Finals Mcq Pain Medicine

Front 1

ANZCA July 2007 [1] Which statement regarding the use of opioids for the management of acute pain is true?

A. in adults patient weight is the best predictor of opioid requirements

B. metabolism to codeine-6-glucuronide produces the analgesic effect of codeine

C. morphine produces more nausea and vomiting than pethidine

D. pethidine is superior to morphine in the management of renal colic pain

E. tramadol has a lower risk of respiratory depression than other opioids at equianalgesic doses

Back 1

ANSWER E

A. FALSE : patient's age is a better predictor than weight of opioid requirement but there is wide interindividual variability

B. FALSE :10% demethylation in liver to morphine, remainder demethylated to inactive norcodeine

C. pethidine induced more nausea and vomiting than morphine when used parenterally in the ED (level III-3) and in first 2 hours after gynaecological surgery (level II, APM 2010)

D. not proven

E. tramadol has a lower risk of respiratory depression than other opioids at equianalgesic doses - true: "Tramadol has a lower risk of respiratory depression and impairs gastrointestinal motor function less than other opioids at equianalgesic doses (U) (Level II)

Front 2

ANZCA

ANZCA April 2007 Q35

In the treatment of phantom limb pain

A. calcitonin infusion is NOT effective

B. gabapentin reduces the pain

C. intravenous lignocaine reduces the pain

D. ketamine provides long-term pain relief

E. opiates are NOT effective

Back 2

ANSWER B

A. FALSE : Calcitonin by IV infusion is effective in the treatment of acute phantom limb pain (Level II). Calcitonin may also be given subcutaneously or intranasally. It was not effective for chronic phantom limb pain (Level II).


B. TRUE : Gabapentin was effective in reducing phantom limb pain

C. FALSE : IV lignocaine has no effect on phantom pain but is effective in reducing stump pp ain (level II)

D. FALSE : Ketamine, an NMDA-receptor antagonist (see Section 4.3.2), provided short-term relief of stump and phantom limb pain. Perioperitve ketamine may orevent severe phantom limb pain

E. FALSE : multiple modal therapy inclusive of opiates.

KEY MESSAGES
1. Continuous regional blockade via nerve sheath catheters provides effective postoperative analgesia after amputation, but has no preventive effect on phantom limb pain (U) (Level II).
2. Calcitonin, morphine, ketamine, gabapentin, amitriptyline and tramadol reduce phantom limb pain (S) (Level II).
3. Sensory discrimination training and motor imagery reduce chronic phantom limb pain (S) (Level II). Examples include sensory discrimination training, mental imagery of limb movement and motor imagery.
4. Ketamine, lignocaine (lidocaine), tramadol and amitriptyline reduce stump pain (S) (Level II).
5. Perioperative epidural analgesia reduces the incidence of severe phantom limb pain (U) (Level III-2).

Front 3

ANZCA july 2007 Q69

AP18b ANZCA version [2005-Sep] Q98, [Apr07] [Jul07]

Each of the following is effective in the treatment of pain from acute herpes zoster EXCEPT

A. acyclovir

B. amitriptyline

C. carbamazepine

D. corticosteroids

E. topical aspirin

Back 3

ANSWER C

A. FALSE : Level I evidence to reduce clinical course and acute pain, but no risk reduction in developing trigeminal neurolgia

B. FALSE : early use has been shown to reduce risk by half (Level II)

C. TRUE : no role

D. FALSE : level II evidence, reduction in acute pain within 72 hours

E. FALSE : topical aspirin and lignocaine should to reduced acute pain (Level II)

Front 4

ANZCA Version [Apr07] Q72

When compared with intra-muscular or subcutaneous opioid regimens, patient controlled analgesia (PCA} with opioids

