Pain Flashcards
A patient who underwent a thoracotomy six months ago reports shooting pain on
the chest wall occurring without any trigger. This is known as:
Post thoracotomy pain syndrome
IASP Post-thoracotomy pain syndrome:
“Pain that recurs or persists along a thoracotomy incision at least two months following the surgical procedure” in general it is burning or stabbing pain with dysesthesia thus shares many features of neuropathic pain.
Dysesthesia: unpleasant abnormal sensation spontaneous or evoked
The analgesic drug with the most favourable Number Needed to Treat (NNT) for neuropathic pain is:
a) Amitriptyline
b) Gabapentin
c) Tramadol
d) Pregabalin
e) Carbamazepine
REPEAT
Tramadol
APMSE 5th edition:
Tramadol is an effective treatment for neuropathic pain with NNT of 4.4 (95%CI 2.9 to 8.8)
Alpha-2-delta ligands (gabapentinoids) are the only anticonvulsants with proven efficacy in the treatment of chronic neuropathic pain.
At doses of 1,800 mg to 3,600 mg/d, gabapentin is effective in treating neuropathic pain, in particular caused by postherpetic neuralgia (NNT 6.7; 95%CI 5.4 to 8.7)
Pregabalin
Postherpetic neuralgia: 300 mg/d pregabalin (NNT 5.3; 95%CI 3.9 to 8.1) (4 RCTs, n=713) and 600 mg/d (NNT 3.9; 95%CI 3.1 to 5.5) (4 RCTs, n=732);
* Painful diabetic neuropathy: 600 mg/d pregabalin (NNT 7.8; 95% CI 5.4 to 14) (5 RCTs, n=1,015);
* Mixed or unclassified post-traumatic neuropathic pain: 600 mg/d pregabalin (NNT 7.2; 95%CI 5.4 to 11) (4 RCTs, n=1,367);
* Central neuropathic pain (mainly SCI): 600 mg/d pregabalin (NNT 9.8; 95%CI 6.0 to 28) (3 RCTs, n=562).
Amitriptyline NNT 4.6 (TCAs are effective in treatment of neuropathic pain (amitrip NNT 4.6))
Amitriptyline
By order of favourable NNT:
- TCAs (amitriptyline) NNT: 3.6, NNH: 9
- Strong opioids NNT 4.3 NNH 11.7
- Tramadol NNT: 4.7, NNH 12.6
- SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8
- Gabapentin NNT: 7.2 NNH 25.6
- Pregabalin NNT:7.7, NNH 13.9
ANZCA Pain book
Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend:
- First line: pregabalin, gabapentin and amitriptyline;
- Second line: tramadol and lamotrigine (in incomplete SCI);
- Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion;
- Fourth line: TENS, oxycodone and dorsal root entry zone lesions.
NP Self-report of pain in children is usually possible by the age of:
a. 2 yo
b. 4 yo
c. 6 yo
d. 8 yo
REPEAT
A) 4
4 yo = wong baker faces score 3-18.
8 yo = Visual analogue scale.
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_assessment_and_measur ement/
APMSE 5 also
A 30-year-old has had a free-flap operation of eight hours duration. They received an intraoperative remifentanil infusion and 10 mg morphine 30 minutes before the end of the operation. During recovery their pain score increased from 6/10 on arrival to 9/10 despite a further 10 mg of intravenous morphine. The most likely diagnosis is:
a. Acute behavioural change
b. OIH
c. Inadequate analgesia
D. Physical dependence
Nikki:
B)
Opioid induced hyperalgesia;
The key features are long case with Remi running, as well as increased pain following additional opioids.
