Surgery Pharm Pain Management

Question 1

Goal of perioperative pain management

Answer 1

Goal of perioperative pain management is to have the patient comfortable when they awaken from anesthesia

Question 2

Undertreated Perioperative pain Adverse Outcomes?

7

Answer 2

1. Thromboembolic complications
2. Pulmonary complications
3. Increase length of hospitalization
4. Hospital readmission for further pain management
5. Needless suffering
6. Impairment of quality of life
7. Development of chronic pain

Question 3

Adverse Outcomes of Perioperative Pain Management

10

Answer 3

1. Respiratory depression
2. Brain injury
3. Neurologic injury
4. Sedation
5. Circulatory depression
6. Nausea and vomiting
7. Pruritus
8. Urinary retention
9. Impairment of bowel function
10. Sleep disruption

Question 4

Perioperative pain management:

Must always document? 3

Answer 4

1. Pain intensity
2. The effects of pain therapy
3. Side effects caused by the therapy

Question 5

Approach to the patient: factors to consider

6

Answer 5

1. Type of surgery
2. Expected severity of postoperative pain
3. Underlying medical conditions- CVD, Pulomonary, allergies, renal or liver failure
4. Risk-benefit ratio for the available techniques
5. Patient’s preferences
6. Patient’s previous experience with pain

Question 6

Preoperative preparation of the patient

3

Answer 6

1. History
2. Physical
3. Post operative pain control plan

Question 7

Preoperative:
Prepare the patient
1. Adjust or continue meds that may provoke what?
2. Examples?

3. Treatment to reduce what?
   - Consider initiation of post operative pain management
4. Premedications before surgery?
5. Patient and family education
   - Needs to include? 3

Answer 7

1. a withdrawal syndrome
3. preexisting pain and anxiety
5. • Addiction
   • Adverse effects of meds
   • Optimal use of patient-controlled analgesia

Question 8

Perioperative techniques for pain management

3

Answer 8

1. Central regional opioid analgesia
2. Patient controlled analgesia with systemic opioids
3. Peripheral regional analgesia

Question 9

Perioperative techniques for pain management: Peripheral regional analgesia? 3

Answer 9

1. Intercostal blocks
2. Plexus blocks
3. Local anesthetic infiltration of incisions

Question 10

Central regional opioid analgesia

1. Epidural is what?
2. Intrathecal administration of analgesia is what?
3. Benefit?
4. Risks? 2

Answer 10

1. Epidural – injection outside the dura
2. Intrathecal aka spinal anesthesia – injection through the dura directly into the CSF
3. Improved pain relief when preincisional epidural or intrathecal morphine is administered compared with po, IV or IM morphine
4. • Increased pruritus and
   • urinary retention in post operative epidural anesthesia compared to IM morphine

Question 11

Intrathecal administration of opioids

1. Intrathecal: What drugs are used? 2

Answer 11

1. morphine (0.1 to 0.2 mg) or fentanyl (10 to 20 mcg)

Question 12

Intrathecal administration of opioids
1. A single dose of intrathecal opioid (morphine) can provide pain relief for up to _______ hours post operatively.

2. Onset of action?
3. Fentanyl provides pain relief for how long?
4. Onset of action?

Answer 12

1. 18-24
2. 45 minutes
3. 1 to 2 hours
4. 5-10 minutes

Question 13

Patient controlled analgesia

1. Used for?
2. Benefits? 2
3. Used for how long?
4. Which drugs can be given this way? 3
5. Fentanyl is less desirable due to what?
   - May be useful if what? 2

Answer 13

1. For moderate to severe post op pain
2. Benefits
   - Decreased delay in pt access to pain medication
   - Decreased likelihood of overdose
3. Pump usually discontinued when able to take oral meds
4. • Morphine,
   • hydromorphone and
   • fentanyl can be given via PCA
5. Short DOA
   - morphine allergy,
   - easier to use in hepatic or renal insufficiency than others

Question 14

1. Multimodal techniques for pain management is what?
2. Systemic meds used? 2
3. Central and regional meds used? 2
4. Advantage of Central or regional meds?
   - More of which SE? 2

Answer 14

1. Using 2 or more drugs that act by different mechanisms for providing analgesia
2. Systemic medications: Opioids + NSAIDs
3. • Central and regional meds: epidural + local anesthetics (Ex: fentanyl + bupivocaine administered via epidural)
4. Better pain control
   - but more muscle weakness and pruritus noted

Question 15

Systemic analgesics

-Improved pain scores and reduced analgesic use when given IV morphine + what compared to IV morphine alone?

Answer 15

ketorolac

Question 16

Systemic analgesics
1. What is more effective at decreasing pain vs. COX-2 or nonselective NSAIDs ?

2. Lower pain scores when adding what to IV opioids? 2
3. Unless contraindicated patients should receive scheduled regimen of what? 3

Answer 16

1. Ketorolac along with the PCA opioid administration
2. gabapentin or pregabalin
3. • NSAIDs,
   • COXIBs or
   • acetaminophen

Question 17

Peripheral regional techniques
1. What are they? 3

2. Preoperative nerve blocks are effective at reducing what? 2
3. Preoperative infiltration of the incision with local anesthetic decreases what?
   - Drug?

