletal
pain. - Opioid analgesic drugs are effective for
relieving moderate to severe pain. - Nonopioid analgesic medications may be
appropriate for some patients with neuropathic
pain and other chronic pain syndromes. - Nonpharmacologic approaches (eg, patient
and caregiver education, cognitive-behavioral
therapy, exercise), used alone or in combination
with appropriate pharmacologic strategies,
should be an integral part of care plans
in most cases. - Referral to a multidisciplinary painmanagement
center should be considered
when pain-management efforts do not meet
the patients’ needs. Regulatory agencies
should review existing policies to enhance
access to effective opioid analgesic drugs for
older patients in pain. - Pain-management education should be
improved at all levels for all health care
professionals.
4
Q
- The functional pain scale has been standardized
for the older population. Which of the following
includes levels of assessment in this
scale?
(A) Rating pain as tolerable or intolerable
(B) A functional component that adjusts the
score depending on whether a person
can respond verbally
(C) A 0 to 5 scale that allows rapid comparison
with previous pain levels
(D) Only A and C are correct
(E) A, B, and C are correct
A
- (E) The functional pain scale, which has been
standardized in an older population for reliability,
validity, and responsiveness, has three
levels of assessment: first, the patient rates the
pain as tolerable or intolerable. Second, a functional
component adjusts the score depending
on whether a person can respond verbally.
Finally, the 0 to 5 scale allows rapid comparison with prior pain levels. Ideally all patients should reach a 0 to 2 level.
5
Q
- Which of the following is a major concern
regarding antiepileptic agents when used to
treat neuropathic pain in the elderly patient?
(A) Propensity to interfere with vitamin D
metabolism
(B) Need to use higher doses than those
used in the young adult
(C) May disrupt balance
(D) Only A and C are correct
(E) A, B, and C are correct
A
- (D) Antiepileptic medications are used to
manage certain painful conditions, including
trigeminal neuralgia. Gabapentin is indicated
for postherpetic neuralgia and may be effective
when administered initially at 100 mg
orally one to three times per day and increased
by 300 mg/d as needed. Clonazepam, phenytoin,
and carbamazepine are other alternatives.
The greatest concern with antiepileptic agents
is their propensity to disrupt balance and to
interfere with vitamin D metabolism.
6
Q
- Which of the following is true regarding opioid
use in the geriatric patient?
(A) Use of long-acting opioids may facilitate
tolerance and lead to higher opioid
dosage requirements for adequate pain
control
(B) μ-Receptor antagonists are less desirable
in the elderly
(C) Meperidine is an excellent choice alone
or in combination with adjuvant medications
for intractable pain
(D) Moderate to severe pain responds well
to agonists-antagonists agents
(E) The transdermal route of fentanyl
should be used as the first choice in the
elderly, in order to increase compliance
with the treatment
A
- (B)
A. Use of short-acting opioids (not long-acting
opioids) may facilitate tolerance and lead
to higher opioid dosage requirements for
adequate pain control.
B. Opioids that are antagonistic to the μ-
receptor are less desirable, given the high
prevalence of unrecognized and untreated
depression in seniors who can benefit from
the euphoric component that occurs with
binding to the μ-receptor.
C. Meperidine has been associated with a host
of adverse events in seniors and should be
avoided either alone or in combination with
a product such as hydroxyzine, which is
anticholinergic and can be associated with
orthostatic hypotension and confusion.
D. There is no role for the geriatric patient for
agonist-antagonists.
E. Transdermal fentanyl patch may be useful
when oral medications cannot be administered
and subcutaneous and intrathecal
routes are too cumbersome. In the older
patient, these patches should be carefully
considered before using as a first-line
agent because age-related changes in body
temperature and subcutaneous fat may
cause fluctuations in absorption.
7
Q
- Which of the following is true about the elderly
and pain?
(A) Incidence of chronic pain in the
community-dwelling elderly is the same
as in nursing home residents
(B) The prevalence of pain in patients older
than 60 years of age is twice the incidence
of those younger than 60 years of age
(C) The geriatric population in the United
States consumes more than 50% of all
prescription drugs
(D) The elderly often report pain differently
from other patients because of
decreased pain threshold
(E) None of the above
A
- (B)
A. Of the community-dwelling elderly, 25% to
50% suffer from chronic pain. Of nursing
home residents, 45% to 80% have chronic
pain.