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.13602
NP The oral morphine equivalent of tapentadol 50 mg (immediate release) is:
a) 5mg
b) 10mg
c) 15mg
d) 20mg
e) 25mg
B) 15mg
50mg x0.3
Tapentadol Conversion at 0.3
Tramadol conversion at 0.2
Oxycodone 1.5
Hydromorphone 5
Buprenorphine patch mcg/hr@2
Fentanyl patch mcg/hr @3
Oral Tapentadol 25mg = 8mg Oral Morphine
Oral Oxycodone 5mg = 8mg Oral Morphine
Oral Tramadol 25mg = Oral Morphine 5mg
Oral Hydromorphone 4mg = Oral Morphine 20mg
S/L Buprenorphine 200mcg = 8mg Oral Morphine
IV Oxycodone 5mg = Oral Morphine 15mg
IV Morphine 5mg = Oral Morphine 15mg
IV Hydromorphone 1mg = Oral Morphine 15mg
21.1 A woman is having a potentially curative primary breast cancer resection. Compared with a sevoflurane and opioid technique, using a regional anaesthesia-analgesia technique with paravertebral block and a propofol infusion will result in
a. Decreased cancer recurrence
b. Decreased chronic pain and recurrence
c. Decreased incision pain at 6 months
d. Decreased CPSP pain at 6 months
e. Decreased CPSP pain at 12 months
Fuck this question
e. Decreased CPSP pain at 12 months
or it could be updated with an option that says makes no difference
most likely they will just remove the question and this is a big waste of time
https://pubs.asahq.org/anesthesiology/article/135/6/1091/117748/Preoperative-Paravertebral-Block-and-Chronic-Pain
—>This says it makes no difference in 2021
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007105.pub4/full
—-> this says weak evidence but it helps prevent persistent post surgical pain at 3-12months in 2018
—-> ANZCA pain book references this article
ANZCA pain book
https://www.bjaed.org/article/S2058-5349(18)30101-X/fulltext
A recent review showed that, whilst there was little effect on intra- and postoperative opioid consumption and PONV, patients receiving either both single-shot injections or placement of paravertebral catheters had less acute pain in the first 72 h after surgery.
There is also a suggestion that the use of TPVB for acute postsurgical pain may protect against the development of chronic postsurgical pain after breast surgery at 6 months.
For breast cancer surgery any form of regional anaesthesia (18 RCTs, n=1,297) reduces CPSP 3 to 12 months after surgery compared with systemic analgesia (OR 0.43; 95%CI 0.28 to 0.68) (NNT 7); specifically paravertebral block (PVB) (6 RCTs, n=419) is effective (OR 0.61; 95%CI 0.39 to 0.97) (NNT 11).
In our study population, regional anaesthesia-analgesia (paravertebral block and propofol) did not reduce breast cancer recurrence after potentially curative surgery compared with volatile anaesthesia (sevoflurane) and opioids. The frequency and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Clinicians can use regional or general anaesthesia with respect to breast cancer recurrence and persistent incisional pain.
https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(19)32313-X.
23.1 A patient has an acute attack of shingles (herpes zoster). The development of post-
herpetic neuralgia can best be reduced by the administration of
A. Ibuprofen
B. Gabapentin
C. Aciclovir
D. Amitriptyline
E. Oxycodone
D. Amitriptyline
Amitriptyline (used in low doses for 90 days from onset of the herpes zoster rash) reduces the incidence of postherpetic neuralgia
N.B
Antiviral agents started within 72 hours of onset of the herpes zoster rash accelerate the resolution of acute pain (U) (Level I) but do not reduce the incidence, severity and duration of postherpetic neuralgia
UTD
Both Gabapentinoids and TCAs are effective at TREATING postherpetic neuralgia. The former have lower risk of discontinuation due to adverse side effects.
For moderate or severe pain, use gabapentinoids.
