Pain

Question 1

Cancer pain caused by what. Physical and mental fx

Answer 1

Bone invasion, peripheral nerve compression. Loss of sleep and appetite, NV, anxiety, low self esteem, disfigurement

Question 2

Pre op eval of pain

Answer 2

Pain hx, physical exam, self resport measurement scale, meds, doc

Question 3

Control of postop pain beneficial why

Answer 3

Reduced stress response, shorter time to extubation/ICU stays, imp resp and bowel func, less risk DVTs/better mobilization, early d/c

Question 4

Opioids: how they work, disadvantages

Answer 4

Mu and kappa receptors, gold standard in pain manage. Resp dep, low bp, NV, sedation, itching, urin ret

Question 5

How NSAIDs work, use

Answer 5

Inhibit cox and prevent prostaglandin synthesis. Mild to mod pain d/t inflammation, opioid adjunct. Attenuated pain peripherally and SC

Question 6

NSAID SE

Answer 6

Plt dysfunc, inhibit txa2- bleed, renal dysfunc, gi bleed, fx on bone healing, liver dysfunc

Question 7

Acetaminophen: IV dose, rate, SE

Answer 7

Ofirmev 650-1000 mg q6h, max dose 4g 24 hrs. NV, HA, hepatotoxic

Question 8

Dose: ketamine, tramadol

Answer 8

0.15-.25 mg/kg IV. 50 mg IV

Question 9

Dose: Nubain, methadone

Answer 9

10-20 mg IV, 10-20 mg IV

Question 10

Dose neurontin and Celebrex

Answer 10

900 mg PO, 400 mg PO

Question 11

PN blocks where catheters can be places

Answer 11

Brachial plexus, femoral nerve, sciatic-popliteal intercostal, intrapleural

Question 12

Benefits of neuraxial anesthesia

Answer 12

Better analgesia than systemic opioids, reduced stress response, GI motility return, dec pulm complic, dec coag related adverse events

Question 13

Hydrophilic neuraxial opioids and about them

Answer 13

Morphine and dilaudid. Stay in CSF. Delayed onset, longer duration, high incidence SE

Question 14

Lipophilic neuraxial opioids and about them

Answer 14

Fentanyl and sufentanil. Rapid onset, short dureation, minimal CSF spread, less SE

Question 15

Neuraxial opioids

Answer 15

Morphine, fentanyl, sufentanil, demerol, dilaudid

Question 16

LAs vs opioids in epidural

Answer 16

LA: high failure rate, motor block, hypotension. Opioids: less motor block and hypotension, resp depression and pruritis

Question 17

LA plus opioids in epidural

Answer 17

Better choice. Limits regression of sensory block, less motor block, dec total dose LA.

Question 18

LAs used for epidural

Answer 18

Lidocaine, bupivicaine, ropivicaine

Question 19

Opioids used in epidural

Answer 19

Morphine, dilaudid, fentanyl, sufentanil

Question 20

Adjuvants to neuraxial drugs

Answer 20

Clonidine (prolongs DOA, limited by lowering bp and hr and sedation). Epi and neosynephrine prolong block duration and intensity

Question 21

Catheter insertion site for: thoracic surgery, upper abd/cholecystectomy, nephrectomy

Answer 21

T4-8. T6-8. T7-10.

Question 22

Catheter insertion site for: lower abd, lower extremity

Answer 22

T8-11. L1-4.

Question 23

Ambulatory pt pain consid

Answer 23

Postop pain prolongs stay. NV issue. Multimodal approach best

Question 24

Elderly pt pain consid

Answer 24

Diff physio/pharmacodynamics/kinetics. Inc comorbitidies and dec physiologic reserves. Barriers to pain management. Regional may be best

Question 25

Opioid tolerant pt goals

Answer 25

Provide baseline opioid reqs, anticipate inc in postop analgesia reqs, maximize use of adjunct drugs/consider regional

Question 26

Ped pt pain management. Issues, encouraged, discouraged

Answer 26

Under tx, difficult assessment. Regional and pca encouraged. IM discouraged

Question 27

Obesity/OSA high risk for what, goals

Answer 27

Pulm complic and resp arrest. Avoid resp depressants, epidural anes w/o opioids, nsaids, post op cpap

Question 28

How TCAs help w pain

Answer 28

Elevate mood, help w sleep. Block reuptake of serotonin and NE. Potentiate narcotics.

Question 29

TCAs dosing and SE

Answer 29

Smaller doses than depression dose, monitor levels. Anticholinergic: dry mouth, tired, ortho hypo, arrhythmias

Question 30

Anticonvulsant drugs: how they work, SE

Answer 30

Alter ion channels along nerve fiber, block action potential and pain stimuli. Sedation, dizzy, ataxia

Question 31

How alpha 2 agonists work

Answer 31

Clonidine and preceded, pre and post synaptically inhibit neuron firing in dorsal horn. Precedex also works centrally to inhibit release of sub P

Question 32

How GABA agonists work

Answer 32

Inhibitory NT, acts in SC to prevent release of excitatory NTs. Baclofen

Question 33

Sympathetic nerve blocks

Answer 33

Stellate block (cervicothoracic), thoracic sympathetic chain block, sphlanchnic, lumbar sympathetic, hypogastric plexus

Question 34

Somatic nerve blocks

Answer 34

Trigeminal, facial, glossopharyngeal, occipital, phrenic, supraschpular, cervical/thoracic/lumbar paravertebral, trans sacral, pudendal

Question 35

What neuroleptic blocks do, where they’re used, what is used int hem

Answer 35

Destroys nerve w alcohol and phenol. Lumbar sympathetic chain, celiac plexus, hypogastric plexus, ganglion impar (retroperitoneal), intercostal

Question 36

How SC stim works, which conditions used for

Answer 36

Activates descending modulating sys, inhibits sympathetic outflow. Phantom limb pain, ischemic pain, PVD, SC lesions

Question 37

Inadequate pain management in cancer due to what

Answer 37

Poor pain assessment, poor tx plan, lack of knowledge/analgesics, fear of addiction or resp depression

Question 38

Steps of WHO analgesic ladder

Answer 38

1- mild pain, non opioids. 2- mild-most, weak opioids PO. 3- mod-severe, parenteral/potent opioids. 4- intractable pain, invasive therapy

Question 39

Step 2 WHO meds

Answer 39

Codeine, hydrocodone, oxycodone, dihydrocodeine, tramadol

Question 40

Step 3 who pain meds

Answer 40

Morphine, dilaudid, methadone, leborphanol, fentanyl, oxycodone

Question 41

Cancer pain management adjuncts

Answer 41

Steroids (prevent prostaglandin release), psychotherapy, PT, antidepressants