B. The prevalence of pain is twofold higher in
those older than 60 years (250 per 1000)
compared with those younger than 60 years
(125 per 1000).
C. Older Americans make up approximately
13% of the US population, yet consume
30% of all prescription drugs (including
pain medications) and about 50% of all
over-the-counter medications purchased.
D. The elderly often report pain very differently
from the younger people suffering
from pain and are more stoic, consequently
underreporting their pain.
8
Q
770. When referring to pharmacokinetics in the elderly, which of the following variables is altered in the elderly? (A) Volume of distribution (Vd) (B) Clearance of drugs (Cl) (C) Elimination half-life (t1/2 β) (D) Receptor binding affinity (E) All of the above
A
- (E)
A. Vd is a function of drug protein binding
and its lipid solubility. Vd is altered significantly
in the elderly, in that the lipid content
increases from 14% to 30%, with a
decrease in the lean body mass between
ages 25 and 75 years. As a result of the
increased lipid content in older people,
lipid-soluble drugs (opioids, benzodiazepines,
barbiturates) can therefore have
dramatically altered elimination t1/2 in this
patient population.
B. The clearance of drugs from the body (Cl) is
the rate at which drugs are removed from
the blood (ie, mL/min/m2). This elimination
of drugs usually occurs in the liver and
kidneys, but lungs and other organs may
also contribute. In general, most drugs
undergo somewhat slower biotransformation
and demonstrate prolonged clinical
effects if they require hepatic or renal
degradation.
C. Aging adversely affects the elimination t1/2
of drugs.
D. Receptor-binding affinity is a pharmacodynamic
variable.
9
Q
771. Which of the following is true regarding pharmacodynamics in the elderly? (A) Pharmacodynamic changes in the elderly are closely associated with agerelated decline in central nervous system (CNS) function (B) Decreased sensitivity to benzodiazepines (C) Increased sensitivity to β-blockers (D) Decreased sensitivity to opioids (E) When compared to the young adult, there are no changes in pharmacodynamics in the elderly
A
- (A) Pharmacodynamic principles describe the
responsiveness of cell receptors at the effector
site. In general, the elderly usually have
increased sensitivity to centrally acting drugs
(ie, benzodiazepines and opioids), whereas the
adrenergic and cholinergic autonomic nervous
systems generally have decreased sensitivity
to receptor-specific drugs (ie, β-blockers). Pharmacodynamic changes in the elderly are
closely associated with age-related decline in
CNS function.
10
Q
772. Which of the following includes factors with clear associations contributing to poor compliance in the elderly? (A) Race (B) Religious beliefs (C) Physician-patient communication (D) Only A and C are correct (E) A, B, and C are correct
A
- (D) The rate of compliance with long-term
medication regimens is approximately 50%
across most age groups. Many reasons have
been cited for this low rate, but the major factor
predicting compliance is because of simply the
total number of different medications taken;
the more the medications, the worse the compliance.
Other factors with clear associations
contributing to poor compliance in the elderly
include race, drug and dosage form, cost, insurance
coverage, and physician-patient communication.
Alternatively, inconsistent findings
regarding compliance and the following factors
have also been noted: age, sex, comorbidity,
socioeconomic status, living arrangement,
number of physician visits, and knowledge,
attitudes, and beliefs about one’s health.
11
Q
- An 82-year-old male suffers from low back pain
caused by facet arthropathy. His pain has been
well under control with weak opioids for several
years. Over the last year pain has increased in
severity and current pain medications, although
still make him slightly drowsy, do not provide
adequate pain relief. The next step in the management
of this patient’s pain should be
(A) switching to strong opioids
(B) diagnostic lumbar facet blocks
(C) radiofrequency lesions to the lumbar
medial branches
(D) using a combination of two different
weak opioids
(E) intrathecal opioids
A
- (B) In the elderly, if weak opioids are not efficacious
in attenuating pain intensity, an
analysis of the risk to benefit ratio would recommend
that therapeutic nerve blocks or lowrisk
neuroablative pain procedures should be
employed prior to strong opioids. For example,
a geriatric patient with severe lower back pain
resulting from facet arthropathy might significantly
benefit from a facet rhizotomy after a
diagnostic nerve block with local anesthetic
proves efficacious. In this case, the risk to benefit
ratio is tilted toward minimally invasive
pain procedures, as opposed to opioid therapy,
since opioid therapy has the potential to impair
both cognitive and functional status in addition
to its many other known side effects.