Answer 17

1. • Peripheral nerve blocks,
   • intraarticular blocks, and
   • infiltration of the incisions
2. • post operative pain and
   • decrease the need for opioid use (post operative blocks are not as helpful)
3. decreases post operative pain scores
   - (ex. Bupivicaine)

Question 18

Patients at risk for inadequate pain control

5

Answer 18

1. Pediatrics
2. Geriatrics
3. Critically ill
4. Cognitively impaired
5. Others who may have difficulty communicating

Question 19

What is the role of the PA in the management of the post surgical pt?
6

Answer 19

1. Know the patient’s history
2. Procedure performed and any complications
3. Type of anesthesia used for the case
4. Duration of the case and if that is normal for the procedure mentioned
5. What has the pt received so far, did it work, any adverse reactions and what other modalities are in play? (Epidural pain management, nerve block, etc)
6. Adjustment of opioid dose and/or initiation of acetaminophen, NSAIDs or gabapentin may be needed

Question 20

Most widely used medication for the treatment of postoperative pain?

Answer 20

Opiods

Question 21

Opiod drugs are?

3 most commonly used for post op IV pain management?

Answer 21

1. Morphine
2. Hydromorphone (Dilaudid)
3. Fentanyl
   Three most common
4. Meperidine

Question 22

Opioids:

1. Bolus injections are often used
   - Given this way they fail to provide what?
2. Continuous infusions: Risks? 2

Answer 22

1. a steady state of the drug
2. • May be dangerous due to the potential for drug build up and cause respiratory depression
   • Must be given in a highly supervised environment

Question 23

Opioid metabolism

1. All opioids are metabolized how?
   - to what?
   - Eliminated how?
2. Patients with severe liver disease will need what?

Answer 23

1. hepatically metabolized
   - to active and inactive metabolites which
   - are eliminated in the urine
2. dosage adjustments

Question 24

Morphine:
1._______ opioid

2. Onset of analgesia is what?
3. Peak when?
4. Elimination half life is what?
5. Analgesic duration of action is what?
6. IV ____ mg
7. Q ______ until pain relief or
   - adverse effects like what occur? 4

Answer 24

1. Prototypical
2. rapid
3. 1-2 hours
4. 2-3 hours
5. 4-5 hours
6. 1-3
7. 5min
   - sedation,
   - hypotension,
   - respiratory depression and
   - hypoxemia

Question 25

Morphine 1. Active metabolites eliminated where? 2. In renal insufficiency the active metabolites may accumulate and cause what? - This may manifest how? 4 3. Relatively contraindicated in what? 4. Describe its absorption?

Answer 25

1. renally 2. neurotoxicities - Myoclonus, - confusion, - coma, - death 3. severe renal disease 4. Erratic absorption from the GI tract

Question 26

Hydromorphone (Dilaudid) 1. More rapid onset of analgesia reaching peak within ____ min? 2. Half life ____ hours 3. Approximately _____ times more potent than morphine 4. Dosing?

Answer 26

1. 30 2. 2.4 3. 4-6 4. 0.2-1 mg q 2-3 hours

Question 27

Fentanyl: 1. Synthetic derivative of what? 2. Approximately ____ times more potent than morphine 3. More ______ soluble than morphine 4. Onset of action? 5. Improved penetration of the what? 6. Half life? 7. Elimination half life is what? 8. Does not release histamine and may be preferred in the presence of what? 2

Answer 27

1. morphine 2. 100 3. lipid 4. More rapid onset of action than morphine 5. blood-brain barrier 6. Shorter half life 7. 2-4 hours 8. - hemodynamic instability or - bronchospasm

Question 28

Fentanyl 1. Moderate pain dosing? 2. Mderate to severe pain dosing? 3. IV infusion for pain control in mechanically ventilated pts? 4. Administration > 5 days may lead to what?

Answer 28

1. Moderate pain: 25-50 mcg IV Q 5 min up to a max dose 2. Moderate to severe pain 50-100 mcg Q 2-5 min until pain relief 3. IV infusion for pain control in mechanically ventilated patients - 0.7-10 mcg/kg/hr 4. deposition of the drug in adipose tissue and prolonged sedation

Question 29

Meperidine 1. Indicated for what? 2. Contraindicated in patients on what? 3. Lowers what? 4. Has a ________ effect 5. Downsides? 2 6. Not used for PCA pumps because of the risk for what?

