PERI - Pain Management

Question 1

3 features of pain management

Clinical Assessment of Pain
Consequences of Poor Pain Control
Patient Controlled Analgesia (PCA)

Answer 1

1. ) Clinical Assessment - should be assessed when mobile, taking deep breath, and when lying in bed
   - subjective: mild, moderate, severe
   - objective: tachycardia, tachypnoea, HTN, sweating, flushing, unable to mobilise, agitation
2. ) Consequences of Poor Pain Control - ↓recovery
   - reluctant to mobilise –> ↓rehabilitation capacity
   - shallow breathing –> inadequate ventilation –> atelectasis, hospital-acquired pneumonia

3.) Patient Controlled Analgesia - IV pumps providing a bolus dose when the patient presses a button

Question 2

WHO Analgesic Ladder

Simple Analgesics
Weak Opiates
Strong Opiates

Answer 2

1. ) Simple Analgesics - paracetamol, NSAIDs
   - regular paracetamol given if regular opiates are needed to reduce the requirement of opiates
   - oral paracetamol never given on its own
2. ) Weak Opiates - codeine, tramadol
   - can be prescribed with a laxative or anti-emetic
   - avoid prescribing with strong opiates
3. ) Strong Opiates - morphine, oxycodone, fentanyl
   - oxycodone, fentanyl preffered in renal impairment
   - often prescribed with laxatives or antiemetics

Question 3

6 features of NSAIDs

Examples x6
Mechanism
COX-2 Selectivity
Usage x6
Caution x3
Side Effects (IGRAB)

Answer 3

1. ) Examples - aspirin, ibuprofen, naproxen, diclofenac
   - celecoxib and etoricoxib are COX-2 selective
2. ) Mechanism - competitive inhibition of COX enzymes
   - ↓prostaglandin, prostacylin and thromboxane synthesis
3. ) COX-2 Selectivity - aspirin is least selective
   - less GI ADRs but similar renal ADRs
   - doesn’t inhibit prostacyclins, leaving TXA2 unopposed which can be bad for the CVS
4. ) Usage - pain, fever, inflammation
   - arthritis, menorrhagia, opioid sparing
   - long term usage could be prescribed with a PPI (omeprazole)
5. ) Caution
   - GI risk factors: elderly, smoking, alcohol, H. pylori
   - GI diseases: peptic ulcers, IBD
   - drugs: PPI, anticoagulants, ACEi (also ↓GFR)
6. ) Side Effects - IGRAB
   - Interactions w/ other medication e.g. warfarin
   - Gastric ulceration, Renal impairment
   - Asthma sensitivity, Bleeding risk