12
Q
- Chronic use of NSAIDs in the geriatric patient
should be accompanied by
(A) monitoring liver function test when
appropriate
(B) monitoring renal function
(C) concomitant use of medications such as
misoprostol or histamine-2 (H2)-blockers
(D) occasional testing for occult blood in stool
(E) all of the above
A
- (E) Chronic use of NSAIDs in the elderly must
be accompanied by vigilance in monitoring for
the various side effects. This vigilance includes
determining (when appropriate) liver function
tests, hematocrit, renal function, and occult
blood in stool. Long-term use should probably
also include use of misoprostol, which can
reduce the incidence of NSAID-induced
ulcers; empirical data suggest that other drugs
(H2-blockers, sucralfate, antacids, H+ pump
blockers) may have similar effects.
13
Q
- When opioid therapy is first begun in the geriatric
patient which of the following should be
considered?
(A) It is desirable to use drugs with short
half-life (t1/2)
(B) Close monitoring of side effects should
occur for the first three t1/2 while a therapeutic
blood level is obtained
(C) Meperidine would be a better choice as
an initial opioid than hydromorphone
(D) Methadone is an excellent choice owing
to its t1/2
(E) If pain control with minimal side effects
has been established with a short-acting
opioid, it is never recommended to
switch to a controlled-release formulation
of the opioid
A
- (A) When opioid therapy is first begun, it is
desirable to use drugs with short t1/2 so that a
therapeutic blood level of drug can be reached
relatively quickly. It is during this initial trial of
opioids that close monitoring for side effects
must occur, especially during the first six t1/2
while a therapeutic blood level of drug is being
obtained. Consequently, drugs such as hydromorphone
and oxycodone, which have minimal
active metabolites and relatively short t1/2
(ie, 2-3 hours), are more desirable than drugs
with variable t1/2, such as methadone (ie, 12-
190 hours) or meperidine with its accumulation
of metabolites toxic to both the kidneys and
the CNS.
14
Q
- Which of the following is an important goal
for the elderly patient undergoing physical
therapy for pain management?
(A) Obtaining a gainful employment
(B) Live a more independent life with
enhanced dignity
(C) Improve sleeping pattern
(D) Gain back the physical skills they had as
a young adult
(E) None of the above
A
- (B) Rehabilitation is an important treatment
modality for the older patient in pain. By
decreasing pain and improving function, rehabilitation
allows the patient to live a more independent
life with enhanced dignity. This is in
contrast to the rehabilitation goals of persons
younger than 65 years of age in whom the primary
emphasis is on obtaining gainful employment.
Rehabilitation among chronic geriatric
pain patients involves adapting, in an optimal
way, to the loss of physical, psychologic, or
social skills they once possessed prior to complaints
of chronic pain.
15
Q
- Prior to a chemical neurolysis to be performed
in an 80-year-old male for trigeminal neuralgia,
potential risks must be explained to the patient.
Which of the following is a potential hazard?
(A) Motor weakness
(B) Neuritis
(C) Deafferentation pain
(D) Persistent pain at the site of injection
(E) All of the above
A
- (E) Prior to a chemical neurolysis, patients must
have had successful pain relief after a diagnostic
local anesthetic block and no intolerable
side effects. They must also be fully informed
of the risks, benefits, and options available to
them prior to consenting for the procedure.
Many medicolegal issues have resulted from
this technique because of its complications.
Most of these complications result from the
spread of the neurolytic solution to the surrounding
anatomic structures. Frequent side
effects (depending on location) can include persistent
pain at the site of injection, paresthesias,
hyperesthesia, systemic hypotension,
bowel and bladder dysfunction, motor weakness,
deafferentation pain, and neuritis.
