Pain Flashcards
[21B15] Outline the clinical features, differential diagnoses, and management of serotonin syndrome in the peri-operative period.
- Clinical features
- variable, potentially life-threatening
- MAN - mental status, autonomic, neuromuscular - Differential dx
- NMS
- MH
- Anticholinergic sx
- Emergency delirium - Mx
- Dx of exclusion
- Discontinue all serotonergic agent
- Supportive care
– Stabilise
– Give O2
– fluids
– continuous cardiac monitoring
– Sedate with benzo
DO NOT give
- dantrolene (MH)
- bromocriptine (NMS)
[20A08] A 80-year-old lung cancer patient is planned to undergo an open thoracotomy involving possible rib resection
a. List the regional techniques available for post-operative pain management and justify your choice of regional technique for this patient. (50%) b. Outline your management plan if pain is still present at the operative site 14 days later. (50%)
Thoracotomy - high incidence of chronic pain
Any CPSP - 65%
Severe CPSP - 10%
Neuropathic pain - 45%
TEA gold standard
PVB if unilateral, less resp compl and hypotension
ESPB - newer block, lower risk
ICB
The second part of the question was answered well by a sizable minority, with these answers canvassing the possibilities of
1) surgical complications,
2)persistent surgical pain, or neuropathic pain.
These answers followed up with a management plan for analgesia using
1) medication,
2) regional and
3) non-pharmacological techniques, then
4) referring appropriately to a pain specialist for follow-up.
[19B12] List the advantages and disadvantages of opioid-free approaches for laparoscopic sleeve gastrectomy. (50%) Justify your choice of opioid-free technique for this procedure. (50%)
Adv:
1* Avoid opioid related SE - resp dep, sedation, N/V, pruritis
2. Enh post op recovery
Disadv (of non-opioids)
1. Ket - affect BIS
2. vasopressor
3. unfam
4. awareness
5.
My choice of OFA
Volatile or TIVA
- Sympatholysis
a) Dexmed
b) esmolol - Analgesia
a) Ket
Bolus 0.125-0.25mg/kg, infusion 0.125-0.25mg/kg
b) Lignocaine
Bolus 1.5mg/kg, infusion 1.5mg/kg
c) Mag
40mgkg (2.5g=10mmol=5mL)
d) Dex
c) Simples - Regional
[18B03] One of your anaesthetic colleagues is prescribing fentanyl patches as discharge medication for patients following total hip joint replacement. Evaluate this practice.
Establishment of APS
Benefit
1. Better pain relief
2. Lower incidence of AE
3. Lower postop M&M
4. May reduce PERSISTENT PAIN
5. Cost-effective patient care
6. Reduce persistent pain and discharge opioid use after surgery
VIC Long Course; APMSE
What is pain
UNPLEASANT
sensory or emotion
experience
associated with (resembling)
actual or potential
tissue damage
Establishing a service
Requirements (PS55 Minimum safe facilities 2021)
- Staffing
- Physical location
- Equipment
- Emergency medications
[18A15] Evaluate the use of intravenous lignocaine infusions for perioperative analgesia.
Pharm
Uses
1. Best evidence in ABDOMINAL surgery
Adv
1. Reduced post op pain score
2. reduced opioid-related side effects (PONV, ileus)
Disadv
1. Not appropriate single agent replacement of opioids
2. Risk of LAST (CVS/CNS)
3. Risk of arrhythmia
4. Accumulation of active metabolite (MEG-X) in hepatic/renal impairment
[20A05] A 36-year-old with a history of opioid dependence is booked for spinal surgery. The patient is no longer on opioids and is maintained on 50mg of oral naltrexone daily. Discuss the implications of the history of opioid dependence and current naltrexone treatment for the provision of effective perioperative analgesia, including an analgesia plan upon hospital discharge.
opioid antagonist
structurally ~ naloxone, higher oral efficacy + longer udration
Pre-op
- minor intermediate
- major - ** discontinue 72h!
