Test 4: Multimodal Pain Assessment Flashcards
What are the Predictors of Acute Post-Op Pain? (Blue Box!)
- Pre-op Pain
- Patient fear r/t outcome
- Patients who catastrophize pain
- Expected post-op pain
Blue box!
How do you assess pain pre-op?
-Full H&P including Labs & Diagnostic tests (pt and surgery specific)
-Current pain state
-Invasiveness of procedure
-Individual’s pain response
-Identifying risk of acute post-op pain
-Pt education: Expectations for post-op pain control
What are the issues with the numerical value pain scale?
-Subjective & multidimensional
-Does not account for age or cognitive level
Why do you re-assess pain scores?
-Vigilance in pain management
-Repetitive/regular evaluation of treatment
-Change modalities as needed
What should you do if your patient is on continuous methadone therapy
1) consult with addiction specialists/clinics if indicated.
2) Consider adjuvants intraop: corticosteroids, ketamine, clonidine, dex
3) Continue ketamine or low dose ketamine infusion if started in the OR.
Patients on chronic opioid therapy (COT) are at higher risk for what post-operatively?
-COTs at risk for higher than normal levels of post-op pain, slower pain resolution, prolonger recovery.
-Patient specific perioperative pain management plan is necessary!
What should you do pre-op for your patient on methadone?
Complete H&P
-Meds, dosages, duration of therapy (if chronic pain pt)
-Full pre-operative pain assessment
Continue methadone dose throughout periop period to maintain baseline and avoid withdrawal.
Continue non-opioid meds for pain as well.
Establish rapport
Discuss regional anesthesia/anaglesia
Start Benzos & multimodal agents 1-2 hours prior to surgery
What should you do for a patient on an opioid maintenance program in the periop environment?
-Methadone dose should be confirmed with prescribing provider
-Continued throughout the periop period – maintain baseline & avoid withdrawal
-Transdermal fentanyl should remain intact. Collaborative decision to remove it – start gtt and maintain perioperatively. Equipotent morphine can be administered
-Implanted intrathecal/epidural opioids should be continued perioperatively
Why is it important to establish rapport with patients on chronic opioid therapy (COT)?
-COT pts potential for high anxiety, fear, depression
-Require reassurance that pain will be treated diligently
-Realistic expectations/outcomes should be discussed
How much more narcotic do COT patients need compared to opiate naive patients?
30-100% more
Use routine assessment skills
-HR, BP, pupil size
-RR & depth of the SV pt
What do you avoid with someone on COT?
AVOID opioid antagonists and agonist-antagonists due to risk of precipitating acute withdrawal syndrome (!!)
What should you do intra-op for the patient on COT?
-Ensure adequate baseline opioid requirements are met
-opioid rotation may be necessary
-Non-opioid adjuncts (ketamine, clonidine, dex, celebrex)
-Local anesthesia if possible
T/F: intrathecal and/or epidural opioids are adequate for baseline opioid therapy.
False; intrathecal and/or epidural opioids are NOT adequate for baseline opioid therapy.
- IV opioids should be utilized to prevent withdrawal.
What should you do post-op for a patient on COT?
-May need to contact a pain specialist
-PCA
-Local anesthetic nerve block catheter if possible
What is a PCA?
-Basal continuous infusion to replace daily opioid requirement
-Demand doses for breakthrough pain
-Wean to presurgical plan when able to take PO intake