16
Q
- Which of the following best describes the definition
of recurrent abdominal pain in childhood
and adolescence?
(A) Abdominal pain resulting from gastrointestinal
disease occurring on at
least three occasions over a 3-month
period
(B) Abdominal pain resulting from gastrointestinal
disease, gynecologic conditions,
or congenital anomalies, occurring
on at least three occasions over a
3-month period
(C) Abdominal pain with no organic cause
occurring on at least three occasions over
a 3-month period that is severe enough
to alter the child’s normal activity
(D) Abdominal pain with an organic cause,
such as metabolic disease, neurologic
disorders, hematologic disease, gastrointestinal
disease, gynecologic condition,
or other, that occurs at least in three
occasions over a 3-month period
(E) Acute abdominal pain from intestinal,
renal, and gynecologic disorders, which
can be treated surgically
A
- (C)
A. and B. The definition of recurrent abdominal
pain in childhood excludes abdominal pain resulting from known medical conditions
such as pain from neurologic disorders,
metabolic disease (diabetes, porphyria,
hyperparathyroidism), hematologic disease
(sickle cell anemia), gastrointestinal disease,
gynecologic conditions, chronic infection,
and pain related to congenital anomalies
C. The definition of recurrent abdominal pain
in childhood and adolescence is pain with
no organic cause occurring on at least three
occasions over a 3-month period that is
severe enough to alter the child’s normal
activity.
D. and E. The definition of recurrent abdominal
pain in childhood excludes abdominal
pain resulting from known medical conditions
such as pain from neurologic disorders,
metabolic disease (diabetes, porphyria,
hyperparathyroidism), hematologic disease
(sickle cell anemia), gastrointestinal disease,
gynecologic conditions, chronic infection,
and pain related to congenital anomalies. It
also excludes acute pain from acute renal,
intestinal, and gynecologic disorders, which
can be treated surgically.
17
Q
- Which of the following is true regarding
migraine headaches in the pediatric population?
(A) Incidence of migraine is higher in prepubertal
children when compared to
those who have reached puberty
(B) In children with common migraine,
there is unilateral localization of pain
which is mostly preceded by an aura
(C) Classic migraine usually present in children
with an aura, followed by a
bifrontal or bitemporal pain
(D) Most children with common migraine
present with abdominal pain
(E) Ophthalmoplegic migraine is fairly
common in children younger than
4 years of age, and is usually accompanied
by miosis
A
- (D)
A. The incidence of migraine is about 3% to
5% of prepubertal children. After puberty,
the incidence of migraine increases notably,
reaching 10% to 20% of children by age
20 years.
B. Common migraine is the type seen in children
before puberty. Most recurrent childhood
migraine is of this type. There is no
aura before the headache and no unilateral
focal localization of the pain. The pain is
usually bifrontal or bitemporal.
C. Classic migraine is different from common
migraine; the former starts with a visual
aura in 30% of children affected and a
sensory, sensorimotor aura, or speech
impairment in 10%. These auras are followed
by severe, throbbing, hemicranial,
well-localized headache.
D. Migraine in children can be defined as
recurrent headache accompanied by three
of the following symptoms:
• Recurrent abdominal pain with or without
nausea or vomiting
• Throbbing pain on one side of the cranium
• Relief of the pain by rest
• A visual, sensory, or motor aura
• A family history of migraine
About 70% of children with common
migraine have abdominal pain.
E. Ophthalmoplegic migraine is rare in children
before 4 to 5 years of age, usually
affects only one eye, and is often accompanied
by mydriasis.
18
Q
- Which of the following best describes chest
pain during childhood?
(A) Cardiac involvement is extremely rare;
an electrocardiogram (ECG) is indicated
but mainly for reassurance of the parents,
since it will be normal in most cases
(B) It is seen more often in children younger
than 10 years of age
(C) It is more common than abdominal pain
or headaches
(D) Costochondritis ranks second to cardiac
involvement in being the most common
cause of chest pain in this population
(E) Muscle strain is the most common cause
of chest pain in children
A
- (A)
A. Identification of the origin of the pain and
reassurance of the patient and family are
often the most important elements of treatment
provided that specific organic causes
have been investigated. Since cardiac
involvement is what worries the child and
family most, it should be stressed that this
cause is extremely rare. An ECG will be
normal and is indicated only to reassure
the parents.