2023 blue book article
t1/2 = 5hrs
low dose = 1-6mg
high dose effect on opioid req = increased!
primary clinical use - rx etoh dependence/opioid addiction
inc being prescribed for WEIGHT LOSS!
main risk periop = resp depression
high dose ~ joint pain
[16B07] A new hospital is setting up its pain service and you have been asked to write the administration guidelines for ketamine infusions on the ward. Outline the information you would include in these guidelines.
Safety considerations
1. Daily APS review
2. S8 - lockable pump
3. Special code to alter dose
4. Special chart for recording infusion + documentation of vitals + pain scores
Nursing protocol
Notification systems
1. High pain score
2. Resp dep
3. Dose adjustments
4. Equipment
5. Any concerns/AE
[23B01] Evaluate the use of long-acting opioids in the treatment of acute pain.
advantages and disadvantages to the long half-life
Adv
- multiple traumatic and burns injury
- pre-existing long acinng opioid –> dependent on that opioid
- spinal morphine for specific types of surgery
Disadv vs IR
1) Provide less effective pain relief.
2) increase the risk of OIVI and other opioid-related adverse events.
3) Increase the risk of PPOU.
* Persistent postdischarge opioid use (PPOU)
*extended risk of opioid-induced ventilatory depression
Better answers discussed the
a) college position statement PS41 2023 7.1.1
Routine prescription of long acting opioids for the management of acute pain should be avoided unless there is a
1) demonstrated need,
2) close monitoring is available, and
3) a cessation plan is in place.
b) differences with long-acting partial agonists
and
c) differences in vulnerability in different subpopulations.
- opioid naive - response and predicting dose impossible
[21A08] A patient takes a 60mg slow-release morphine tablet twice daily for chronic low back pain. They have been appropriately investigated and there is no surgically treatable pathology.
In relation to this patient
List the risks of long-term opioid therapy. (30%)
Justify the appropriate treatment of chronic low back pain. (70%)
Pass rate 85.7%
This question was answered well with the better answers critically appraising (rather than simply listing) the various approaches and treatment options in managing chronic low back pain in relation to this patient.
A huge volume of opioid medication is used in the community for non-malignant pain – mostly unnecessarily and ineffectually – leading to the ‘opioid crisis’ and significant harm to patients. Many of these prescriptions start in hospital and are continued upon discharge.
Chronic back pain is common and should not be treated with opioids. Anaesthetists should be able to explain ‘Why?’ opioids are harmful and what the alternatives therapies are.
[22B02] Discuss the intraoperative and postoperative pain management of a trauma patient who requires a semi- elective below knee amputation for an isolated injury.
Pass rate 77.3%
This was a well answered question where the majority of candidates considered a range of options and techniques for such a patient.
Better candidates discussed the use of tricyclics and antineuropathic agents within their management plan in an attempt to reduce the incidence/severity of phantom limb pain.
[24A01]
You are asked to review a healthy 20-year-old patient for severe post-operative pain in a stand-alone day surgery unit. Describe your assessment and justify your management.
Pass Rate 77.0%
Minimum standard answers required a description of a systematic assessment of an acute pain patient and an appropriate analgesia strategy to facilitate discharge from a day surgery facility.
Systematic assessment
APMSE
Progression of acute to chronic pain
Perioperative IV ketamine reduces the incidence of chronic postsurgical pain in selected procedures
Following thoracotomy, epidural analgesia reduces the incidence of chronic postsurgical pain
Following breast cancer surgery, paravertebral block (S), local infiltration (N) (Level I [Cochrane Review]) and IV lidocaine reduce the incidence of chronic postsurgical pain (N) (Level I [PRISMA]).
Pregabalin reduces the incidence of chronic postsurgical neuropathic pain, but does not affect non-neuropathic chronic postsurgical pain (N) (Level I [PRISMA]).
Spinal anaesthesia in comparison to general anaesthesia reduces the risk of chronic postsurgical pain after hysterectomy and Caesarean section (