22.2 A 48-year-old man is day two post-laparoscopic high anterior resection. He has used 42 mg of intravenous morphine in the past 24 hours. You wish to start him on oral tapentadol immediate release. The most appropriate equianalgesic dosage would be
a) 50mg six times a day
b) 100mg six times a day
c) 200mg six times a day
d) 300 mg six times a day
a) 50mg six times a day
42mg IV Morphine = 126mg Oral Morphine
126/8= 15.75
15.75 x 25 = 393.75 (*400mg/day Tapentadol)
Option 50mg 6 times a day = 300mg
As direct OME to tapentadol conversion is 400mg, a 300mg dose represents a 25% dose reduction, which is line with a 25-50% dose reduction due to incomplete cross-tolerance during opioid rotation.
Oral Tapentadol 25mg = 8mg Oral Morphine
Oral Oxycodone 5mg = 8mg Oral Morphine
Oral Tramadol 25mg = Oral Morphine 5mg
Oral Hydromorphone 4mg = Oral Morphine 20mg
S/L Buprenorphine 200mcg = 8mg Oral Morphine
IV Oxycodone 5mg = Oral Morphine 15mg
IV Morphine 5mg = Oral Morphine 15mg
IV Hydromorphone 1mg = Oral Morphine 15mg
22.1 Complex regional pain syndrome is NOT characterised by
a. Vasomotor
b. Sudomotor
c. Pain distal to primary injury
d. Hypoaesthesia
e. Edema
Hypoasthesia - Veldman criteria
Pain distal to primary injury – Not mentioned specifically in Budapest criteria, but in Veldman
Hypoaesthesia = reduced sensation to pain
23.1 A risk factor for the development of chronic postsurgical pain is having
a. Age >65
b. Male
c. Pain at site 1 month prior to surgery
d. Higher SES
c. Pain at site 1 month prior to surgery
Pain itself is a risk factor: the strongest predictors of CPSP are chronic preoperative pain and the severity of acute postoperative pain
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741327/#:~:text=Pain%20its
23.1 Self-report of pain in children is usually possible by the age of
a. 2 yo
b. 4 yo
c. 6 yo
d. 8 yo
b) 4yo
4 yo = wong baker faces score 3-18.
8 yo = Visual analogue scale.
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_assessment_and_measur ement/
APMSE 5 also
23.1 Of the following, the drug that is LEAST likely to provide effective analgesia following paediatric tonsillectomy is
A. Inhalational anesthesia
B. Remifentanil at end of case
C. Dexamethasone
D. Intranasal ketamine
or
a. Ketamine
b. Clonidine
c. NSAIDs
d. Paracetamol
e. Dexamethasone
A. Inhalational anesthesia
or
b. Clonidine
Prospect: two studies focused on tonsillectomy, and those did not show any additional analgesic effect of clonidine when used on top of adequate baseline medication after tonsillectomy.
PROSPECT
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15299#:~:text=The%20basic%20analgesic%20regimen%20should,analgesic%20and%20anti%2Demetic%20effects.
21.2, 22.2 Of the following, the procedure that is most commonly associated with chronic pain after surgery is
a) Amputation
b) Mastectomy
c) Thoracotomy
d) TKR
e) Hernia repair
a) Amputation
Top 10 Rank order:
1. Amputation 30-85%
2. Thoracotomy 5-67%
3. Mastectomy 11-57%
4. Inguinal hernia repair 0-63%
5. Sternotomy 28-56%
6. Cholecystectomy 3-56%
7. Knee arthroplasty 19-43%
8. Breast Augmentation 13-38%
9. Vasectomy 0-37%
10. Radical prostatectomy 35%
23.1 A technique which is NOT effective in providing analgesia for a sternal fracture is a
A. Pecs 1
B. Pecs 2
C. Thoracic transversus plane block
D. Subpectoral fascial plane block
A. Pecs 1
https://www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/thorax/pectoralis-serratus-plane-blocks/