B. and C. Chest pain is relatively common in
children. It ranks third in frequency after
headache and abdominal pain and may be
as common as limb pain. It is seen most
often between 10 and 21 years of age.
D. Costochondritis is the most common cause
of chest pain in children. It often occurs
after an upper respiratory infection, can
radiate to the back, and can last from a few
days to several months. The pain can be
reproduced by palpating the painful area
or by mobilizing the arm or shoulder.
E. Costochondritis is the most common cause
of chest pain in children. Trauma, muscle
strain, chest wall syndrome, rib anomalies,
and hyperventilation have been cited as
other causes of the pain.
19
Q
- Which of the following is false regarding sickle
cell anemia in children?
(A) Pain occurs when and where there is
occlusion of small blood vessels by sickled
erythrocytes, usually small bones of
the extremities in smaller children and
abdomen, chest, long bones, and lower
back in older children
(B) Tricyclic antidepressants are recommended
for analgesia during the acute
phase of a vasoocclusive crisis
(C) Use of opioids is indicated in patients
with severe pain
(D) Painful crisis can be triggered by hypoxemia,
cold, infection, and hypovolemia
(E) In children with excruciating pain that
does not respond to nonnarcotic analgesics,
and inadequate treatment of the
painful crisis can lead to drug-seeking
behavior and profound psychosocial
problems
A
- (B)
A. Sickle cell anemia is the most common
hemoglobinopathy in the United States. It
occurs in 0.3% to 1.3% of the African
American population. Pain occurs during
vasoocclusive crisis, the frequency of which is unpredictable and ranges from less than
one crisis a year to a crisis several times a
year or several times a month. Pain occurs
when and where there is occlusion of small
blood vessels by sickled erythrocytes, usually
small bones of the extremities in smaller
children and abdomen, chest, long bones,
and lower back in older children.
B. Tricyclic antidepressants are not recommended
for analgesia during the acute
phase of a vasoocclusive crisis because they
do not act quickly enough. They can, however,
be useful for long-term use in patients
who have frequent crises.
C. and E. Although the use of narcotics can
lead to complications such as respiratory
depression as well as complications from
atelectasis and focal pulmonary hypoxia,
this issue alone should not preclude the use
of potent analgesics for patients in severe
pain. On the contrary, these children can
have excruciating pain that does not
respond to nonnarcotic analgesics, and inadequate
treatment of the painful crisis can
lead to drug-seeking behavior and profound
psychosocial problems.
D. The painful crisis can be triggered by
hypoxemia, cold, infection, and hypovolemia
and evolves in three phases: - The prodromal phase occurs up to 2 days
before the actual sickle crisis with paresthesias,
numbness, and an increase in
circulating sickle cells. - The following phase or initial phase lasts
1 to 2 days and includes pain, anorexia,
and fear and anxiety. - During the established phase, pain that
lasts 3 to 7 days, inflammation, swelling,
and leukocytosis are present.
20
Q
782. Which of the following is the best choice for management of the painful hemarthroses in children suffering from hemophilia? (A) Aspirin (B) Pentazocine (C) Cortisone (D) Ibuprofen (E) Acetaminophen
A
- (E)
A. Analgesic therapy is an important part of
the management of hemophilia, although
it is secondary to replacement therapy.
Aspirin and drugs that inhibit platelet
function should be avoided, but acetaminophen,
codeine, hydromorphone, and
methadone can be given orally.
B. Pentazocine is never indicated in patients
with painful hemarthroses secondary to
hemophilia because it causes dysphoria.
C. and D. Steroids and NSAIDs can be used to
relieve pain from arthritis, but caution
should be exercised when these drugs are
used because they inhibit platelet activity.
E. Acetaminophen, codeine, hydromorphone,
and methadone can be given orally for the
treatment of painful hemarthroses in these
patients.
