Pain Management

Question 1

What are the two types of pain?

Answer 1

Nociceptive and Neuropathic

Question 2

________ pain responds best to opiates

Answer 2

Nociceptive

Question 3

Neuropathic pain responds best to _______

Answer 3

Neurontin (GABA), Lyrica (GABA), Methadone (NMDA), Anti-seizure meds

Question 4

Stimulation of nociception occurs when a ___________ (chemical, thermal, mechanical) of nociceptors releases neural chemicals that also stimulate other nociceptors, the signal is transmitted to the _______

Answer 4

noxious stimulus

spinal cord

Question 5

Transmission of nociception occurs when an Action potential moves from site of stimulus to the _______________, then to the_________. From the dorsal horn, _________ are released.

Answer 5

dorsal horn of the spinal cord
CNS
neurotransmitters ex) glutamate, substance P, Calcitonin related peptide

Question 6

Perception of pain is the ___________ of pain. Pain impulses are relayed through the _______ and _____________ transmit pain.

Answer 6

Conscious experience
thalamus
higher cortical structures

Question 7

Modulation is the inhibition of impulses via the _____________

Answer 7

brain stem

Question 8

Neuropathic Pain is sustained by abnormal processing of

Answer 8

sensory output

• Nerve damage, persistent stimulation, autonomic dysfunction
• Burning, tingling, shocks, hyperalgesia, allodynia

Question 9

Monitoring Pain:

Answer 9

P: palliative and provocative factors 
Q: Quality
R: Radiation
S: Severity
T: Temporal relations

Question 10

All pain is measured _______

Answer 10

subjectively

-No lab tests to “measure” pain
-All subjective
- External and Internal signs and symptoms
¨-Grimacing, guarding, sweating, nausea -Hypertension, tachycardia, tachypnea

Question 11

Opioid receptors are located throughout the

Answer 11

brain, spinal cord, GI tract

Question 12

The four subtypes of opioid receptors include

Answer 12

Delta
Kappa
Mu
Nociceptive

Question 13

The mu receptors include:

Answer 13

Mu1: analgesia, dependence
Mu2: side effects: respiratory depression, euphoria, reduced GI motility, dependence
Mu3: unknown

Question 14

Mu receptors are found on the presynaptic and postsynaptic clefts. THis is where morphine can work by pumping in _____ and pumping out ________. ________ is key!

Answer 14

Calcium in
Potassium Out
Hyperpolarization is key

Question 15

Most opiates are ______ and work on the ____ receptor

Answer 15

agonists

mu

Question 16

_______ is a natural opiate that has a ________ nucleus

Answer 16

Morphine

pheanthrene

Question 17

_______ forms of opioids have agonist action

Answer 17

levo-rotary

Question 18

Opioids must exist in an _______ state to form strong bonds at the opioid receptor

Answer 18

ionized

Question 19

Morphine is most effective when given ______ acute surgical stimulus

Answer 19

before

Question 20

Morphines metabolites include

Answer 20

M-3 inactive

M-6 active, will build up if not peed out (CKD)

Question 21

Morphine causes a ________ release

Answer 21

histamine

Question 22

Fentanyl does not cause a ______ release

Answer 22

histamine

Question 23

Morphine use should be cautiously used in

Answer 23

head injury patients

Question 24

During cholecysectomy _____ may cause a opioid induced spasm of the sphincter of ______. Tx is ______.

Answer 24

morphine
oddi
glucagon 2mg IV

Question 25

Morphine side effects include

Answer 25

PONV, biliary colic, delayed gastric emptying, constipation, difficulty voiding

Question 26

Opioids and ________ may cause an exaggerated CNS depression and hyperpyrexia. (especially Demerol)

Answer 26

MAO Inhibitors

Question 27

Dilaudid lacks any ___________ , which makes it a good candidate for patients with renal failure.

Answer 27

active metabolites

Question 28

Opioids and benzo combinations demonstrate a marked _________ effect, in regards to hypnosis and depression of ventilation

Answer 28

synergistic

Question 29

All opioids demonstrate a decrease in plasma concentration with inititation of _______, especially __________.

Answer 29

cardiopulmonary bypass | especially fentanyl

Question 30

Sufentanil is a _____ potent form of fentanyl

Answer 30

more

Question 31

Alfentanil is a _____ potent form of fentanyl

Answer 31

less

Question 32

______ is useful in quick, single, brief stimulus procedures, such as intubation and cardioversion

Answer 32

alfentanil

Question 33

Remifentanil requires __________

Answer 33

high post operative analgesic requirements

Question 34

Demerol is a

Answer 34

synthetic opioid agonist at mu and kappa receptors

Question 35

Decreased renal function can cause an accumulation of __________, the metabolite of Demerol, which can cause toxicities.

Answer 35

normeperidine

Question 36

Half life of normeperidine is _____ hours, and ______ hours in patients with renal failure

Answer 36

15 hours | >35 hours

Question 37

Normeperidine causes CNS ________, and CNS toxicity leads to ______ and _______ and _______.

Answer 37

stimulation myoclonus and seizures Demerol induced delirium: confusion and headache

Question 38

Demerol should not be taken for more than

Answer 38

48 hours. (600 mg/day max)

Question 39

When Demerol is given with SSRI's it may cause

Answer 39

``` Serotonin Syndrome -Autonomic Instability HTN Hyperthermia Hyperreflexia No true reversal, stop demerol, tx symptoms ```

Question 40

Advantages of agonist-antagonists include

Answer 40

drugs have a ceiling effect | analgesic effect with hopefully less respiratory effect

Question 41

Opioid antagonists demonstrate a high affinity for

Answer 41

the opioid receptor and result in displacement of the opioid agonist from the mu receptor

Question 42

Use of Naloxone results in

Answer 42

prompt reversal of opioid depression of ventilation and induced analgesia

Question 43

Toradol is a _______ | Black box warning:

Answer 43

NSAID | 5 day max (GI Bleed)

Question 44

IV APAP

Answer 44

Reduced Opioid Use | Questionable mechanism