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BARASH | Chapter Digest > Chapter 55 | Acute Pain > Flashcards

Chapter 55 | Acute Pain Flashcards

1
Q

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

A

D. All of the above

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2
Q

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.

A

TRUE

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3
Q

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

A

TRUE

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4
Q

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

A

A. 2 month old to 7 years old

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5
Q

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

A

A. 6 - 18 years old

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6
Q

In general, acute pain resolves within:

A. 1 month

B. 6 months

C. 1 year

D. 12 weeks

A

A. 1 month

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7
Q

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

A

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

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8
Q

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

A

A. Dorsal root ganglia

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9
Q

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

A

A. Polymodal C fibers

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10
Q

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

A

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.

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11
Q

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

A

A. Lamina I

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

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12
Q

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

A

TRUE

WDR neurons = L456

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13
Q

TRUE or FALSE

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

A

TRUE

NOT PASSIVELY TRANSMITTED.

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14
Q

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

A. Hyperalgesia

B. Allodynia

C. Central sensitization

D. Withdrawal

A

A. Hyperalgesia

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15
Q

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

A. Hyperalgesia

B. Allodynia

C. Central sensitization

D. Withdrawal

A

B. Allodynia

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16
Q

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

A

A. Transduction

Stimuli —> Action Potential = TRANSDUCTION.

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17
Q

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

A

B. Transmission

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18
Q

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

A

C. Modulation

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19
Q

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.

A

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.

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20
Q

TRUE or FALSE

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

A

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.

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21
Q

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

A

A. ‘Wind up’

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22
Q

An exaggerated response to pain at
the site of injury:

A. Primary hyperalgesia

B. Tolerance

C. Allodynia

D. Spinal modulation

A

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.

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23
Q

Which of the following compound is INHIBITORY?

A. Glycine

B. Substance P

C. Neurokinin A

D. Glutamate

A

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

24
Q

Which of the following compound is EXCITATORY?

A. Glycine

B. GABA-A

C. Endorphin

D. GABA-2

A
25
Q

This allogenic substance is produced from PLATELET:

A. Serotonin

B. TNF

C. Interleukin

D. Bradykinin

A

A. Serotonin

26
Q

This allogenic substance is produced from MACROPHAGES:

A. Serotonin

B. Glutamate

C. Adenosine

D. Bradykinin

A

D. Bradykinin

27
Q

Prolonged depolarizations of second-order neurons leads to:

A. Primary hyperalgesia

B. Tolerance

C. Allodynia

D. Spinal modulation

A
28
Q

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

A

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.

29
Q

TRUE or FALSE

Postoperative pain and the surgical stress response are not the same.

A

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.

30
Q

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

A

TRUE

31
Q

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

A

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.

32
Q

Three critical principles for PREVENTIVE ANALGESIA to be successful:

A

(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

33
Q

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

A

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.

34
Q

Nociceptive pain BEST responds to:

A. NMDA receptor
antagonists

B. α2-agonists

C. α2–δ subunit calcium channel ligands

D. NSAIDS

A

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

35
Q

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

A

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!

36
Q

Pain that escalates above a persistent background pain:

A. Hyperalgesia

B. Breakthrough pain

C. Intermittent background pain

D. Allydonia

A

B. Breakthrough pain

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

37
Q

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

A

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.

38
Q

Which of the following opioid is considered ‘BROAD-spectrum’ opioid?

A. Nalbuphine

B. Methadone

C. Remifentanil

D. Oxycodone

E. Morphine

A

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.

39
Q

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

A

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.

40
Q

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

A

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.

41
Q

True or False

Respiratory depression in opioid is usually preceded by sedation?

A

TRUE

42
Q

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

A

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.]

43
Q

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

A

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

44
Q

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

A

B. Maldistribution of LA

KEYWORD concept:

  • complications of SPINAL ANESTHESIA
45
Q

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

A

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.

46
Q

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.

A

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.

47
Q

Which of the following pain modulating neurotransmitter is INHIBITORY?

A. Glutamate
B. Aspartate
C. Vasoactive intestinal polypeptide
D. Cholecystokinin
E. Enkephalins

A

E. Enkephalins

The rest of the choices are EXCITATORY neurotransmitters.:)

Tatlo lang INHIBITORY according kay Miller:

Enkephalins
Somatostatin
Endorphins

48
Q

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

A

A. Lockout Interval

49
Q

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

A

A. Tolerance

50
Q

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

A

A. Differential tolerance

51
Q

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

A

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.

52
Q

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

A

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.

53
Q

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.

A

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

54
Q

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

A

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

55
Q

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

A

B. 3 days

BARASH | Chapter Digest (24 decks)

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