A. is equally preferred by patients

B. provides better analgesia

C. results in less opioid-related adverse effects

D. results in lower opioid consumption

E. results in shorter hospital stay

Back 4

ANSWER B

Patient-controlled analgesia
1. Intravenous opioid PCA provides better analgesia than conventional parenteral opioid regimens (S) (Level I [Cochrane review]).
2. Opioid administration by intravenous PCA leads to higher opioid consumption (R), a higher incidence of pruritus (R), and no difference in other opioid-related adverse effects (S) or hospital stay (S) compared with traditional methods of intermittent parenteral opioid administration (Level I [Cochrane review]).
3. In settings where there are high nurse-patient ratios there may be no difference in effectiveness of PCA and conventional parenteral opioid regimens (N) (Level I).
4. Patient preference for intravenous PCA is higher when compared with conventional regimens (U) (Level I).
5. The addition of ketamine to PCA morphine does not improve analgesia or reduce the incidence of opioid-related side effects (U) (Level I).
6. Iontophoretic fentanyl PCA may not be as effective as intravenous morphine PCA, with more patients withdrawing from studies because of inadequate pain relief (Level I).
7. There is little evidence that one opioid via PCA is superior to another with regards to analgesic or adverse effects in general; although on an individual patient basis, one opioid may be better tolerated than another (U) (Level II).
8. There is no analgesic benefit in adding naloxone to the PCA morphine solution; however in ultra-low doses the incidence of nausea and pruritus may be decreased (U) (Level II).
9. The addition of a background infusion to intravenous PCA does not improve pain relief or sleep, or reduce the number of PCA demands (U) (Level II).
10. Subcutaneous PCA opioids can be as effective as intravenous PCA (U) (Level II).
11. Intranasal PCA opioids can be as effective as intravenous PCA (U) (Level II).
12. The risk of respiratory depression with PCA is increased when a background infusion is used (U) (Level IV).

Front 5

AP02 [Aug91] [Mar92] [Aug93] [Aug94] [Jul98]

"Allodynia" is:

A. Pain caused by stimuli that are usually not painful

B. The 'burning' sensation of causalgia

C. Red flare with nerve damage

D. Due to reflex sympathetic dystrophy

E. Not associated with nerve damage

Back 5

ANSWER A

Allodynia is a pain due to a stimulus which does not normally provoke pain and can be either thermal or mechanical

Front 6

AP04 ANZCA version [2002-Mar] Q70, [2002-Aug] Q29, [2004-Aug] Q32, [2005-Apr] Q19 (Similar question reported in [Mar91] [Mar92] [Aug92] [Aug99] [Mar00] [Jul00])

The pain of chronic herpetic neuralgia is best controlled by

A. ipsilateral stellate ganglionectomy

B. intrathecal alcohol injection

C. analgesic drugs

D. dorsal rhizotomy

E. topical capsaicin

Back 6

ANSWER C

A - False

Stellate ganglion block is used as a treatment for CRPS. Is ALSO used in post-herpetic neuralgia, though not obviously the first or best choice.

CRPS is defined by the IASP as follows:
CRPS Diagnosis triad
* Allodynia, Hyperalgesia or pain after original injury has passed
* Oedema and vasomotor instability
* Absence of other causes

B - False.

C - Best answer

The drug of choice for post-herpetic neuralgia is controversial.

D - False. This is the treatment for intractable pain, and is not without risk. There are better and less invasive options available.

E - True but not best answer. Capsaicin has been used for treatment of post-herpetic neuralgia.


Herpes Zoster-associated pain
-reactivation of varicella-zoster virus
-dormant in DORSAL root and cranial nerve ganglia
-increased risk with increasing age and diseases and drug which impair immunity

Characteristics
-80% prodromic pain (burning, throbbing, shooting, dysaesthesia and allodynia)
-rash
-self limiting

Post-herpetic neuralgia
-pain persists > 3 months
-followed by postherpetic neuralgia

Prevention
-live attentuated VZV vaccine reduces incidence of
1. HZ infection 50%
2. PHN 65%
-recommended for all person >60 yo

Treatment
1. antiviral agents started within 72 ours of onset of herpes zoster rash accelerate the resolution of acute pain
-does not reduce the incidence of postherpatic neuralgia

2. Multimodal anaglesia with regarular paracetamol with oxycodone or tramadol as required.

3. Corticosteriods : little effect on pain intensity or skin healing

4. Anticonvulsants : single dose of gabapentin reduced acute pain intensity and aloodynia in first 6 hour
-no difference in long term

4.Amitriptyline (used in low doses for 90 days from onset of the herpes zoster rash) reduces the incidence of postherpetic neuralgia

6. Topical aspirin, topical lignocaine patch or oxycodone controlled release, provide analgesia in herpes zoster

Front 7

AP06 [1985] [1987] [Aug91] [Mar92] [Aug92] [Mar93] [Apr98] (type A)

Neurolytic lumbar sympathetic block: Confirm needle placement by:

A. Injection local anaesthetic to check effect just prior to alcohol injection

B. Nerve stimulator

C. Injection gives sensation of warmth in affected area

D. Use an image intensifier

Back 7

ANSWER D

Needle position MUST be confirmed radiographically prior to injection” – Miller 5th 2364

Front 8

Coeliac plexus block

Back 8

A coeliac plexus block is used to treat visceral pain of malignant origin,
particularly pain from carcinoma of the pancreas.

It has also been used successfully for acute & chronic pancreatitis,
or for other upper abdominal malignancies where there is a significant visceral pain component.