Answer 29

1. the short term management of acute pain 2. MAOIs 3. seizure threshold 4. dysphoric 5. - Not as effective as other drugs - Slower rate of metabolism in the elderly or if liver or renal failure 6. accumulation of the active metabolite

Question 30

Opioid side effects | 7

Answer 30

1. Somnolence 2. Depression of brainstem control of respiratory drive 3. Hypotension 4. Urinary retention 5. N/V 6. Slowing of GI transit - Constipation, ileus 7. Histamine release (most common after morphine)

Question 31

``` Histamine release (most common after morphine) may cause what opioid SE? 5 ```

Answer 31

1. Flushing, 2. tachycardia, 3. hypotension, 4. pruritus, 5. bronchospasm

Question 32

Transitioning from IV to oral opioids 1. Switch from IV to oral once the patient can tolerate PO - Calculate the what to determine the coverage needed? 2. PO – analgesic effects take how long? 3. Switch to one of the following? 4

Answer 32

1. 24 hour opioid consumption - Consult equianalgesic charts 2. 30-60 minutes 3. - Oxycodone, - hydrocodone, - hydromorphone, - morphine Ex: 40 mg of IV morphine given in 24 hours would require 20 mg oxycodone Q 4 hours or 5 mg of hydromorphone Q 4 hours

Question 33

Oral Opioids Classes? | 4

Answer 33

1. Oxycodone (Oxycontin)(Roxicodone) 2. Hydrocodone (Hysingla ER) (Zohydro ER) 3. Hydromorphone (Diluadid) 4. Morphine (Avinza) (Duramorph) (Kadian) (MS Contin)

Question 34

Oral Opioids Classes - Oxycodone (Oxycontin)(Roxicodone) 1. Drugs in this category? 2 2. Schedule? - Hydrocodone (Hysingla ER) (Zohydro ER) 3. Drugs in this category? 2 4. Schedule? Hydromorphone (Diluadid) 5. Schedule? 6. Morphine (Avinza) (Duramorph) (Kadian) (MS Contin) schedule?

Answer 34

1. - Oxycodone/acetaminophen (Percocet) * - Oxycodone/ibuprofen (Combunox) 2. Schedule II 3. - Hydrocodone/acetaminophen (Lortab) (Vicodin) (Norco) * - Hydrocodone/ibuprofen (Vicoprofen) 4. Schedule III 5. Schedule II 6. Schedule II

Question 35

Duration of action 1. Short-acting opioids? 1 2. Moderate Acting? 4 3. How long is the DOA of moderate acting drugs? 4. Long acting drugs? 2

Answer 35

1. Short acting - Fentanyl 2. Moderate acting - Morphine, - codeine, - hydromorphone, - oxycodone 3. DOA 4-6 hours 4. Long acting - Methadone - Long acting morphine preparations

Question 36

For patients with impaired renal function | 3

Answer 36

1. Hydromorphone and 2. oxycodone have inactive metabolites 3. Fentanyl Safer than morphine for use in renal impairment

Question 37

Opioid Reversal agent?

Answer 37

Naloxone (Narcan)

Question 38

Naloxone (Narcan) 1. Reversal of what with therapeutic opioid doses? 2. Administered how? 4 3. Dose?

Answer 38

1. respiratory depression 2. IV, IM, SubQ. endotracheally 3. Initial: 0.04 to 0.4 mg; may repeat until desired response achieved. (example 0.4 mg X 2) If desired response is not observed after 0.8 mg total, consider other causes of respiratory depression

Question 39

Non-opioid adjunctive medications | 5

Answer 39

1. NSAIDs 2. Ketamine 3. Lidocaine 4. Magnesium 5. IV acetaminophen

Question 40

Non-opioid adjunctive medications: NSAIDs 1. Advantage? 2. Caution in who? 3. Nonselective NSAIDS? 2 4. Selective NSAIDS are only available how?

Answer 40

1. Administration of NSAIDs can reduce the dose of opioid required 2. Caution with kidney impairment 3. Nonselective NSAIDs IV formulations: Ketorolac and ibuprofen 4. Selective NSAIDs No IV formulation available Sometimes just a single dose might suffice

Question 41

Non-opioid adjunctive medications: Oral NSAIDs 1. Nonselective PO or PR? 3 2. Selective? 1

Answer 41

1. - Ibuprofen 400 mg Q 4-6 hours - Diclofenac 50mg Q 8 hours - Ketoprofen 50 mg QID 2. Celecoxib (Celebrex) 400mg po X 1 then 12 hours later start 200mg po BID

Question 42

Non-opioid Adjunctive medications 1. Ketamine is in what class of drug? 2. Use limited due to? 3. Reduces what? 2

Answer 42

Ketamine 1. NMDA receptor inhibitor 2. Use limited due to hallucinations 3. Reduces - hyperalgesia and - opioid tolerance

Question 43

Acetaminophen 1. First line administration is? 2 2. Dosing? 3. May be given in addition to what? 4. Contraindicated in what?

Answer 43

1. Oral or rectal first line then can give IV 2. 325mg-1000mg PO or PR Q 4-6 hrs/max dose 4 g 3. NSAIDs 4. hepatic failure

Question 44

Non-opioid adjunctive medications Lidocaine 1. Class of drug? 2. Administered how? 3. Most effective for what? Magnesium sulfate 4. Can reduce what? 5. Class of drug? Not routinely used at this time despite many studies to show it’s effectiveness

Answer 44

1. Class I antiarrhythmic 2. IV infusion intra-op or post-op for control of pain 3. analgesia following major abdominal surgery 4. opioid requirements 5. NMDA receptor antagonist