Self-Assessment Questions

Select the ONE BEST ANSWER from the four options listed for each question: Predictors of high postoperative pain scores and/or high opioid requirements include all of the following EXCEPT: Preoperative anxiety Pain catastrophising Older patient Presence of preoperative pain Information given to patients about opioid analgesia should include all of the following EXCEPT: The aim is to enable early restoration of good physical function The aim is to provide complete pain relief That more opioid may not be appropriate even if their pain scores are high Safe use of opioids after discharge from hospital Simple methods of opioid analgesia (for example, oral or subcutaneous (SC) injections of opioids given as needed) can be more effective if there is: Appropriate staff and patient education Provision of appropriate guidelines, policies, and monitoring Regular patient assessment and individualisation of treatment All of the above The assessment of pain in a cognitively intact patient should include all of these EXCEPT: The verbal descriptor scale for pain at rest The verbal descriptor scale for pain on movement Observation of patient behaviour Observation of patient function Signs and symptoms that suggest a patient may have acute neuropathic pain include: Pain that is dull or cramping Pain that is sharp and well localised to the area of injury Pain that appears to be responding poorly to opioids Decreased pain in response to a stimulus that is normally painful Opioid-induced ventilatory impairment (OIVI ) can lead to high carbon dioxide levels by: Depression of the respiratory centre leading to a decreased respiratory rate Depression of the central nervous system (CNS) in general leading to increasing sedation Upper airway obstruction (leading to snoring in some patients) All of the above A patient who is noticed to be snoring after being given an opioid: Should be woken to have their level of sedation checked Should be left to sleep as they are probably comfortable Should be left to sleep as they probably have sleep apnoea Should be given naloxone The most reliable clinical indicator of OIVI is: A decrease in respiratory rate Increasing sedation Increasing confusion Low oxygen saturation (SpO 2 ) levels in a patient receiving supplemental oxygen Psychological factors such as anxiety and depression are predictors of all of the following EXCEPT: Persistent postoperative opioid use High unidimensional pain scores Chronic postsurgical pain Opioid-induced ventilatory impairment Which medication given to a patient who is also receiving opioids is unlikely to increase the risk of OIVI? Pregabalin A nonsteroidal anti-inflammatory drug Promethazine (Phenergan) A benzodiazepine (for example, diazepam) Causes of low oxygen saturation levels (SpO 2 ) in the postoperative period could include all of the following EXCEPT: OIVI Postoperative changes in lung function Anaemia Sleep apnoea An oxygen saturation level (SpO 2 ) of 90% indicates a PaO 2 of approximately: 90 mmHg (12.0 kPa) 60 mmHg (8.0 kPa) 40 mmHg (5.3 kPa) 26 mmHg (3.5 kPa) A patient wakes easily when you go to give him his medications. He stays awake while you are talking to him. His sedation score is: 0 1 2 3 A patient wakes easily when you go to give him his medications, but he appears drowsy and keeps falling asleep while you are talking to him. His sedation score is: 0 1 2 3 A patient is wide awake and has been watching television all afternoon. His sedation score is: 0 1 2 3 The least effective antiemetic drug in the postoperative setting is: Aprepitant Dexamethasone Ondansetron Metoclopramide The best predictor of the amount of opioid an opioid-naïve patient is likely to need after major surgery is: Sex of the patient Age of the patient Weight of the patient Estimated lean body weight of the patient The following statements about the atypical opioid tapentadol are true EXCEPT: It has an active metabolite that is dependent on the kidney for excretion Its analgesic effect does not only depend on its action on opioid receptors It can be given to patients with mild to moderate renal impairment In equianalgesic doses, there is a lower risk of sedation than conventional opioids If an injection of morphine is given intravenously ( IV), the average time it will take for the full effect of the morphine to be seen is around: 30 seconds 1 minute 5 minutes More than 10 minutes If an injection of fentanyl is given IV, the average time it will take for the full effect of the fentanyl to be seen is around: 30 seconds 1 minute 5 minutes More than 10 minutes Morphine-6-glucuronide (M6G), a metabolite of morphine: May lead to hyperalgesia and allodynia Does not accumulate in renal failure Has analgesic activity Has a shorter half-life than morphine Codeine, a naturally occurring alkaloid of opium: Will not result in effective analgesia in over 50% of Caucasian patients Is metabolised in the liver, where it is converted into morphine Has a high affinity for the opioid receptor Is useful for the treatment of severe pain Fentanyl is a synthetic opioid that: Results in more histamine release than other opioids Has active metabolites that are excreted primarily in faeces Is very effective when administered orally Can be administered intranasally Long-term adverse effects of opioids include all of the following EXCEPT: Depression of the immune system Increased risk of falls Decreased sensitivity to pain Depression of adrenal function The following statements about the atypical opioid tramadol are true EXCEPT: Its analgesic effect is mediated only via its action on opioid receptors It produces less risk of OIVI than conventional opioids It has an active metabolite (M1) that is dependent on the kidney for excretion There is a risk of serotonin syndrome if given to patients taking selective serotonin reuptake inhibitors (SSRIs) The following statements about the atypical opioid buprenorphine