20.1 Which drug not metabolised by CYP2D6?
a) Oxycodone
b) Tramadol
c) Amitryptiline
d) Codeine
e) Hydromorphone
e) Hydromorphone
22.2 An analgesic which is a category A drug using the Australian and New Zealand categories for prescribing medicines in pregnancy is
a. codeine
b. morphine
c. fentanyl
d. tramadol
e. oxycodone
a. codeine
Oxycodone B
Morphine C
Tramadol C
Fentanyl C
21.1 A 48 year old male is day two post-laparoscopic high anterior resection. He has used 42 mg of intravenous morphine in the past 24 hours. You wish to start him on oral tapentadol immediate release. The most appropriate equianalgesic dosage would be
a. 50 QID
b. 100 QID
c. 150 QID
d. 200 QID
b. 100mg QID
42mg IV Morphine = 126mg Oral Morphine
126/8= 15.75
15.75 x 25 = 393.75 (*400mg/day Tapentadol)
Oral Tapentadol 25mg = 8mg Oral Morphine
Oral Oxycodone 5mg = 8mg Oral Morphine
Oral Tramadol 25mg = Oral Morphine 5mg
Oral Hydromorphone 4mg = Oral Morphine 20mg
S/L Buprenorphine 200mcg = 8mg Oral Morphine
IV Oxycodone 5mg = Oral Morphine 15mg
IV Morphine 5mg = Oral Morphine 15mg
IV Hydromorphone 1mg = Oral Morphine 15mg
20.2, 22.2 The analgesic drug with the most favourable Number Needed to Treat (NNT) for neuropathic pain is
a) Amitriptyline
b) Gabapentin
c) Tramadol
d) Pregabalin
e) Carbamazepine
Tramadol
APMSE 5th edition:
Tramadol is an effective treatment for neuropathic pain with NNT of 4.4 (95%CI 2.9 to 8.8)
Alpha-2-delta ligands (gabapentinoids) are the only anticonvulsants with proven efficacy in the treatment of chronic neuropathic pain.
At doses of 1,800 mg to 3,600 mg/d, gabapentin is effective in treating neuropathic pain, in particular caused by postherpetic neuralgia (NNT 6.7; 95%CI 5.4 to 8.7)
Pregabalin
Postherpetic neuralgia: 300 mg/d pregabalin (NNT 5.3; 95%CI 3.9 to 8.1) (4 RCTs, n=713) and 600 mg/d (NNT 3.9; 95%CI 3.1 to 5.5) (4 RCTs, n=732);
* Painful diabetic neuropathy: 600 mg/d pregabalin (NNT 7.8; 95% CI 5.4 to 14) (5 RCTs, n=1,015);
* Mixed or unclassified post-traumatic neuropathic pain: 600 mg/d pregabalin (NNT 7.2; 95%CI 5.4 to 11) (4 RCTs, n=1,367);
* Central neuropathic pain (mainly SCI): 600 mg/d pregabalin (NNT 9.8; 95%CI 6.0 to 28) (3 RCTs, n=562).
Amitriptyline NNT 4.6 (TCAs are effective in treatment of neuropathic pain (amitrip NNT 4.6))
Amitriptyline
By order of favourable NNT:
- TCAs (amitriptyline) NNT: 3.6, NNH: 9
- Strong opioids NNT 4.3 NNH 11.7
- Tramadol NNT: 4.7, NNH 12.6
- SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8
- Gabapentin NNT: 7.2 NNH 25.6
- Pregabalin NNT:7.7, NNH 13.9
ANZCA Pain book
Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend:
- First line: pregabalin, gabapentin and amitriptyline;
- Second line: tramadol and lamotrigine (in incomplete SCI);
- Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion;
- Fourth line: TENS, oxycodone and dorsal root entry zone lesions.
23.1 A 36-year-old woman sustains an injury to her left arm and presents with pain. She informs you that she experiences unpleasant intermittent and spontaneous shooting sensations in her arm. This sensation is
a. Dysaesthesia
b. Allodynia
c. Hyperalgesia
d. Hyperaesthesia
e. Paraesthesia
a. Dysaesthesia
Chronic pain that may involve itchiness, burning, electric shock, or a general tightening in any part of the body.