21
Q
- Which of the following is false regarding complex
regional pain syndrome type I (CRPS I) in
children?
(A) The affected area is usually the upper
limb as opposed to the lower limb in
adults
(B) Physical therapy is withheld for cases
that do not respond to oral medication
and/or sympathetic blocks in the first
place
(C) Multidisciplinary treatment combining
transcutaneous electrical nerve stimulation
(TENS), physical therapy, psychotherapy
using behavior modification
techniques, and oral medications is
effective in most children
(D) Typical children with CRPS I or CRPS II
show a profile of being intelligent,
driven overachievers who are involved
in very competitive activities and who
often react to the loss of this activity
with depression
(E) Sympathetic blocks are indicated to permit
more vigorous physical therapy if
pain prevents the start of these therapies
A
- (B)
A. CRPS I has been reported in children as
young as 3 years. It is characterized by
severe pain, often burning in quality, persisting
much longer than would be
expected after the initial injury. The
affected area, more often an upper limb
than a lower limb in children (most common
areas are hand or wrist, elbow, shoulder,
or hip), is intermittently swollen, mottled,
and alternately red or cyanotic.
B. Physical therapy is probably the most
important intervention and combines cautious
manipulation of the affected limb,
hot and cold therapy, whirlpool massages,
and a program of intense active exercise.
C. Multidisciplinary treatment combining
TENS, physical therapy, psychotherapy
using behavior modification techniques,
and oral medications is effective in most
children. The TENS unit is worn for a few
hours every day or for 1 to 2 hours before
going out for some activity or to school.
TENS brings some degree of pain relief to
many patients and produces spectacular
results in a few. Behavior modification is
an important part of the treatment and
should be instituted from the beginning of
the therapeutic plan. Patients are taught
relaxation techniques and are given relaxation
tapes to use at home. An NSAID and an antidepressant at a low analgesic dose
are often given, as is an anticonvulsant.
D. Sometimes a particular psychologic profile
can be seen in children with CRPS I or
CRPS II. The children are intelligent, driven
overachievers who are involved (usually with success) in very competitive activities
and who often react to the loss of this activity
with depression. Other psychologic
issues such as family discord or divorce and
enmeshment with one parent are found.
School attendance is often an issue.
E. In patients with CRPS, if pain or dysfunction
prevents the start of physiotherapy or
persists despite these treatments, sympathetic
blocks such as lumbar, stellate ganglion,
or epidural with dilute solutions of
local anesthetics are indicated. The goals of
the sympathetic blockade are to - Ascertain the sympathetic origin of the
disorder. - Break the vicious circle of sympathetically
maintained pain. - Permit more vigorous physical therapy.
22
Q
784. Which of the following is true regarding sport injuries in the pediatric patient? (A) The injuries encountered are overuse injuries similar to those found in the adult recreational athlete who does not train correctly, usually doing too much in too short a time (B) Growth is not an important factor in these injuries (C) Growth spurts in children cause tendon and muscle tightness, both of which minimize the chances of a sport injury (D) Treatment options such as oral acetaminophen, NSAIDs and aspirin do not provide adequate pain relief and should not be used in these cases (E) Sport injuries are responsible for less than 10% of the cases of low back pain in children
A
- (A)
A. The sports injuries encountered in children
are overuse injuries similar to those found
in the adult recreational athlete who does
not train correctly, usually doing too much
in too short a time. The causes of these
injuries also include muscle-tendon imbalance,
anatomical malalignment, inadequate
footwear, and growth.
B. and C. Growth is an important factor in
sports injuries for two reasons: - Growth cartilage is less resistant to
injury than the adult-type cartilage. - Growth spurts in children cause tendon
and muscle tightness, leading to pain
and sometimes stress fracture. These
fractures are most often seen in the tibia
or the fibula.
D. Treatment consists of immobilization of
fractures, straight leg strengthening exercises
with use of leg braces in cases of knee
injuries, rest, and use of orthotic footwear.
