Perioperative Analgesia

Question 1

What aspects of pain management should be discussed with the patient prior to surgery? (5)

Answer 1

1. Patient’s pain history
2. Preferences and expectations
3. Likely impact of procedure on their pain
4. Potential benefits and risks of treatments
5. Discharge plan

Question 2

A ___________ approach using _____________ to manage postoperative pain should be offered

Answer 2

multimodal

a combination of analgesics from different classes

Question 3

Consider prescribing ____________ analgesia to ensure that the patient’s pain is managed when the effects of ______________ wears off

Answer 3

pre-emptive

local anaesthesia

Question 4

Oral _____________ should be offered before and after surgery irrespective of pain severity, with intravenous _____________ reserved for patients unable to take oral medication

Answer 4

paracetamol

paracetamol

Question 5

Oral paracetamol should be offered ________________ surgery irrespective of pain severity, with intravenous paracetamol reserved for patients unable to take oral medication

Answer 5

before and after

Question 6

Offer oral ibuprofen to manage ___________ pain of all severities, except for patients who have had surgery for a hip fracture

Answer 6

immediate postoperative (pain during the first 24 hours after surgery)

Question 7

Offer _______________ to manage immediate postoperative pain (pain during the first 24 hours after surgery) pain of all severities, except for patients who have had surgery for a hip fracture

Answer 7

oral ibuprofen

Question 8

Intravenous NSAIDs should be reserved for patients __________________; if offering intravenous NSAIDs, choose a traditional NSAID rather than a COX-2 (cyclo-oxygenase-2) inhibitor

Answer 8

unable to take oral medication

Question 9

Intravenous NSAIDs should be reserved for patients unable to take oral medication; if offering intravenous NSAIDs, choose ________________

Answer 9

A traditional NSAID rather than a COX-2 (cyclo-oxygenase-2) inhibitor

Question 10

Intramuscular injections of diclofenac sodium and ketoprofen are _____________ (frequently/rarely) used in the management of perioperative pain; they are given deep into the gluteal muscle to minimise pain and tissue damage

Answer 10

Rarely

Question 11

Suppositories of ______________ and ____________ may be effective alternatives to the parenteral use of these drugs in the management of perioperative pain.

Answer 11

diclofenac sodium

ketoprofen

Question 12

Since non-steroidal anti-inflammatory drugs (NSAIDs) do not _____________, do not _____________, and do not _______________, they may be useful alternatives or adjuncts to opioids for the relief of postoperative pain.

Answer 12

depress respiration

impair gastro-intestinal motility

cause dependence

Question 13

Opioid analgesics are now rarely used as ____________ in perioperative drug regimens; they are more likely to be administered at induction

Answer 13

premedicants; pre-operative use of opioid analgesics is generally limited to those patients who require control of existing pain.

Question 14

Pre-operative use of opioid analgesics is generally limited to those patients who require _____________.

Answer 14

control of existing pain

Question 15

An oral opioid should only be offered post-operatively if ____________________

Answer 15

immediate postoperative pain is expected to be moderate to severe

*should be given as soon as the patient can eat and drink after recovery

Question 16

If using oral opioids for the management of post-operative pain, when should they be offered?

Answer 16

As soon as the patient can eat and drink after surgery

*patients unable to take oral opioids should be offered either a patient controlled analgesia or a continuous epidural

Question 17

An oral opioid should only be offered if immediate postoperative pain is expected to be moderate to severe. Patients unable to take oral opioids should be offered either a(n) ______________ or _____________.

Answer 17

patient-controlled analgesia (PCA)

continuous epidural

Question 18

The benefit of a continuous epidural should be taken into consideration for patients who are having ___________________, are expected to have _____________, or those who have ______________.

Answer 18

major or complex open-torso surgery

severe pain

cognitive impairment

Question 19

____________ analgesics given in small doses before or with induction reduce the dose requirement of some drugs used during anaesthesia

Answer 19

Opioid

Question 20

Which drugs may be used for intra-operative analgesia? (2)

Answer 20

1. Opioids including alfentanil, fentanyl, remifentanil

2. Ketamine (unlicensed

Question 21

Alfentanil, fentanyl, and remifentanil are particularly useful for providing intra-operative analgesia because they act within _____________ and have ___________ (long/short) durations of action

Answer 21

1–2 minutes

Short

Question 22

____________, ____________, and _____________ are particularly useful for intra-operative analgesia because they act within 1–2 minutes and have short durations of action

Answer 22

Alfentanil

fentanyl

remifentanil

Question 23

The initial doses of alfentanil or fentanyl are followed either by successive _______________ or by ________________; prolonged infusions increase the ______________ of effect.

Answer 23

intravenous injections

an intravenous infusion

duration

Question 24

Repeated intra-operative doses of alfentanil or fentanyl should be given with care since the resulting _________________ can persist postoperatively and occasionally it may become apparent for the first time postoperatively when monitoring of the patient might be less intensive

Answer 24

respiratory depression

Question 25

Alfentanil, fentanyl, and remifentanil can cause ________________, particularly of the ___________ or ____________; this can be managed by the use of neuromuscular blocking drugs

Answer 25

muscle rigidity

chest wall

jaw

Question 26

Alfentanil, fentanyl, and remifentanil can cause muscle rigidity, particularly of the chest wall or jaw; this can be managed by the use of _________________

Answer 26

neuromuscular blocking drugs

Question 27

In contrast to other opioids which are metabolised in the liver, ________________ undergoes rapid metabolism by nonspecific blood and tissue esterases; its short duration of action allows prolonged administration at high dosage, without accumulation, and with little risk of residual postoperative respiratory depression

Answer 27

remifentanil

Question 28

In contrast to other opioids which are metabolised in the liver, remifentanil undergoes rapid metabolism by nonspecific blood and tissue esterases; its ___________ duration of action allows ____________ administration at high dosage, without ____________, and with little risk of residual postoperative _____________

Answer 28

Short

prolonged

accumulation

respiratory depression

Question 29

Remifentanil should not be given by _______________ intraoperatively, but it is well suited to _______________; a supplementary analgesic is given before stopping the infusion of remifentanil.

Answer 29

intravenous injection

continuous infusion

Question 30

A single dose of intravenous _____________ [unlicensed] should be considered either during or immediately after surgery to supplement other types of pain relief if, the patient’s pain is expected to be moderate to severe and an intravenous opioid alone does not provide adequate pain relief, or the patient has opioid sensitivity

Answer 30

ketamine

Question 31

A single dose of intravenous ketamine [unlicensed] should be considered either _____________ or _____________ surgery to supplement other types of pain relief if, the patient’s pain is expected to be moderate to severe and an intravenous opioid alone does not provide adequate pain relief, or the patient has opioid sensitivity

Answer 31

during

immediately after

Question 32

A single dose of intravenous ketamine [unlicensed] should be considered either during or immediately after surgery to supplement other types of pain relief if, the patient’s pain is expected to be _______________ and an intravenous opioid alone does not provide adequate pain relief, or the patient has ______________

Answer 32

moderate to severe

opioid sensitivity