Allodynia Pain from stimuli which are not normally painful. The pain may occur other than in the area stimulated.
Hyperalgesia is an abnormally increased sensitivity to pain
Hyperesthesia is a condition that involves an abnormal increase in sensitivity to stimuli of the sense
https://www.iasp-pain.org/resources/terminology/#:~:text=DYSESTHESIA,sen
23.1 A 30-year-old woman has her bipolar disorder well controlled with lithium therapy. The analgesic agent LEAST suitable for her is
a. Tramadol
b. Diclofenac
c. Oxycodone
d. Methadone
b) diclofenac
LIthium perioperative concerns:
- Prolongation of NMB
- Reduction in anaesthetic agent requirement
- Avoid NSAIDs
- No withdrawl symptoms
- Discontinue 24hrs before surgery
NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2
BJA: perioperative advice for psychotropic drugs
21.2 The most reliable clinical indicator of opioid-induced ventilatory impairment (OIVI) is
decreased
a) level of consciousness
b) RR
c) SpO2
d) Vt
A) level of consciousness
In any patient who is given an opioid, oversedation should be considered to indicate OIVI until proven otherwise, regardless of a patient’s respiratory rate or oxygen saturation levels.
Source ANZCA PS 41
21.1 A patient who usually takes oral morphine 50 mg bd develops a bowel obstruction and experiences withdrawal symptoms. They may be described as having
a) Tolerance
b) Physical dependence
c) Addiction
d) Abuse
Physical dependence
Physical dependence = presence of withdrawal symptoms when the drug is not taken.
21.2 When performing a paediatric pain assessment, the five elements assessed to obtain the FLACC score are
a) face, legs, activity, cry, consolability
b) face, legs, arms, cry, consolability
c) function, legs, arms, cry, crossed legs
d) frown, legs, activity, cry, crossed arms
a) face, legs, activity, cry, consolability
22.1 A 30-year-old woman has had a free flap operation of eight hours duration. She received an intraoperative remifentanil infusion and was given 10 mg morphine 30 minutes before the end of the operation. In recovery her pain score has increased from 6/10 on arrival in recovery to 9/10 in spite of a further 10 mg of intravenous morphine. The most likely diagnosis is
a. Acute behavioural change
b. OIH
c. Inadequate analgesia
D. Physical dependence
b. OIH
20.1 A patient with persistent pain on oral hydromorphone 12mg per day is admitted to hospital unable to tolerate oral intake. The equivalent parenteral morphine dose per day is:
a) 12mg
b) 20mg
c) 40mg
d) 60mg
e) 80mg
b) 20mg
hydromorphone PO: morphine PO = 1: 5
So 12mg x 5= 60mg Morphine PO
Which to convert to PO morph: IV morph is 3:1, so 60mg/3 = 20mg of parenteral morphine
IV hydromorphone:
IV hydromorphone 1mg = 15mg PO Morphine = 5mg IV morphine.
How to remember this:
- hydromorphone PCA is a 200mcg (1ml) bolus; 20mg into 100mls for PCA; therefore 20mg IV hydromorphone = 100mg IV morphine (i.e. 300mg PO morphine)
- vial in recovery for pain protocol also comes as 2mg (i.e. 10mg IV morphine equivalent)
20.1 Patient on chronic daily oral hydromorphone 12mg, what is an appropriate daily parenteral morphine dose
a. 5
b. 10
c. 15
d. 20
e. 25mg
20mg
12mg PO hydromorphone = 60mg PO morphine
(Factor of 5)
PO - IV Morphine = factor of 3
FPM App
21.2 A patient who usually takes oral morphine 50 mg bd develops a bowel obstruction and
experiences withdrawal symptoms. They may be described as having
a) Tolerance
b) Physical dependence
c) Psychological dependence
d) Pseudo-addiction
e) Addiction
physical dependance
BARASH:
Physical dependence is a “physiologic state of adaptation to a specific psychoactive substance characterized by the emergence of a withdrawal syndrome during abstinence, which may be relieved in total or in part by re-administration of the substance.”