NSAIDs and minor pain medicine, such as
aspirin and acetaminophen, are useful
when pain is present. These injuries usually
respond well to these conservative measures
but are best avoided through primary
prevention, because it is recognized that
they are bound to happen in young children
involved in sports.
E. Low back pain is rare in children and shares
neither the etiology nor the poor prognosis
with the adult form. Most cases of low back
pain in children and adolescents are sportsrelated
and occur during the growth spurt
phase. A tendency for lordosis of the spine
to develop appears at that time. With overuse,
low back pain may develop.
23
Q
785. Which of the following statements is false regarding pediatric cancer pain? (A) Phantom sensations and phantom limb pain are common among children following amputation for cancer in an extremity (B) Phantom pain in children tends to increase with time (C) Some patients have chronic lower extremity pain caused by avascular necrosis of multiple joints (D) An example of a neuropathic pain syndrome in pediatric cancer patients is postherpetic neuralgia (E) Children with cancer pain often present with longstanding myofascial pain
A
- (B)
A. and B. Phantom sensations and phantom
limb pain are common among children following
amputation for cancer in an extremity.
Phantom pain in children tends to
decrease with time. Preamputation pain in
the diseased extremity may be a predictor
for subsequent phantom pain.
C., D., and E. Long-term survivors of childhood
cancer occasionally experience chronic pain.
Neuropathic pains include peripheral neuralgias
of the lower extremity, phantom limb
pain, postherpetic neuralgia, and central
pain after spinal cord tumor resection. Some
patients have chronic lower extremity pain
caused by a mechanical problem with an
internal prosthesis or a failure of bony union
or avascular necrosis of multiple joints.
Others have long-standing myofascial pains
and chronic abdominal pain of uncertain etiology.
Some patients treated with shunts for
brain tumors have recurrent headaches that
appear unrelated to intracranial pressure or
changes in shunt functioning.
24
Q
- Which of the following statements is false
regarding interventional approaches for pediatric
cancer pain management?
(A) In the pediatric cancer population, many
children and parents are reluctant to
consider procedures with the potential
for irreversible loss of somatic function
(B) Dose requirements vary dramatically for
spinal infusions in children, and they
require individualized attention
(C) For pediatric spinal infusions, the
process of converting from systemic to
spinal drug is often quite unpredictable,
with the potential for either oversedation
or withdrawal symptoms
(D) As opposed to the adult population,
celiac plexus blockade barely produces
pain relief for children with severe pain
caused by massively enlarged upper
abdominal viscera owing to tumor
(E) In pediatric patients, it is recommended
to place catheters while patients are
under general anesthesia or deep sedation,
not awake
A
- (D)
A. and D. As with adults, celiac plexus blockade
can provide excellent pain relief for
children with severe pain caused by massively
enlarged upper abdominal viscera
owing to a tumor. Many children and
parents are reluctant to consider procedures
with the potential for irreversible loss
of somatic function. Decompressive operations
on the spine can in occasional cases
produce dramatic relief of pain.
B., C., and E. Spinal infusions can provide excellent
analgesia in refractory cases, but they
require individualized attention and should
not be undertaken by inexperienced practitioners
without guidance. Dose requirements
vary dramatically, and the process of
converting from systemic to spinal drug is
often quite unpredictable, with the potential
for either oversedation or withdrawal symptoms.
If children with spinal infusions are to
be treated at home, it is essential to have
resources available to manage new symptoms,
such as terminal dyspnea and air
hunger. In pediatric patients, it is recommended
to place catheters while patients are
under general anesthesia or deep sedation,
not awake.
25
Q
- In the immediate postoperative period, why
are parenteral pain medications best given by
continuous infusion rather than intermittent
intravenous (IV)/intramuscular (IM) boluses?
(A) Opioid infusions do not cause nausea or
vomiting
(B) Continuous infusions are associated with
higher serum concentrations of the drug
(C) Opioid infusions are not associated with
somnolence or respiratory depression, as
opposed to intermittent opioid dosing
(D) No need of monitoring pediatric
patients with continuous opioid infusions
as opposed to constant monitoring
in patients with intermittent boluses
(E) Boluses are associated with frequent
periods of inadequate pain relief
A
- (E)
A., B., C., and D. The most common side
effects found with narcotic administration
are nausea or vomiting and pruritus. The
former usually respond to perphenazine or
prochlorperazine and the latter to diphenhydramine
or promethazine. Because somnolence
and respiratory depression can
also occur, patients receiving infusions of
narcotics require close attention, especially
when the pain is so well-controlled that the
pain stimulus of respiration is no longer
present.
