Chronic Pain and Psych, Substance Abuse, Drug OD Flashcards
A patient with a history of opioid tolerance is considered for ketamine infusion as part of perioperative pain management for spinal fusion surgery. Given ketamine’s mechanism of action, which of the following best explains its efficacy in this patient’s pain management strategy?
Ketamine antagonism of NMDA receptors reduces central sensitization, thereby mitigating the development of chronic post-surgical pain and opioid induced hyperalgesia.
In the context of systemic lidocaine infusion for acute perioperative pain management, which of the following best describes the underlying pathophysiological mechanism for its prolonged analgesic and anti-inflammatory effects?
Lidocaine modulates inflammatory response and inhibits pain pathways by acting on NMDA receptors, PMNs, and blocking sodium channels which extends its analgesic effect beyond its plasma half life.
Rationale:
A patient with chronic opioid therapy presents with generalized, burning pain that is more intense than their baseline chronic pain. This new onset of pain is not associated with any new pathology. Considering the mechanisms behind opioid-induced hyperalgesia (OIH), which of the following best explains the pathophysiological basis for the patient’s symptoms?
OIH is characterized by increased production of nociceptive neurotransmitters such as substance P and OGRP, and the sensitization of peripheral nerve endings leading to enhanced pain perception.
A patient on buprenorphine therapy for chronic pain management is undergoing elective surgery. Given buprenorphine’s pharmacological profile, what is a key consideration in managing acute postoperative pain in this patient?
Given buprenorphine high receptor affinity it can replace opioid agonist from receptor. The long half life (6 hours) and the reported analgesic ceiling effect provide further potential for uncontrolled post-op pain. Consider the use of multimodal analgesics and regional anesthesia when appropriate.
Which of the following best describes the pathophysiological mechanisms contributing to phantom limb pain (PLP) in patients following limb amputation?
PLP arises from a combination of peripheral nerve changes, including neuroma formation, and central changes such as central sensitization and cortical reorganization
In the context of Phantom Limb Pain (PLP), which of the following statements most accurately describes the interaction between peripheral and central mechanisms contributing to the sensation of pain in the absent limb?
The development of neuromas at the site of nerve severance leads to aberrant ectopic discharges, which, in conjunction with cortical somatosensory reorganization, results in the brain interpreting these signals as originating from the absent limb.
Which nonpharmacologic intervention has been reported as effective for phantom limb pain (PLP) in both lower and upper limb amputees?
Mirror Therapy
Considering the impact of renal or hepatic disease in cancer patients on the metabolism and effects of analgesic medications, particularly acetaminophen and NSAIDs, which pathophysiological considerations are critical for nurse anesthesiologist in planning postoperative pain management?
Any disease burden that involves the liver or hepatic blood supply may result in alterations in coagulation; therefore, appropriate lab work, including platelets, INR, prothrombin (PT)/ partial thromboplastin time (PTT), must be drawn prior to regional or neuraxial procedures.
In cancer patients with chronic pain who are undergoing surgery, the phenomenon of opioid tolerance and opioid-induced hyperalgesia (OIH) presents a significant challenge for postoperative pain management. Considering the pathophysiological mechanisms involved, which statement best explains why these patients may require higher doses of intraoperative opioids and the inclusion of adjuncts like methadone or ketamine?
The etiology of pain may be from disease progression, iatrogenic, or unrelated to their cancer (e.g., myofascial pain from deconditioning, diabetic neuropathy, or osteoarthritis). Often these patients are on preoperative opioid analgesics, which can result in tolerance and/or hyperalgesia. Therefore, may require higher doses on intraoperative opioids, an escalation of the opioid dose in the immediate postoperative period, as well as adjuncts such as intraoperative methadone or ketamine. It is critical to review the possible systemic effects of the malignancy and treatment and how it may impact pain management.