are all true EXCEPT: It is used as an analgesic agent and in opioid addiction treatment programmes In case of an overdose, higher than usual doses of naloxone may be required It should be given orally and swallowed It is available as a transdermal preparation for the treatment of chronic and cancer pain A patient is taking 300 mg/day of a modified-release (MR) oral morphine preparation. On average, this would be equivalent to: 300 mg IV morphine 150 mg IV morphine 100 mg IV morphine 50 mg IV morphine MR tablets of morphine or oxycodone: Provide no better pain relief but an increased risk of side effects compared to immediate release preparations Should be ordered on an “as needed” (PRN) basis Are suitable for the rapid titration of acute pain relief Can be crushed if the patient does not like swallowing tablets If a postoperative patient's opioid dose trajectory is not decreasing as would be expected, the following should be excluded: Surgical complications Non-opioid responsive pain Psychological distress All of the above Signs and symptoms of local anaesthetic systemic toxicity (LAST) include: Drowsiness Numbness around the mouth and tongue Muscle twitching All of the above Treatment of LAST in a patient in a general ward includes: Large doses of adrenaline Use of lipid emulsions Treatment of ventricular arrhythmias with lidocaine All of the above The most common local anaesthetic associated with LAST is now: Ropivacaine Bupivacaine Lidocaine Levobupivacaine Paracetamol (acetaminophen): Should be used with caution in patients with mild-to-moderate renal impairment Can be given in doses of up to 8 g/day Has analgesic, antipyretic, and anti-inflammatory activity Should not be used in combination tablets with other drugs for acute pain Nonsteroidal antiinflammatory drugs (NSAIDs): Should be used with caution in patients with renal impairment Should not be given concurrently with paracetamol Result in fewer side effects when given by the rectal route rather than the oral route Are as effective as paracetamol for mild-moderate acute pain Nonselective NSAIDs (for example, ibuprofen and diclofenac): Do not reduce the incidence or severity of postoperative nausea and vomiting when given with opioid medications Are “opioid-sparing” Inhibit only COX-1 and not COX-2 Do not result in better pain relief when given with paracetamol Risk factors for the development of postoperative acute kidney injury in association with the use of NSAIDs include all of the following EXCEPT: Hypotension Intraoperative bleeding Concurrent administration of gentamicin Younger patient age The risk of developing gastric erosions following the use of nonselective NSAIDs is decreased by all of the following EXCEPT: Concurrent use of proton pump inhibitors (for example, omeprazole) Short-term use of the drug Avoiding use in patients with a history of gastric bleeding The use of the rectal rather than the oral route for administration of the drugs Coxibs: Are more effective analgesics than nonselective NSAIDs Have a lower risk of GI adverse effects than nonselective NSAIDs Decrease platelet function Should not be used in patients with NSAID-exacerbated respiratory disease Ketamine: Acts on N-methyl-D-aspartate (NMDA) receptors Is unhelpful in the management of acute pain in patients with opioid tolerance Increases tolerance to opioids Has a high incidence of CNS side effects when used by infusion in low doses (for example, 0.1 mg/kg/h in the average adult) Tricyclic antidepressant agents: Do not lead to sedation Are not effective for the management of neuropathic pain Act by inhibiting reuptake of noradrenaline and serotonin Are useful in the management of acute nociceptive pain Which of the following drugs are least effective in the management of neuropathic pain? Gabapentin Carbamazepine Amitriptyline Fluoxetine The gabapentinoids (pregabalin and gabapentin): Are excreted unchanged by the kidney, and dose adjustments are required in patients with renal impairment Have similar half-lives Do not cause sedation, dizziness, or visual disturbances Do not increase the risk of OIVI Nitrous oxide is sometimes used as analgesia for short painful procedures. Contraindications to the use of nitrous oxide include all of the following EXCEPT: Concurrent use of opioids Vitamin B 12 deficiency Pneumothorax Bowel obstruction Immediate-release opioids such as oxycodone, morphine, and hydromorphone are commonly used in the management of acute pain. When given orally: Their peak effect will be seen within 10–15 minutes They should only be ordered at fixed time intervals They can be given if a patient is fasting prior to elective surgery The doses used are the same as for the intramuscular (IM) dose of each opioid When morphine is given by intermittent SC injection: Absorption into the bloodstream will be slower than following an IM morphine injection Higher doses of morphine will be needed than if given by IM injection Morphine should be given in the smallest volume possible Injection must not be given more often than every four hours A 23-year-old patient is prescribed “7.5–15 mg SC morphine 1-hourly PRN” for pain relief after a laparotomy for a ruptured spleen the day before. He is wide awake and watching television. His last injection of morphine was 15 mg 90 minutes ago. He says his pain score is 9 and that he cannot cough because of the pain. He would like another injection of morphine. You would: Suggest he wait another 30 minutes Give 15 mg morphine Give 5 mg morphine Give 2.5 mg morphine A 23-year-old patient is prescribed “7.5–15 mg SC morphine 1-hourly PRN” for pain relief after a laparotomy for a ruptured spleen the day before. His last injection of morphine was 15 mg 90 minutes ago. When you wake him, he says his pain score is 9 and that he would like another injection of morphine, but his sedation score is 2. You would: Not give any more morphine until his sedation score is