Indications

For relief of pain from non-pelvic intra-abdominal organs.

Acute pain - may be performed during surgery for postoperative pain relief.
Chronic pain - useful for any condition that causes chronic severe upper abdominal visceral pain - e.g. chronic pancreatitis (local anaesthetic blocks only).
Cancer pain - useful for upper abdominal organ cancer pain, and is frequently used for carcinoma of the pancreas - initial diagnostic local anaesthetic block, followed by neurolytic block.
Contraindications

Bleeding and infection risks.
Where the source of the pain is no longer being transmitted through the autonomic nerves.
It is dangerous to perform the block in the presence of a large aortic aneurysm.

Anatomy

The celiac plexus is situated retroperitoneally in the upper abdomen. It is at the level of the T12 and L1 vertebrae, anterior to the crura of the diaphragm. The celiac plexus surrounds the abdominal aorta and the celiac and superior mesenteric arteries.

Innervation

It is the main junction for autonomic nerves supplying the upper abdominal organs (liver, gall bladder, spleen, stomach, pancreas, kidneys, small bowel, and 2/3 of the large bowel). The celiac plexus proper consists of the celiac ganglia with a network of interconnecting fibers. The ganglia lie on each side of L1 (aorta lying posteriorly, pancreas anteriorly and inferior vena cava laterally).

Sympathetic supply:

Greater splanchnic nerve (T5/6 to T9/10)
Lesser splanchnic nerve (T10/11)
Least splanchnic nerve (T11/12)

The upper abdominal organs receive their parasympathetic supply from the left and right vagal trunks, which pass through the coeliac plexus but do not connect there.

Technique

The block is performed using X-ray screening, intravenous sedation, local anaesthetic infiltration of the superficial layers, with the patient in the prone position.
Intravenous fluids are required pre-block to reduce the risk of hypotension after the procedure. It normally takes two needle insertions, one on each side to block both of the coeliac ganglia, but on some occasions good spread to both sides is achieved just using one needle. The needle entry point is just below the tip of the 12th rib, and using X-ray screening in two planes, the needle is advanced until it hits the side of the L1 vertebra.

The needle is withdrawn slightly and then redirected forwards until it is in the area of the coeliac plexus, avoiding the aorta and inferior vena cava. Radio-opaque dye is injected to confirm the correct placement of the needle, and then the appropriate mixture is injected:

For non-malignant pain: 10 ml 0.5% chirocaine on each side
For malignant pain: 5 ml 6% aqueous phenol + 5 ml 0.5% chirocaine on each side

As the block causes dilatation of the upper abdominal vessels, venous pooling can occur, leading to hypotension. This can be excacerbated by pre-existing dehydration, hence the need for IV hydration before performing the block.
Complications

* Severe hypotension may result, even after unilateral block.
* Bleeding due to aorta or inferior vena cava injury by the needle.
* Intravascular injection (should be prevented by checking the needle position with radio-opaque dye).
* Upper abdominal organ puncture with abscess/cyst formation.
* Paraplegia from injecting phenol into the arteries that supply the spinal cord (prevented by checking the needle position with radio-opaque dye).
* Sexual dysfunction (injected solution spreads to the sympathetic chain bilaterally).
Intramuscular injection into the psoas muscle.
* Lumbar nerve root irritation (injected solution tracks backwards towards the lumbar plexus).

Front 9

AP07 [1986] [1987]
In the placement of a needle for a coeliac plexus block, the correct position can be ascertained by:

A. The use of lignocaine immediately prior to phenol

B. Patient reporting immediate warmth

C. Use of a nerve stimulator

D. Use of an image intensifier

Back 9

ANSWER D

Front 10

AP08b [Mar94] [Aug94]

A coeliac plexus block with alcohol may cause:

A. Hypotension

B. Abdominal pain

C. Diarrhoea

D. Paraplegia

E. Pleuritic chest pain

F. Groin pain

Back 10

ANSWER A, B, D,

* 3 common transient adverse effects
1. Local pain (96%)
2. Diarrhoea (44%)
3. Hypotension (38%)
* Other complications include
o Lower extremity weakness
o Paraplegia
o Parasthesia
o Adjacent organ puncture
o Infection
o Bleeding → retroperitoneal haematoma
o Epidural injection
o Subarachnoid injection
o Intravascular injection
o Pneumothorax
o Chylothorax

* Neurology caused by
o Direct injury to spinal cord or somatic nerves
o Spinal cord ischaemia

Front 11

AP08c ANZCA version [2001-Apr] Q37, [2002-Mar ] Q27, [2002-Aug] Q33, [2004-Aug] Q25, [2005-Apr] Q4 (Similar question reported in [Jul97] [Apr98] [Jul98] [Jul00])