23.1 You are asked to review a 5-year-old child weighing 24 kg in the recovery room for acute pain management after a tonsillectomy performed for obstructive sleep apnoea. The most appropriate analgesic regimen would be
Painstop formulation (codeine 1mg/ml, paracetamol 24mg/ml). (interestingly composition of painstop not included in the released stem but was on the day of the exam)
A Painstop q6h PRN, ibuprofen, tramadol
B Painstop q6h, oxycodone PRN
C Paracetamol 300mg q6h oxycodone
D Paracetamol 300mg QID, ibuprofen 200mg TDS, tramadol 20mg PRN
Poorly remembered options
Definitely do not give Painstop as contains codeine
Opioids should be PRN only
c or d
-go with D - tramadol versus oxycodone re OSA
paracetamol 15mg/kg (360mg) QID
ibuprofen 10mg/kg (240mg) TDS
tramadol 1mg/kg (24mg) QID
oxycodone 0.1-0.2mg/kg (2.4-4.8mg) 4hourly
Codeine should not be used. Deaths. Ultrafast metabolisers –> high levels of morphine.
Nonselective NSAIDs may increase the risk of any bleeding-related outcome after
tonsillectomy in adults (U) (Level I); however, not in paediatric patients
Prospect advice:
The basic analgesic regimen should include paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) administered pre-operatively or intra-operatively and continued postoperatively.
A single dose of intravenous (i.v.) dexamethasone is recommended for its analgesic and anti-emetic effects.
Pre-operative gabapentinoids, intra-operative ketamine (only in children) and dexmedetomidine are recommended in patients with contra-indications to the basic analgesic regimen.
Analgesic adjuncts such as intra-operative and postoperative acupuncture and postoperative honey are recommended.
Opioids should be reserved as rescue analgesics in the postoperative period
21.2 Identified risk factors for opioid-induced ventilatory impairment DO NOT include
a) Opiate use preoperatively
b) Male gender
c) Sleep disordered breathing
d) Obesity
e) Renal impairment
b) Male gender
Patient-related risk factors for OIVI are
older age,
female gender,
sleep disordered breathing (SDB),
obesity,
renal impairment,
pulmonary disease (in particular chronic obstructive pulmonary disease),
cardiac disease,
diabetes,
hypertension,
neurologic disease,
two or more comorbidities,
genetic variations in opioid metabolism,
and opioid-tolerant patients.
Modifiable risk factors include:
* Coadministration of sedatives (e.g. benzodiazepines, gabapentinoids, antipsychotics and sedating antihistamines)
- Simultaneous use of multiple opioid agents (this does not include verified doses of opioids taken for management of chronic pain, where the patient has developed a tolerance to and physical dependence on these medications)
- Continuous infusions of opioids
- Initiation of long-acting opioid preparations (including methadone)
- Multiple prescribers
- Inadequate nursing assessments or responses
- Reliance on unidimensional pain scores alone to assess adequacy of analgesia, and chasing’ pain scores – that is, titrating opioids to pain scores alone to reduce them to a predetermined acceptable number
- Using opioids for pain that is not opioid-responsive
Source ANSCA PS 41
20.2 An analgesic which is a category A drug using the Australian and New Zealand categories for prescribing medicines in pregnancy is
a) Codeine
b) Methadone
c) Tramadol
d) Oxycodone
e) Morphine
Answer: a) Codeine
TGA Pregnancy categories https://www.tga.gov.au/prescribing-medicines-pregnancy-database
Category A
■ Codeine
Category C
■ Methadone
■ Tramadol
■ Oxycodone
■ Morphine
22.1 Of the following, the drug that is LEAST likely to provide effective analgesia following paediatric tonsillectomy is
a. Ketamine
b. Clonidine
c. NSAIDs
d. Paracetamol
e. Dexamethasone
b. Clonidine
PROSPECT 2021
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15299
Pre-operative and intra-operative interventions that improved postoperative pain were:
- paracetamol;
- non-steroidal anti-inflammatory drugs;
- intravenous dexamethasone;
- ketamine (only assessed in children);
- gabapentinoids;
- dexmedetomidine;
- honey;
- acupuncture.
