Pain management Q+A

Question 1

how would you treat majority of pts presenting with acute pain?

Answer 1

dilute morphine to a 1mg in 1ml solution and titrate in 1-2mg increments to effect, observing pt for side effects

• dilute 10mg of morphine in 0.9% saline to 10mlx (ie 1mg/ml) and give 1-2mg increments until comfortable.

Question 2

after titrating morphine for acute pain. in the pre -op setting is there any other analgesic you would administer?

Answer 2

IV paracetamol. as remember pre-op the oral route is unavailable.

paracetamol is the ideal adjunct to IV morphine

Question 3

why would you not give a non-steroidal as analgesia in a pre-op patient?

Answer 3

it is unadvisable due to dehydration and the risk of renal impairment

Question 4

pt has been to theatre and has been on the ward for a no of hours and is managing oral intake. she has a standard morphine PCA. she is still uncomfortable what do you do next?

Answer 4

add in regular oral paracetamol and a non-steroidal

she has been back from theatre for a no of hours and vomiting should have settled so oral route is ideal

she is asthmatic, she has taken ibuprofen in the past without problem, so a NSAID should be tolerated.

Question 5

pt is on ward with breathing problems. he has also received 10mg of morphine in A+E. he is a smoker but no COPD hx. he is complaining of pain, not breathing adequately and his RR is 25/min and SpO2 90% on 2l o2 via nasal cannulae. what is your initial mx?

Answer 5

• administer 100% O2 via a non-rebreathing mask
• although his pain control needs attention you need to take ABC approach and tx appropriately.
• although smoker, no hx of COPD and therefore you dont need to be cautious in amount of O2 required ie 28% o2 via venturi mask

Question 6

you have patients O2 under control. He is still sore and cannot get a deep breath? what is your next course of action?

Answer 6

prescribe regular oral paracetamol and regular oral tramadol.

many pts w rib factures manage w oral analgesia so try initially

prescribe as 1g tds and 100mg qds

Question 7

one hour post paracetamol and tramadol pain is not better and getting worse, what is your next course of action (pt has bilteral rib #’s and pneumothoraxes)

Answer 7

• stop regular tramadol, titrate IV morphine to effect and start a morphine PCA
• requires stronger opioid analgesia as rib fractures are v painful and tramadol is insufficient to control pain

NSAIDs are a useful adjunct esp for bony injuries but CI in pts w hx of GI bleed

Question 8

pt who has been prescribed morphine PCA RR is 6bpm, drowsy and difficult to rouse. what do you to to mx this?

Answer 8

• IV naloxone, titrated in 40mcg increments and reassess the pt.
• naloxone is an opioid receptor antagonist.
• best given in small increments and titrated to effect
• this will reverse the sedation and resp depression without reversing the analgesia

Question 9

side effects of naloxone?

Answer 9

hypertension
arrythmias
pulmonary oedema
cardiac arrest

-> side effects following IV bolus injection

Question 10

pt is not tolerating morphine for pain what is next best course of action for him? (he is opioid sensitive but in severe pain)

Answer 10

• discuss w anaesthetist/acute pain team w regards to siting an epidural
• an epidural infusion is a continuous local anaesthetic infusion via a small catheter into the epidural space. this will provide excellent analgesia

Question 11

risks of epidural placement

Answer 11

dural tap and post-dural puncture headache
hypotension
epidural haematoma
inadequate block/pain relief
abscess formation/meningitis neurological damage

Question 12

pt w hypertension post op, nil by mouth as they predict he will develop an ileus. he has wound pain, how can you manage his pain initially?

Answer 12

check he is on regular paracetamol

• he should be on reg paracetamol if not already prescribed
• on-call anaesthetist is correct person to contact for overnight difficult pain problems but mx w paracetamol first

Question 13

who does an epidural top up?

Answer 13

• anaesthetist
• or nursing staff specially trained to do this

Question 14

anaesthetist is busy so can’t do an epidural top up how might else you manage this patients worsening pain?

Answer 14

• titrate morphine IV in increments and start a morphine PCA

Question 15

what is a standard morphine PCA prescription?

Answer 15

• 1mg morphine bolus, 5 minute lockout

Question 16

over past 24 hrs pt has used 60mg of IV morphine what does this equate to orally.

Answer 16

oral route is double the IV dose
- 120mg

Question 17

oxycontin (modified release oxycodone) has a 12 hr duration of action, what total daily dose of oral oxycontin is equivalent of 120mg oral morphine

Answer 17

• conversion for oxycodone is half oral morphine
  amdinistered 2x a day ie 8am and 8pm
• he is getting 60mg total but prescribed 12 hrs apart so 30mg bd

Question 20

how do you calculate breakthrough dose of oxynorm

Answer 20

• one sixth of total daily dose of oxycontin

Question 21

reviewing patient after femoral fracture who is unable to mobilise and in pain. she is prescribed paracetamol and has not been prescribed any analgesia since her op. what do you do

Answer 21

• prescribe regular oral paracetamol
• cannot used NSAIDs in chronic renal impairment
• ortho surgeons don’t agree w NSAIDs as they can affect bone healing

Question 22

cannot adequately control pain with paracetamol trying to mobilise what is next step?

Answer 22

prescribe regular codeine and a laxative

Question 23

name a drug not recommended in epilepsy?

Answer 23

• tramadol

Question 24

pt feels nauseous after codeine, what do you do?

Answer 24

• prescribe anti-emetic
• best given parenterally it may not be absorbed oraly if she is vomiting