Complications of coeliac plexus block include

A. hypertension

B. failure of erection

C. constipation

D. paraplegia

E. dysaesthesia along L3-4

Back 11

ANSWER D

* 3 common transient adverse effects
1. Local pain (96%)
2. Diarrhoea (44%)
3. Hypotension (38%)
* Other complications include
o Lower extremity weakness
o Paraplegia
o Parasthesia
o Adjacent organ puncture
o Infection
o Bleeding → retroperitoneal haematoma
o Epidural injection
o Subarachnoid injection
o Intravascular injection
o Pneumothorax
o Chylothorax
* Neurology caused by
o Direct injury to spinal cord or somatic nerves
o Spinal cord ischaemia

Front 12

AP08d ANZCA version [2002-Aug] Q114

Side effects or complications of coeliac plexus block using a neurolytic agent include all of
the following EXCEPT

A. hypotension

B. paraplegia

C. intestinal hypermotility

D. pneumothorax

E. retroperitoneal haematoma

Back 12

ALL TRUE

* 3 common transient adverse effects
1. Local pain (96%)
2. Diarrhoea (44%)
3. Hypotension (38%)
* Other complications include
o Lower extremity weakness
o Paraplegia
o Parasthesia
o Adjacent organ puncture
o Infection
o Bleeding → retroperitoneal haematoma
o Epidural injection
o Subarachnoid injection
o Intravascular injection
o Pneumothorax
o Chylothorax

* Neurology caused by
o Direct injury to spinal cord or somatic nerves
o Spinal cord ischaemia

Front 13

AP13 [Mar95] [Aug95] [Apr97]

With an opioid addict, which would you recommend for postop analgesia following an operation (?cholecystectomy) ?

A. Oral pentazocine

B. Pethidine 100 mg 4th hourly IMI

C. PCA 1 mg bolus, 5 minute lockout

D. PCA 2 mg bolus with background infusion

E. Oral analgesia

Back 13

ANSWER D

Front 14

AP14 [Mar95] [Apr97] [Jul97] [Jul98]

A patient with cancer pain has good analgesia with MS Contin 120 mg BD but has unmanageable nausea & vomiting and confusion. You would change the treatment to:

A. Morphine syrup 40mg q4h

B. Subcutaneous morphine 80mg over 24 hours

C. Epidural morphine 80mg over 24 hours

D. Intrathecal morphine 0.2 to 0.3 mg per 24 hours

E. An alternative opioid because the patient has developed an allergy to morphine

Back 14

ANSWER E

According to Acute Pain Management - Scientific Evidence (2nd ed, 2005):

* A - Apparently no difference with lockout period of 7 or 11 minutes (Level II)
* B - FALSE
* C - Nil benefit in routine use (Level II), useful in opiate tolerante (Level IV)
* D - Dose limits have no evidence of benefit
* E - As effective as IV Morphine PCA (Level II)

Front 15

AP15 [Mar93]

Patient Controlled Analgesia (PCA) is an analgesic technique which is particularly suited to patients with severe and prolonged pain.

Desirable features and acceptable practices include:

A. A lockout period greater than 10 minutes

B. The selection of methadone as an analgesic

C. A constant background infusion

D. Limitation of the 4 hourly dose of morphine to a maximum of 0.4 mg/kg

E. Use of the sub-cutaneous route for long term infusions

Back 15

ANSWER D

A = False. Transient or long lasting damage to peripheral nerves depending on how low the temp is. One month is more accurate. pg 996 Cousins

B = False. Unmyelinated axons blocked at a lower temp. pg 995 Cousins

C = ?

D = ? "initial local anaesthetic effect is mentioned on pg 1024 Cousins - but no mention of waiting 24hrs.

E = False. It is hypobaric, phenol is hyperbaric. pg 1024 Cousins


* Phenol in glycerin is hyperbaric
* Hypertonic saline (10%) causes severe pain on injection so inject local first.

Phenol has local anaesthetic effect so have to wait 24-36 hrs before deciding in neurolysis has been successful.

Front 16

AP17 ANZCA version [2002-Aug] Q103, [2003-Apr] Q31, [2004-Apr] Q7, [2004-Aug] Q2 (Similar question reported in [Apr97])

First-line therapy for trigeminal neuralgia is

A. carbamazepine

B. amitriptyline

C. mexilitene

D. gabapentin

E. baclofen

Back 16

ANSWER A

Trigeminal neuralgia is a neuropathic disorder characterized by episodes of intense pain in the face, originating from the trigeminal nerve.