Inconsistent evidence was found for:
- local anaesthetic infiltration;
- antibiotics;
- magnesium sulphate.
Limited evidence was found for
- clonidine.
The analgesic regimen for tonsillectomy should include:
1. paracetamol;
2. non-steroidal anti-inflammatory drugs; and
3. intravenous dexamethasone,
4. with opioids as rescue analgesics.
Analgesic adjuncts such as:
1. intra-operative and postoperative acupuncture as well as
2. postoperative honey are also recommended.
3. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first-line analgesics are contra-indicated
22.2 You are called to recovery to review an 80-year-old woman post neck of femur fracture fixation performed under general anaesthesia with a fascia iliaca block. She has a history of mild dementia. She has become confused and agitated after initially being cooperative and pain-free. The most appropriate drug therapy to manage her is intravenous
a. Clonidine
b. dexmedetomidine
c. propofol
d. midazolam
e. haloperidol
e. haloperidol
Clonidine-> no mention in the evidence
dexmedetomidine-> as an infusion seems to reduce risk of post-op delerium and could be used to treat but not necessarily practical in combative patient
Propofol-> not mentioned
Midazolam-> avoid benzos as can worsen delerium
If pharmacological approaches are required to reduce
risk of harm to the person with agitated delirium, then
haloperidol can be administered in incremental 0.5-mg
doses. Benzodiazepines should be used for people with
alcohol-related cognitive disorders or in people with
Parkinsonian dementia. There is no evidence to support the
use of prophylactic pharmacological measures
(cholinesterase inhibitors, antipsychotics, melatonin) in
routine peri-operative care for patients at risk of POD
https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_Perioperative_care_of_people_with_dementia_2019.pdf?ver=2019-02-11-121238-777×tamp=1549888049165&ver=2019-02-11-121238-777×tamp=1549888049165
Duan and colleagues conducted a meta-analysis of 18 clinical trials and found that intraoperative and postoperative dexmedetomidine administration significantly reduces the risk postoperative delirium (odds ratio 0.35).
->
https://www.bjanaesthesia.org/article/S0007-0912(20)30566-3/fulltext
21.1 A patient has bipolar disorder and is on long term lithium therapy. An analgesic which should be avoided is
a. Diclofenac
b. Tramadol
c. Oxycodone
d. Methadone
a. Diclofenac
LIthium perioperative concerns:
- Prolongation of NMB
- Reduction in anaesthetic agent requirement
- Avoid NSAIDs
- No withdrawl symptoms
- Discontinue 24hrs before surgery
NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2
BJA: perioperative advice for psychotropic drugs
21.1 Risk factors for chronic post surgical pain do NOT include
a. Smoking
b. Pre-existing pain
c. High level of anxiety
d. Young age
e. High level of education
high level of education
BJA: CPSP
Previous chronic pain is the most important clinical risk factor.
Other risk factors for CPSP include:
1. Young age
2. alcohol use
3. smoking
4. unemployed
5. disability
6. obesity
7. type of surgery.