In managing fibromyalgia patients perioperatively, the use of gabapentinoids is recommended to address central sensitization. What pathophysiological mechanism underlies the effectiveness of gabapentin and pregabalin in this patient population, particularly in the context of perioperative pain management?
Gabapentinoids modulate calcium channel function at the spinal and cortical levels, reducing aberrant neuronal firing and thereby mitigating central sensitization seen in fibromyalgia.
How do systemic effects of malignancy, such as cerebral metastatic disease burden and electrolyte abnormalities, complicate the management of pain in cancer patients from a pathophysiological perspective?
Cerebral metastatic disease burden, as well as electrolyte abnormalities and malnutrition, may affect the patient’s mental status and sometimes require adjustments in analgesic agents.
Considering the pathophysiology of CRPS and its implications for perioperative pain management, why might ketamine infusions at subanesthetic doses be particularly beneficial for patients with CRPS undergoing surgery?
Ketamine’s NMDA receptor antagonism plays a critical role in interrupting the central sensitization process that characterizes CRPS, potentially reducing the perpetuation of pain signals.
In patients with severe obesity undergoing surgery, why is the optimization of multimodal analgesia, including the use of systemic lidocaine and α2 agonists, particularly important in minimizing postoperative pain and enhancing recovery?
These meds allow for an opioid sparing pain regimen; severely obese patients have concurrent OSA, this reduces the potential for airway-related and respiratory complications.
During surgery, the use of electrosurgical instruments can pose a risk to patients with SCS devices due to electromagnetic interference (EMI). Considering the pathophysiological implications of EMI on SCS function, which of the following recommendations is most appropriate to minimize the risk of inadvertent reprogramming or device malfunction?
It is recommended that prior to all procedures the device be reprogrammed to the lowest amplitude and turned off prior to induction, which decreases inadvertent reprogramming during surgery from EMI
A 47-year-old patient with a history of chronic neuropathic pain, managed with spinal cord stimulation (SCS), is scheduled for elective laparoscopic cholecystectomy. The patient reports significant relief of pain symptoms with the SCS device but expresses concern about the potential for postoperative pain exacerbation and the impact of surgery on the functionality of their SCS device. The surgical team plans to use electrosurgical instruments during the procedure, raising concerns about electromagnetic interference (EMI) and the risk of SCS device malfunction or inadvertent reprogramming. Given the patient’s dependence on the SCS device for pain management and the necessity of using electrosurgical instruments during laparoscopic surgery, understanding the pathophysiological and technological aspects of managing SCS devices in the surgical environment is crucial for optimal perioperative care.
Clinical Scenario Question:
Considering the potential for EMI from electrosurgical instruments to affect the SCS device during laparoscopic cholecystectomy, which perioperative management strategy best mitigates the risk of device malfunction while ensuring effective postoperative pain control?
It is recommended that prior to all procedures the device be reprogrammed to the lowest amplitude and turned off prior to induction, which decreases inadvertent re- programming during surgery from EMI p.615
Integration with SCS therapy: coordinating postoperative analgesia with the existing SCS settings and manufacturer. Post-operative assessment of the SCS device’s functionality and programming.
Considering the potential risks associated with conducting MRI procedures on patients with implanted SCS devices, such as magnetic pull, device damage, unwanted stimulation, and thermal injury, which statement best describes the appropriate pre-procedural steps to mitigate these risks?
It is recommended that prior to an MRI the device manufacturer and model are identified, and the device representative can provide information about under what MRI conditions the device can be scanned. If elective, delay until adequate information can be obtained.
A pregnant patient with a history of Complex Regional Pain Syndrome (CRPS) managed with spinal cord stimulation (SCS) presents for a scheduled cesarean section. The patient has been experiencing increased CRPS symptoms during pregnancy, including heightened pain and altered sensation in the affected limb, alongside typical physiological changes of pregnancy such as increased cardiac output and blood volume, as well as hormonal fluctuations. These changes have necessitated adjustments to her SCS device settings to manage the exacerbated CRPS symptoms effectively.