-1 or all 3 branches of trigeminal branches may be affect
-Distribution
* V2 + V3 commonest → V3 → V2 → V1 rarest
* Usually unilateral R>L (about 3% bilateral)
-10% bilateral
-intense facial pain last from a few seconds to hours

Well established link to multiple sclerosis (MS)
* MS occurs in 2-4% of patients with Trigeminal neuralgia
* Trigeminal neuralgia diagnosed in 1-5% of MS patients

Treatment
1. Medical
-first line : carbemazepine (NNT=2.6)
-second line : baclofen, lamotrigine, phenytoin, gabapentin (NNT=3.6), valproate
-low doses of amytriptyline (NNT=2.1) is thought to be effective, [pprer side effect profile and dangerous if overdosed
-opiates

2. Surgical
-evidence is poor
-microvascular decompression resluts in longest pain releif
-percutaneous radiofrequency thermorhizotomy → 20% relief at 10 years
-glycerol injections

Front 17

AP18a ANZCA version [2003-Aug] Q107, [2005-Sep] Q26, [Mar06] Q28

Correct statements regarding trigeminal neuralgia include

A. Associated sensory loss is common.

B. lt most frequently occurs in the second or third division of the nerve (V2 or V3).

C. Oedema of the trigeminal ganglion is usually seen on a cranial CAT scan.

D. The pain is often bilateral.

E. The pain is usually described as an intense deep ache.

Back 17

ANSWER B

Trigeminal neuralgia is a neuropathic disorder characterized by episodes of intense pain in the face, originating from the trigeminal nerve.

-1 or all 3 branches of trigeminal branches may be affect
-Distribution
* V2 + V3 commonest → V3 → V2 → V1 rarest
* Usually unilateral R>L (about 3% bilateral)
-10% bilateral
-intense facial pain last from a few seconds to hours

Well established link to multiple sclerosis (MS)
* MS occurs in 2-4% of patients with Trigeminal neuralgia
* Trigeminal neuralgia diagnosed in 1-5% of MS patients

Treatment
1. Medical
-first line : carbemazepine (NNT=2.6)
-second line : baclofen, lamotrigine, phenytoin, gabapentin (NNT=3.6), valproate
-low doses of amytriptyline (NNT=2.1) is thought to be effective, [pprer side effect profile and dangerous if overdosed
-opiates

2. Surgical
-evidence is poor
-microvascular decompression resluts in longest pain releif
-percutaneous radiofrequency thermorhizotomy → 20% relief at 10 years
-glycerol injections

Front 18

AP18b ANZCA version [2005-Sep] Q98, [Apr07] [Jul07]

Each of the following is effective in the treatment of pain from acute herpes zoster EXCEPT

A. acyclovir

B. amitriptyline

C. carbamazepine

D. corticosteroids

E. topical aspirin

Back 18

ANSWER C

Treatments for acute herpes zoster pain: antivirals (treats acute and reduces PHN), analgesics (paracetamol, nsaids, opioids), topical aspirin (not oral), corticosteroids (treats acute but no effect on PHN), epidural local anaesthesia + steroids (treats acute and reduces PHN). Anticonvulsants will have no effect on acute. TCAs: no effect on acute but may reduce PHN.

Carbemazepine no place in the treatment of acute HZ infection.

Front 19

ANZCA Version [Apr 08]

Antidepressant drugs are useful in the management of all of the following conditions EXCEPT:

A. chronic back pain

B. chronic headaches

C. chronic neuropathic pain after breast surgery

D. chronic neuropathic pain after herpes zoster infection

E. trigeminal neuralgia

Back 19

ANSWER B

Front 20

ANZCA Version [Jul07]

Which of the following statements regarding the use of epidurally administered adjuvant drugs with epidural analgesia for acute postoperative pain is FALSE?

A. adrenaline added to the local anaesthetic improves thoracic epidural analgesia

B. clonidine added to epidural opioids improves analgesia

C. clonidine prolongs the effects of epidural local anaesthetics

D. ketamine added to opioid based epidural analgesia improves analgesia

E. neostigmine combined with an epidural opioid reduces the dose of opioid required

Back 20

ANSWER C

* A: True (distinction between thoracic vs lumbar epidural)

* B: True ("the addition of clonidine to PCEA with ropivacaine and morphine after total knee arthroplasty decreased opioid requirements and improved analgesia")

* C: False (most of the info about clonidine is regarding intrathecal rather than epidural, and that seems to be the distinction here. It prolongs intrathecal block, but no reference made of effect on duration of epidural, so this option is false by a process of elimination as all others are true)

* D: True ("Epidural ketamine...added to opioid-based epidual analgesia regimens improves pain relief")