Risk factors for CPSP
Pre-op
1. existence and intensity of pre-op pain is a risk factor for developing CPSP after:
- Hernia repair
- Thoracotomy
- amputation
- mastectomy
- for mastectomy and amputation continuous pre-operative pain for more than 1 month predicts CPSP
- Genetic susceptibility
- Psychosocial factors
Intraoperative factors:
1. longer operations
2. Laparoscopic surgical approaches result in less chronic pain
3. Repeat surgery (for hernias) has higher incidene of moderate to severe pain
Post-operative factors:
1. Radiotherapy increases risk factors
2. Severity of postoperative pain predicts development of CPSP
- repetitive nociceptive stimulation during perioperative period resul;ts in nervous system changes e.g central sensitization
A patient who underwent a thoracotomy 6 months ago reports ongoing pain caused by light brushing of clothes against the skin on the chest wall. This is known as
a) Hyperalgesia
b) Allodynia
c) Hyperaesthesia
d) dysasthesia
Mechanical allodynia
Allodynia IASP definition: pain due to a stimulus that does not normally provoke pain
“The term allodynia was originally introduced to separate from hyperalgesia and hyperesthesia, the conditions seen in patients with lesions of the nervous system where touch, light pressure, or moderate cold or warmth evoke pain when applied to apparently normal skin.”
References IASP https://www.iasp-pain.org/resources/terminology/?ItemNumber=1698
And APMSE 5th Ed pg64.
Dysaesthesia: spontaneous and unpleasant sensation
A patient who is day 3 post laparotomy has used 30 mg oxycodone intravenously via patient controlled analgesia in the last 24 hours. The approximate oral morphine equivalent daily
dose is
a) 30mg
b) 45mg
c) 60mg
d) 90mg
90mg PO morphine
Oral Tapentadol 25mg = 8mg Oral Morphine
Oral Oxycodone 5mg = 8mg Oral Morphine
Oral Tramadol 25mg = Oral Morphine 5mg
Oral Hydromorphone 4mg = Oral Morphine 20mg
S/L Buprenorphine 200mcg = 8mg Oral Morphine
IV Oxycodone 5mg = Oral Morphine 15mg
IV Morphine 5mg = Oral Morphine 15mg
IV Hydromorphone 1mg = Oral Morphine 15mg
The cardiac arrhythmia most commonly associated with the chronic use of methadone is:
a) Torsades
b) VF
c) Tachycardia
a) Torsades
2ry to prolonged QT leading to R on T
PETKOV
Somatic pain in the second stage of labour is NOT transmitted via the
a) Pudendal nerve
b) Illioinguinal
c) pelvic splanchnic
d) genitofemoral
c) pelvic splanchnic
-> visceral not somativ nerve
The most effective treatment for pain following wisdom teeth extraction as a single oral dose is
a) Paracetamol 1000mg
b) Tramadol 100mg
c) Parecoxib 40mg
d) Ibuprofen 400mg
e) Codeine 30mg
d) Ibuprofen 400mg
- Ibuprofen (I think, because of the single oral dose statement)
APMSE 5th edition
Acute pain after third molar extraction is the most extensively studied model for testing postoperative analgesics in single-dose investigations. Nonselective NSAIDs or coxibs are recommended as “first-line” analgesics following third molar extraction (Derry 2011 Level I, 155 RCTs, n=16,104), however paracetamol is also safe and effective with a dose of 1,000 mg providing better pain relief than lower doses (Weil 2007 Level I [Cochrane], 21 RCTs, n=1,968). The best available evidence suggests the use of NSAIDs either with or without paracetamol is effective and well-tolerated (Moore 2018 Level I, 5 SRs, n unspecified).
Nonselective NSAIDs are more effective than paracetamol or codeine (either alone or in combination) (Ahmad 1997 Level I, 33 RCTs, n=5,171). Ibuprofen (200–512 mg) specifically is superior to paracetamol (600–1,000 mg) in this setting and combining these two drugs improves analgesia further (Bailey 2014 Level I [Cochrane], 7 RCTs, n=2,241)
When administered in combination with tramadol, the agent considered highest risk
for the development of serotonin syndrome is:
a) Moclobemide
b) Escitalopram
c) Desvenlafaxine
d) Tapentadol
Moclobemide
- Reversible MAOI
SSRIs and SNRIs are lower risk
Tapentadol - no serotonin effect
Tranylcypromine or phenylzine are irreversible blockers and would be the highest risk
