Pharmacology

Question 1

Goal of Peri-Operative Pain Management

Answer 1

Have the patient comfortable when they awaken from anesthesia

Question 2

SE of Peri-Operative Pain

Answer 2

Thromboembolic complications
Pulmonary complications
Increased length of hospitalization
Hospital readmission for further pain management 
Needless suffering
Impairment of QOL
Development of chronic pain
Respiratory depression
Brain injury
Neurologic injury
Sedation
Circulatory depression
N/V
Pruritis
Urinary retention
Impairment of bowel function

Question 3

What must we always document?

Answer 3

Pain intensity
Effects of pain therapy
SE caused by therapy

Question 4

Factors to Consider When Approaching a Patient with Pain

Answer 4

Type of surgery
Expected severity of postoperative pain
Underlying medical conditions
Risk:benefit ratio for the available techniques
Patient's preferences
Patient's previous experience with pain

Question 5

How to Prepare the Patient Medication Wise for Surgery

Answer 5

Adjust/continue meds that may provoke withdrawal symptoms
Reduce anxiety & pain
Patient & family education

Question 6

Patient & Family Education Prior to Surgery

Answer 6

Addiction
Adverse effects of meds
Optimal use of PCA pump

Question 7

Perioperative Techniques for Pain Management

Answer 7

Central regional opioids analgesia
Patient controlled analgesia with systemic opioids
Peripheral regional analgesia

Question 8

Epidural Administration of analgesia

Answer 8

Injection outside of the dura

Can be placed anywhere along the spine

Question 9

Intrathecal/spinal Administration of Anesthesia

Answer 9

Injection through the dura directly into the SAF

Question 10

Benefits of Central Regional Opioid Analgesia

Answer 10

Improved pain relief when preincisional morphine is administered

Question 11

Risks of Central Regional Opioid Analgesia

Answer 11

Increased pruritus

Increase urinary retention post up

Question 12

How long can a single dose of intrathecal morphine provide pain relief for?

Answer 12

18-24 hours

Question 13

When is a PCA indicated?

Answer 13

Moderate to severe post op pain

Question 14

Benefits of PCA Pumps

Answer 14

Decreased delay in patient access to pain medication

Decreased likelihood of overdose

Question 15

When is a PCA pump discontinued?

Answer 15

When the patient can take oral medications

Question 16

What medications can be given via a PCA pump?

Answer 16

Fentanyl
Hydromorphone
Morphine

Question 17

Multiple Techniques for Pain Management

Answer 17

2+ drugs by different mechanisms
Opioid + NSAIDs
Central + regional meds

Question 18

Peripheral Regional Techniques

Answer 18

Peripheral nerve blocks
Intra-articular blocks
Infiltration of incisions

Question 19

When should a nerve block be performed?

Answer 19

Pre-operative

Question 20

Patients at Risk for Inadequate Pain Control

Answer 20

Pediatrics
Geriatrics
Critically ill
Cognitively impaired
Others with difficulty communicating

Question 21

3 Most Common IV Analgesics

Answer 21

Morphine
Hydromorphone (Dilaudid)
Fentanyl

Question 22

How must opioids be given when postoperative?

Answer 22

IV

In a highly supervised environment

Question 23

Where are all opioids metabolized?

Answer 23

Through the liver

Question 24

Morphine

Answer 24

Rapid onset
Peak: 1-2 hours
Duration: 4-5 hours
IV 1-3 mg Q 5 minutes

Question 25

SE of Morphine

Answer 25

Sedation Respiratory depression Hypoxemia

Question 26

Renal Insufficiency & Morphine

Answer 26

Active metabolites may accumulate | Neurotoxicities: myoclonus, confusion, coma, death

Question 27

Relative Contraindication of Morphine

Answer 27

Severe renal disease

Question 28

Hydromorphone (Dilaudid)

Answer 28

Onset: 30 minutes 4-6 times more potent than morphine 0.2-1 mg q 2-3 hours

Question 29

Fentanyl

Answer 29

``` 100 times more potent than morphine More lipid soluble than morphine Rapid onset Improved penetration of blood-brain barrier Shorter duration of action ```

Question 30

When is fentanyl used?

Answer 30

Moderate pain Moderate to severe pain Pain control in ventilated patients

Question 31

When is meperidine (demorol) indicated?

Answer 31

Short term management of acute pain

Question 32

Contraindications of Meperidine (Demarol)

Answer 32

MAOIs

Question 33

SE of Meperidine (Demorol)

Answer 33

Lowers seizure threshold | Dysphoric effect

Question 34

General Opioid SE

Answer 34

``` Somnolence Depression of respiratory drive Hypotension Urinary retention N/V Slowing of GI transit Histamine release ```

Question 35

Signs of Histamine Release from Opioids

Answer 35

``` Flushing Tachycardia Hypotension Pruritus Bronchospasm ```

Question 36

Oral Opioids for Post-Operation

Answer 36

Oxycodone Hydrocodone Hydropmorphone Morphine

Question 37

Most Common Oxycodone Medication

Answer 37

Oxycodone/acetaminophen (Percocet)

Question 38

Most Common Hydrocodone Medication

Answer 38

Hydrocodone/acetaminophen (Lortab or Vicodin or Norco)

Question 39

Short Acting Opioids

Answer 39

Fentanyl

Question 40

Moderate Action Opioids

Answer 40

Morphine Codeine Hydropmorphone Oxycodone

Question 41

Medications that are Safer in Renal Impairment

Answer 41

Hydromorphone Oxycodone Fentanyl

Question 42

Opioid Reversal Agent

Answer 42

Naloxone (Narcan)

Question 43

MOA of Naloxone (Narcan)

Answer 43

Reversal of respiratory depression

Question 44

Non-Opioid Adjunctive Medications

Answer 44

``` NSAIDs Ketamine Lidocaine Magnesium IV acetaminophen ```

Question 45

Why is ketamine use limited?

Answer 45

Hallucinations

Question 46

What does ketamine reduce?

Answer 46

Hyperalgesia | Opioid tolerance

Question 47

Contraindication of Acetaminophen

Answer 47

Hepatic failure

Question 48

When is lidocaine most effective?

Answer 48

After major abdominal surgery