* E: True ("Epidural neostigmine combined with an opioid reduces the dose of epidural opioid that is required")

Front 21

ANZCA version [Apr07]

A 60-year-old diabetic has had a below knee amputation for an ischaemic leg. He has neuropathic pain being managed with oxycodoiie 40 mg bd and paracetamol 1 g
qid. He is also on omeprazole 20 mg daily for reflux. You decide to commence gabapentin. Before deciding on a dosage regimen and commencing therapy it is most
important that you

A. cease his omeprazole

B. check his hepatic transaminase level

C. check his renal function

D. check his QT interval on a resting EGG

E. reduce his oxycodone dose

Back 21

ANSWER B

Gabapentin, pharmacology and its use in pain management.' Anaesthesia 2002 57, p 451-462 Not metabolised, no induction or inhibition of hepatic enzymes. Excreted unchanged, renal impairment will decrease clearance. Lack of clinically relevant drug interactions. Well tolerated, few adverse effects.

Need dose adjust in renal failure

Front 22

ANZCA Version [Apr07]

When compared with intra-muscular or subcutaneous opioid regimens, patient controlled analgesia (PCA} with opioids

A. is equally preferred by patients

B. provides better analgesia

C. results in less opioid-related adverse effects

D. results in lower opioid consumption

E. results in shorter hospital stay

Back 22

ANSWER B

* "IV opioid PCA provides better analgesia than conventional (IM or SC) opioid regimes."
* "no differences in opioid consumption, duration of hospital stay or opioid-related adverse effects."
* "Patient preference for IV PCA was significantly higher ... although there was no difference in patient satisfaction"

Front 23

Complex Regional Pain Syndrome

Back 23

Complex regional pain syndrome (CRPS)
-chronic neurological disorder
-characterized by disabling pain, swelling, vasomotor instability, sudomotor abnormality, and impairment of motor function
-usually developed after minor trauma or surgery

Type I : formally known as reflex sympathetic dystrophy
-no injury to nerve lesions

Type II : formally known as causalgia
-evidence of nerve lesions

Pathophysiology is poorly understood
-physiological wind up
-central nervous system sensitization (involving sympathetic NS) : upregulation of alpha-adrenergic receptors, adrenergic receptor supersensitivity, functional coupling between sympathetic effect and sensory afferent fibres
-NMDA receptor has a significant involvement
-possible immunological mechanism
-trauma related cytokine release, exaggerated neurogenic inflammation, sympathetic afferent coupling, adrenoreceptor pathology, glial cell activation, cortical reorganisation

Risk factors
-young adults
-women x3 more than men
-psychological factors: stressful life events, inadequate coping mechanisms
-trauma in 50%
-surgery involving extremities 20%
-myocardial infarction
-stroke

Progression of CRPS
1. Stage one is characterized by severe, burning pain at the site of the injury. Muscle spasm, joint stiffness, restricted mobility, rapid hair and nail growth, and vasospasm
2. Stage two (dystrophic) is characterized by more intense pain. Swelling spreads, hair growth diminishes, nails become cracked, brittle, grooved, and spotty, osteoporosis becomes severe and diffuse, joints thicken, and muscles atrophy.
3. Stage three (atrophic) is characterized by irreversible changes in the skin and bones, while the pain becomes unyielding. Marked muscle atrophy, severely limited mobility, fixed flexion deformity.
-considered irreversible by stage 3

Clinical Features
1. Sensory : allodynia, hyperalgesia, hyperesthesia, hyperpathia, hypoesthesia, pain described as deep ache to sharp stinging to burning, aggrevated by cold or anxiety, neglect of hygiene to affected limb
2. Motor : weakness, tremor, dystonia, myoclonus
3. Inflammatory/trophic : nail growth, hair growth, glossy skin, hyperkeratosis
4. Autonomic : skin color changes, sudomotor hyperhidrosis to bone-dry skin, edema, skin temperature difference of 1deg higher or lower in 42%
5. Psychological : fear, anxiety, anger, depression, coping, behavioral illness
6. Other : infection, ulcers

International Association for the Study of Pain (IASP) lists the diagnostic criteria
1. Presence of an initaiting noxious event or a cause of immobilization
2. Continuing pain, allodynia or hyperalgesia
3. Evidence of edema, changes in skin blood flow or abnormal sudomotor activity in the area of pain
4. Exclusion of an condition that would otherwise account for the degree of pain and dysfunction.
-sensitivity of 98-100% and specificity of 36-55%

No diagnostic tests however, thermography, sweat testing, x-rays, electrodiagnostics, and sympathetic blocks can be used to build up a picture of the disorder

