Lecture 5-6

Question 1

Why would we treat acute pain ?

Answer 1

↓ complications
● ↓ likelihood of acute-to-chronic pain conversion

● Improve outcome
○ ↑ speed of recovery → ↓ length of stay → ↓ health care costs

● ↑ patient satisfaction
● Make the period of disease accompanied by pain less unpleasant
● ↑ productivity
● ↑ quality of life

Question 2

what are the renal consequences of poor pain management ?

Answer 2

higher risk of oliguria
urinary retention

Question 3

what are the cardio consequences of poor pain management ?

Answer 3

tachycardia, HTN, high cardiac workload

Question 4

what are the muscular consequences of poor pain management ?

Answer 4

muscle weakness and fatigue

Question 5

What should be part of your pain assessment ?

Answer 5

SCHOLARE/ Pain Experience
Labs tet
Medical history
Red Flags
Current medications

Question 6

What are the RED Flags for diagnosis ?

Answer 6

NIFTI

Fractures
Infections
cancer
Visceral Disease / GI disease

Question 7

What are the PHARM options for acute pain ?

Answer 7

Aceteminophen
NSAIDS
Opioids
Others : Adjuvants

Question 8

What is PRICE ?

Answer 8

Protection, Rest , Ice in the first 48hours, Compression , Elevation

may not be able to do all

Question 9

What are the non-pharmacological Treatment?

Answer 9

Activity as tolerated ( some activity is good!)

● Physiotherapy, range of motion exercises

● External supports (e.g., bandages, tape, braces)

● Cold/heat therapy

● Massage, acupuncture

● Self-management education and support

Question 10

What are the benefit of Non steroid analgesic ?

Answer 10

May not need opioids
even if they need opioids –> might not need as much

Question 11

What is a true weak opioid ?

Answer 11

That is not entirely true, just need to pay attention to the dosing

Question 12

What is a important DDI with acetaminophen ?

Answer 12

Warfarin
Can ↑ INR and would require more warfarin

Question 13

What is the MAX dose of acetaminophen ?

Answer 13

4 g from ALL sources
if long term use or frail / bad liver ( alcoholic) ~ 3 g

Question 14

What are the ADR from NSAIDs ?

Answer 14

GI
CV
Renal
CNS ( decrease the seizures threshold )

Question 15

which of the NSAID has the highest risk of CV ?

Answer 15

Diclofenac

Question 16

Which of the NSAID has the lowest risk of CV ?

Answer 16

Naproxen ~ more CV neutral

Question 17

Which of the NSAIDs has the lowest GI risk?

Answer 17

Diclofenac/celecoxib

Question 18

What is the MOA of Celecoxib + Diclofenac ?

Answer 18

COX2 inhibitor

Question 19

What is the DDI between concurrent use of ASA and Ibuprofen ?

Answer 19

Ibuprofen causes steric hindrance to ASA binding and decreases ASA efficacy ( Cox1)

Question 20

What is the DDI between concurrent use of ASA and Naproxen ?

Answer 20

Conformation change and can take ASA place

Question 21

In terms of GI toxicity , rank the NSAIDS risk ?

Answer 21

High COX1 > non-selective NSAID > COX2

Question 22

What are the risks factors for GI bleeds ?

Answer 22

Age >65
Comorbidities
High Doses of NSAID
Upper GI bleeds
H.pylori infection
Multiple use of NSAID

Question 23

What is the relationship between COX1-2 , GI and CV risks ?

Answer 23

more COX1 ( like ASA) –> more GI risk
More Cox2 ( like diclo) –> more cv risks

Question 24

If you have no risk of GI bleeds, recommended NSAID ?

Answer 24

non- selective : ibuprofen

Question 25

If you have 1-2 risk of GI bleeds, recommended NSAID ?

Answer 25

COX2
non-selective+ PPI or misoprostol

Question 26

If you have >2 risk of GI bleeds, recommended NSAID ?

Answer 26

Celecoxib + PPI or Misoprostol

Question 27

Which of COX inhibition has higher risks of GI bleeds ?

Answer 27

COX1 - naproxen , ASA, Ketorolac

Question 28

Which of COX inhibition has higher risks of CV bleeds ?

Answer 28

COX2 - Celecoxib, Dicofenac

Question 29

What is the systemic absorption rate of TOPICAL NSAIDs ?

Answer 29

<6%

Question 30

Can we use acetaminophen in pregnancy ?

Answer 30

Yes but short term ONLY

Question 31

When can we use NSAIDs in pregnancy ?

Answer 31

Safer 16 weeks to 20 weeks for ORAL
Topical at any stages

Question 32

Can a Breastfeeding mother use acetaminophen or NSAIDs ?

Answer 32

YEs, it is excreted in LOW concentrations

Question 33

Can we use Opioids is Pregnancy ?

Answer 33

try to avoid ! Especially codeine, oxycodone

But can possibly try morphine, fentanyl and hydromorphone

Question 34

Codeine is metabolised by which CYP ?

Answer 34

CYP2D6 –> has multiple polymorphism
could lead to ultra-rapid metablizers –> more risk of ADR

Question 35

Mild pain - WHO analgesi ladder recommendation ?

Answer 35

Weakopiod , or non opioid or adjuvant tx

Question 36

What is the CPOT ?

Answer 36

critical care pain Observation Tool –> used in ICU
observe pts in actions that would cause pain and after the use of analgesics

Question 37

What is the ideal goal in RASS ?

Answer 37

0 –> alert and calm

assess delirium

Question 38

Which of the opioids in better in ICU ?

Answer 38

Hydromorphone –> less effect on the kidneys, less histamine release

Question 39

Why do we refrain from give fentanyl to ICU patients ?

Answer 39

highly lipophilic –> accumulation and prolonged sedation

Question 40

What is the preferred way to manage pain pre-operation ?

Answer 40

multimodal , relieve pain and less need for opioids

Question 41

how are pain medications managed after the surgery ?

Answer 41

ATC non-opioids ( think of gabapentinoids) , Opioids are short term , PCA or PRN

Question 42

What do we need to know about PCA ?

Answer 42

lock interval, 4 hours limit
Goal = 1-3/10
NEVER for non-opioid naive and chronic pain

Question 43

Wich Nsaid can be injected for post-op ?

Answer 43

Ketorolac ( 5-7 days)

Question 44

What is incidental pain ?

Answer 44

predictable pain