PAin management

Question 1

You was called at 22:30 for A 45-year-old ,whose weight is 90kg, post-laparotomy 9 hours ago for perforated diverticulitis. Complaining of abdominal pain. O/E he was conscious , alert & afebrile with BP 148/95 , HR 120/min. the surgical site was normal. Upon reviewing his medication charts , he didn’t receive his paracetamol dose at 18:00.

Q1: What is pain?

Answer 1

Unpleasant sensory and emotional feeling usually due to actual of potential tissue damage

Question 2

Q2: How to assess pain?

Answer 2

According to different scaleing of pain like numerical or visual or verbal
Explain each
Given this VAS

Question 3

Q3: What does it tell?

Answer 3

Most likely moderate pain

Question 4

Q4: Considering VAS & patient’s prescribed analgesia , what’re the instructions you will give to the nurses?

Answer 4

I’ll call nurse to give the pt full dose of paracetamol 1 GM IV and also full dose of morphine sc/Im as pt is in moderate pain and tachycardic or IV bolus of 10 mg
Also may add adjevant dose of NSAIDs orally or rectally.
Q5: What to do if patient’s pain fail to settle?
I can just contact Anastasia team to ask for advice during that I may give another dose of morphine.
Then full assessment of pt to exclude underlying surgical complications
..

Question 5

Q5: What to do if patient’s pain fail to settle?

Answer 5

I can just contact Anastasia team to ask for advice during that I may give another dose of morphine.
Then full assessment of pt to exclude underlying surgical complications

Question 6

Q6: Where’re the harmful effect of post-op pain?

Answer 6

Cardiac complications – > HTN , Tachycardia and also MI due to consumption of myocardial activity
Res –> limited chest movement leading to diaphragm splinting, atelectasis, retained Secretions and pneumonia
Pt may become confused and agitated
and less mobile which lead to dvt and TE events
GI – > delayed gastric emptying, decrease gastric motility and paralytic ileus
..

Question 7

Q7: Where’re the potential side effect of opioid as post-op analgesia?

Answer 7

Respiratory depression
N,V, constipation, itching, hypotension, pt become euphoric
..

Question 8

Q8: Describe pain pathway from receptor to brain?

Answer 8

C fibres and A delta transmit pain from peripheries to 1st Oder neurone and DRG —> 2nd order neurone in spinal cord – > ascending fibres to medulla, pons, midbrain in lat spinothalamic tract – > thalamus 3rd neurone – > sensory area in cerebral cortex

Question 9

Q9: Patient pain failed to settle & anesthesia ST2 recommended PCA device. What’re the features of PCA?

Answer 9

Patient controlled analgesia
Syring pump connected to IV to allow pt to self administer morphine boluses,
Overdose is avoided by limiting size of bolus and Freq of administration
One-way valve prevent backflow of opiates into the infusion which may lead to overdose when readminster .
..

Question 10

Q10: What’re the potential problems with PCA?

Answer 10

Pt has to be alerted an oriented
Run out of battery
Sleep disturbances
Limit pt mobility
Not suitable for pt who are confused

Question 11

Q11: What’re the types of opioid in common use?

Answer 11

Synthetic; pethidine and fantanyl
Semi-synthetic; diamorphine, diahydrocodien
Non-synthetic ; morphine and codiene

Question 12

Q12: What’re the mechanisms of action of paracetamol ( Acetaminophen )?

Answer 12

Not fully understood. Considered weak inhibitor of synthesis of PG
In vivo it’s believed to inhitbit COX-2

Question 13

Q13: How to manage paracetamol toxicity?

Answer 13

Gastric decontamination;
by gastric lavage within 60 mins of ingestion
Active charcoal 30-120 mins of ingestion
Acetyl cysteine as antidote
Liver transplant in acute liver failure