Given the intricate pathophysiological interactions between CRPS, the physiological adaptations of pregnancy, and the neuromodulatory effects of SCS, which of the following considerations is paramount in planning anesthesia for the cesarean section to ensure optimal pain management and maternal-fetal safety?
Utilize a multimodal anesthesia approach that includes careful adjustment of the SCS settings, tailored neuraxial anesthesia to manage CRPS and surgical pain, and close monitoring of maternal and fetal well-being, considering the pathophysiological implications of CRPS exacerbation and pregnancy on anesthetic choices and fetal health.
Given the lack of definitive studies on the effect of spinal cord stimulation (SCS) on human fetal development and the theoretical concerns about teratogenic and abortifacient effects, what is the most prudent approach to managing pregnant patients with implanted SCS devices?
Although there are no studies examining the effect of SCS on human fetal development, the current recommendation of SCS manufacturers is to inactivate the device at gestation.
In patients with treatment-resistant major depression undergoing electroconvulsive therapy (ECT), a procedure known to be effective when antidepressant drugs or psychotherapy have failed, what specific anesthetic considerations must be taken into account given the pathophysiological underpinnings of the treatment?
The patient is preoxygenation before induction. Anticholinergics may be administered as an antisialagogue or to prevent asystole. The induction agent is administered intravenously. Methohexital, propofol, or etomidate may be used without compromise of the therapy. Ketamine is used, although an enhanced hemodynamic response and increased intracranial pressure are possible after using ketamine. After loss of consciousness, positive pressure ventilation is applied to the patient via the breathing bag and a facemask and is continued until after treatment is completed and spontaneous respirations resume. Succinylcholine is typically the muscle relaxant of choice for ECT because of its rapid onset, short duration, and independent reversibility.
Given the neurochemical hypothesis that depression is associated with decreased availability of norepinephrine and serotonin at specific synapses in the brain, how might the use of certain anesthetic agents that influence these neurotransmitter systems impact the perioperative management of patients with major depression?
Patients with major depression may exhibit altered responses to anesthetic agents that affect serotonin and norepinephrine reuptake, such as increased sensitivity to drugs with serotonergic or noradrenergic activity, necessitating careful selection and dosing of anesthetic agents to avoid exacerbating depressive symptoms or precipitating serotonin syndrome.
Given the established link between chronic depression and alterations in amine neurotransmitter pathways, particularly serotonin and norepinephrine, a patient with a diagnosis of major depression undergoing elective surgery presents a unique challenge in anesthetic management. The patient has been on a regimen of selective serotonin reuptake inhibitors (SSRIs) and is scheduled for a procedure known to induce significant postoperative pain. Considering the pathophysiological impact of SSRIs on serotonin pathways and the potential for perioperative pain to exacerbate depressive symptoms, which strategy would optimize the patient’s anesthetic care while mitigating the risk of postoperative depression exacerbation and managing pain effectively?
Incorporating perioperative plan than includes the continuation of SSRIs, utilization of low dose ketamine as an adjunct for its antidepressant effects and to provide analgesia through NMDA receptor antagonism, and careful monitoring for signs of serotonin syndrome, aims to balance the management of depression, postoperaitve pain, and anesthesia safely.
Given the primary mechanism of action of SSRIs in inhibiting serotonin reuptake at the presynaptic neuron, enhancing serotonergic activity in the synaptic cleft, how does this modulation of serotonin levels influence the pathophysiological basis of SSRIs’ therapeutic effects in disorders beyond major depression, such as irritable bowel syndrome (IBS) and panic disorders?
The enhancement of serotonergic activity by SSRIs modulates central and peripheral neural pathways involved in the regulation of mood, anxiety, and gastrointestinal function. In conditions like IBS, increased serotonin levels in the gastrointestinal tract can improve motility and pain signaling, while in panic disorders, enhance serotonergic neurotransmission in the brain can regulate anxiety circuits and mitigate panic symptoms