Perioperative Pain Management

Question 1

what is anesthesia?

Answer 1

a lack of feeling or sensation; a state of unconsciousness

1. analgesia - pain relief
2. amnesia - loss of memory
3. immobilization

Question 2

What are the four types of anesthesia?

Answer 2

1. local - numbs small area of the body
2. conscious or IV sedation (“twilight”)- mild sedative and pain meds
3. regional - block for pain in the area of the body
4. general - affects whole body - asleep and no memory

Question 3

what is a key side effect of sedatives?

Answer 3

respiratory depression

esp. in people with COPD

Question 4

what are some commonly used sedatives?

Answer 4

diazepam - longer-acting. not good for procedures that are short or in patients with liver problems

lorazepam - intermediate (good for hepatic/renal)

midazolam - fast-acting (amnesia good)

Question 5

what is chronic pain?

Answer 5

pain of 3-6 months or more or beyond the expected period of healing

Question 6

what are some important consequences of pain>

Answer 6

• release of stress hormones increases cardiac work
• increased sympathetic activity decreases intestinal motility
• decreased insulin release caues hyperglycemia and poor wound healing
• muscle splinting in abdomen/chest causes decreased VC and decreased alevolar ventilation
• hyperalgesia - sensitization of pain receptors (allodynia)

Question 7

what can you give with opiods to reduce side effects?

Answer 7

metocloperimide (reglan)

ondansetron (Zofran)

Movantik - constipation

diphenhydramine - pruritis

Question 8

what drug is to be avoided in PCA pumps?

Answer 8

meperidine > 48 hours due to CNS toxicity (seizures)

Question 9

when are changing in doses indicated with PCA

Answer 9

if the patient is getting >3-4 doses per hour and pain is not controlled, upward titration of 25-50% is indicated

Question 10

in whom do you want to decrease starting PCA doses?

Answer 10

elderly

hepatic/renal disease

pulmonary compromise

obesity

OSA

Question 11

what should the basal rate be in acute pain? in chronic/cancer pain?

Answer 11

1/3 acute

2/3 chronic or cancer

Question 12

how do you wean opiods?

Answer 12

• goal is to decrease daily medication regimen by 10-25% of the total every visit
• ER/LA formulations can be reduced 20-50% at a time, but then may have to supplement with short-acting/BTP medications

Question 13

how does TENS work?

Answer 13

involves excitation of the A beta sensory fibers, which reduces transmission of the noxious stimulus through the c fibers

Question 14

what are absolute contraindications to neuraxial blockade?

Answer 14

uncorrected hypovolemia

raised ICP

coagulopathy

infection at the insertion site

Question 15

what are the advantages of neuraxial anesthesia?

Answer 15

• superior to IV PCA in OPEN abdominal procedures
• reduce incidence of paralytic ileus
• blunts surgical stress response
• reduces systemic opiod requirements
• facilitates early oral intake, mobilization, and return of bowel fxn

Question 16

how do you discontinue PCA?

Answer 16

• when GI function is restored and morpheine is 50 mg or less
• first dose of PO analgesic given while still on pump
• once oral ER/LA is administered allow PCA access for another 18-24 hours
• 3/4 with ER/LA agent 1/4 with BTP