Treatment
-multidisciplinary approach : combined physiotherapy, pharmacological and psychological therapy
-goals include pain relief, functional recovery and psychological improvement
1. Medical therapy : multimodal anaglesia, few RCTs, leaving a balanced approach
-medications :
-NSIADs
-opiods
-clonidine
-gabapentin
-tricyclic antidepressants : depression, anxiety, insomnia
-membrane-stabilizing anti-epiletic drugs : phenytoin, lamotrigine, carbemazepine
-Vitamin C : prophylatic admin reduces incidence and recurrence
-mixed reports on the efficacy of corticosteriods, ketamine, phentolamine, lignocaine, calcitonin, prazosin
-regional nerve and sympathetic ganglionic blocks : recommended to reduce pain and facilitate physiotherapy
-neuromodulation : peripheral nerve, spinal cord and thalamic stimulation using implantable stimulators
-neuroaxial infusion : epidural clonidine advocated for refractory CRPS
-neuroablative therapy : last resort, surgical, chemical or radiofrequency ablation of sympathetic ganglia

2. Physiotherapy
-desnsitization, reactivation, edema control, range of motion, strengthening, rehabilitation

3. Psychotherapy : imagery, self-hypnosis, cognitive behavioral therapy, relaxation

Front 24

Define allodynia

Back 24

Pain resulting from a stimulus which would not normally provoke pain

such as light touch of the skin

Front 25

Define hyperalgesia

Back 25

An exaggerated sense of pain disproportionate to the inciting event.

Front 26

ANZCA version [Apr 07][Jul07]

A strategy shown to reduce the incidence of severe phantom limb pain is the use of

A. continuous regional blockade using nerve sheath catheters

B. patient controlled analgesia with opioids post-op

C. perioperative ketamine

D. perioperative NSAIDs

E. spinal anaesthesia for the amputation

Back 26

ANSWER C

Ketamine bolus followed by infusion for 72 hours.

Key messages : PREVENTION

1. Perioperative epidural analgesia effective in reducing severe phantom limb pain NNT6 (Level 3)

2. Perioperative ketamine bolus prior to skin incision followed by infusion for 72 hours reduced incidence of severe phantom limb pain
-no effective with epidural ketamine

3. Perioperative gabapentin is ineffective in reducing incidence and severity of phantom limb pain

4. Continuous regional blockade via nerve sheath catheters provides effective postoperative analgesia after amputation, but has no preventive effect on phantom limb pain (U)
(Level II).

TREATMENT
1. Calcitonin intranasal or subcutaneously is effective in treating acute phantom pain but inffective for chronic phantom pain

2. Ketamine provided short-term relief from stump and phantom limb pain

3. Oral slow-release morphine and IV infusions of morphine reduced phantom limb pain

4. Gabapentin is effective in reducing phantom limb pain

5. IV lignocaine reduced stump pain but no effect on phantom pain

6. amitriptyline and tramadol provided good control of stump and phantom pain

7. Sensory discrimination training and motor imagery reduce chronic phantom limb pain.

8. Perioperative epidural analgesia reduces the incidence of severe phantom limb pain (U)
(Level III‐2).

Front 27

Define stump pain, phantom sensation and phantom limb pain

Back 27

Stump pain
-pain localised to the site of amputation
-acute : nociceptive
-chronic : neuropathic
-risk factor : severe pre-ampuation pain

Phantom sensation
-any sensory perception of the missing body part with the exclusion of pain
-almost all patients experience this
-range from vague awareness via associated paraesthesia to complete sensation including size, shape, position, temperature and movement

Phantom limb pain
-any noxious sensory phenomenon in the missing limb or organ
-estimated at 30-85% after limb amputation, usually more distally
-usually immediate
-pain is intermittent and diminises with time
-risk factors : catastrophising, intensity of preamputation pain, acute post operative pain and chemotherapy

Key messages : PREVENTION

1. Perioperative epidural analgesia effective in reducing severe phantom limb pain NNT6 (Level 3)

2. Perioperative ketamine bolus prior to skin incision followed by infusion for 72 hours reduced incidence of severe phantom limb pain
-no effective with epidural ketamine

3. Perioperative gabapentin is ineffective in reducing incidence and severity of phantom limb pain

4. Continuous regional blockade via nerve sheath catheters provides effective postoperative analgesia after amputation, but has no preventive effect on phantom limb pain (U)
(Level II).