E. Drugs can be given as boluses or continuous
infusions. Boluses are easy to administer
and provide rapid pain relief; however,
they have the disadvantage of providing
short periods of analgesia sometimes associated
with side effects when serum drug
concentration peaks, followed by inadequate
pain relief while the level decreases
until the next injection. Continuous infusions,
conversely, avoid this roller coaster
of pain relief followed by pain and provide
continuous analgesia with low plasma levels
of drugs even in newborns and infants.
26
Q
788. Which of the following is an acceptable alternative for postoperative pain management in children when able to tolerate the oral route? (A) Codeine (B) Acetaminophen (C) Methadone (D) Immediate-release morphine (E) All of the above
A
- (E) Postoperatively, when the oral route can
again be used, methadone can be prescribed at
a dose one- to twofold that of the IV route. Oral
morphine sulfate can also provide adequate pain relief for moderate to severe pain. Codeine
can be given orally alone or in combination with
acetaminophen or aspirin for moderate pain;
mild pain is relieved by acetaminophen alone in
most cases. In any case, the most important
aspect of postoperative pain control is to assess
pain repeatedly with simple pain and behavior
scales and to adapt pain medication to the pain
scores provided by these scales and physiological
findings.
27
Q
789. Which of the following is true regarding pediatric regional anesthesia? (A) Epidural catheters placed in the thoracic or lumbar spine should not be left in place for more than 2 days because of concerns about infection, displacement, or discomfort (B) Caudal epidural catheters are contraindicated for postoperative pain management in small children because of the high incidence of infection (C) Spinal anesthesia has had limited indications in children and adolescents because of the incidence of postspinal headache in this age group (D) In newborns and infants, spinal anesthesia provides anesthesia with a profound motor block for a prolonged period of time, making it a useful alternative for postoperative pain relief (E) All of the above
A
- (C)
A. and B. These catheters can be left in place
for as long as a week or more without concerns
about infection, displacement, or discomfort.
An alternate approach to the
epidural space is catheter placement via the
caudal route, but its proximity to the anus
raises concern about puncture site infection
in the postoperative period, especially in
small children.
C. and D. Spinal anesthesia has had limited
indications in children and adolescents
because of the incidence of postspinal
headache in this age group. In newborns
and infants, it provides anesthesia with a
profound motor block for a short time (45-
100 minutes) and thus cannot be used for
postoperative pain relief. It is indicated in
infants born prematurely and are less than
45 to 60 weeks’ postconceptual age in whom
general anesthesia and sedation have been
shown to induce postoperative apnea.
28
Q
- In pediatric patients taking high doses of opioids,
it is advised that an opioid contract should
be signed by all parties involved. Which of the
following should be included in this contract?
(A) Use of multiple prescriptions for all
pain-related medications
(B) Use of as many pharmacies as possible
(C) A statement specifying that there is no
need for monitoring compliance of treatment
since this does not apply to pediatric
patients
(D) Need for random urine or serum medication
levels screening, regardless that
the patient is a child
(E) None of the above
A
- (D) Opioid contracts are used in many adult
practices, but their use is not common in pediatrics.
The opioid contract clearly defines the
expectations and responsibilities of the patient,
parent, and medical caregiver. Guidelines from
the Medical Society of Virginia’s special
Pain Management Subcommittee have been
employed by many pain physicians throughout
the United States.
Written documentation of both physician
and patient responsibilities must include - Risks and complications associated with
treatment using opioids - Use of a single prescriber for all painrelated
medications - Use of a single pharmacy, if possible
- Monitoring compliance of treatment
a. Urine or serum medication levels
screening (including checks for nonprescribed
medications and substances)
when requested
b Number and frequency of all prescription
refills
c. Reasons for which opioid therapy
may be discontinued