TREATMENT
1. Calcitonin intranasal or subcutaneously is effective in treating acute phantom pain but inffective for chronic phantom pain

2. Ketamine provided short-term relief from stump and phantom limb pain

3. Oral slow-release morphine and IV infusions of morphine reduced phantom limb pain

4. Gabapentin is effective in reducing phantom limb pain

5. IV lignocaine reduced stump pain but no effect on phantom pain

6. amitriptyline and tramadol provided good control of stump and phantom pain

7. Sensory discrimination training and motor imagery reduce chronic phantom limb pain.

8. Perioperative epidural analgesia reduces the incidence of severe phantom limb pain (U)
(Level III‐2).

Front 28

AP39 [Apr07]

Which of the following strategies reduces the incidence of severe phantom limb pain?

A. NSAIDS

B. Ketamine perioperatively

C. Regional nerve catheter with local anaesthetic

D. morphine PCA

E. intravenous lignocaine

Back 28

ANSWER B

Ketamine bolus followed by infusion for 72 hours.

Key messages : PREVENTION

1. Perioperative epidural analgesia effective in reducing severe phantom limb pain NNT6 (Level 3)

2. Perioperative ketamine bolus prior to skin incision followed by infusion for 72 hours reduced incidence of severe phantom limb pain
-no effective with epidural ketamine

3. Perioperative gabapentin is ineffective in reducing incidence and severity of phantom limb pain

4. Continuous regional blockade via nerve sheath catheters provides effective postoperative analgesia after amputation, but has no preventive effect on phantom limb pain (U)
(Level II).

TREATMENT
1. Calcitonin intranasal or subcutaneously is effective in treating acute phantom pain but inffective for chronic phantom pain

2. Ketamine provided short-term relief from stump and phantom limb pain

3. Oral slow-release morphine and IV infusions of morphine reduced phantom limb pain

4. Gabapentin is effective in reducing phantom limb pain

5. IV lignocaine reduced stump pain but no effect on phantom pain

6. amitriptyline and tramadol provided good control of stump and phantom pain

7. Sensory discrimination training and motor imagery reduce chronic phantom limb pain.

8. Perioperative epidural analgesia reduces the incidence of severe phantom limb pain (U)
(Level III‐2).

Front 29

Post-thoracotomy pain syndrome

Back 29

Post-thoracotomy pain syndrome
-common chronic pain
-50% of patients post theracotomy, with 30% still experience after 5 years
-trauma to intercoastal nerves via retraction or resection of ribs
-likely partial nerve injury

Risk factors for chronic post thoractomy pain syndrome
-early post-opertive pain
-surgical approach : lateral thoracotomy >VATS
-cryoanaglesia

In the majority of patients pain is usually mild and only slightly or moderately interferes with normal daily living and is therefore treated conservatively.

Those with severe pain and disability then multidisciplinary pain management involving the pain specialist, social worker, physical therapist, and a psychologist is required.

If pain starts after a pain-free period or gets worse after an interval of relatively mild pain; tumor must be excluded.

Key messages
1. Pre-emptive epidural analgesia initiated prior to thoractomy and continued post operatively superior to IV PCA for post operative analgesia

2. No difference in chronic pain comparing pre-emptive epidural analgesia to post operative epidural analgesia

3. Low dose IV ketamine with thoracic epidural analgesia reduced severity of post thoractomy pain

4. Cryoanalgesia provides effective relief in the immediate post operative period but increases the incidence of chronic pain.

Front 30

Define chronic surgical pain and what are the risk factors?

Back 30

Chronic surgical pain is
1. pain developed after a surgical procedure
2. pain of at least 2 months
3. other causes for pain is excluded (continuing malignancy or chronic infection)
4. exclusion of pre-existing pain problem (eg.exacerbation of back pain)

RISK FACTORS
1. Preoperative
-pain, moderate to severe, lasting more than 1 month
-repeat surgery
-psychological vulnerability : catastrophising
-preoperative anxiety
-female gender
-youger age adults
-perceived level of social support
-Worker's compensation
-Genetic predisposition (possible inheritence, red hair and fair skin)
-past history of chronic pain : backache, IBS, headache, amputation

2. Intraoperative factors
-surgical approach with nerve damage
-experience of surgeon
-Repeat surgery
-Amputation : 30-50% incidence of chronic pain
-Thoracotomy : 20-30%
-Mastectomy : 30-40%
-Inguinal hernia : 10%
-Coronary bypass : 30-50%
-Caesarian section : 10%


3. Postoperative factors
-moderate to severe acute pain
-radiation therapy
-neurotoxic chemotherapy
-depression
-neuroticism
-anxiety

Front 31

Post-mastectomy pain syndrome

Back 31

Post-mastectomy pain syndrome
-common after mastectomy
-chronic pain in 30%
-neuroma : scar pain in 30%
-phantom breast sensation 20%
-phantom breast pain 1-7%
-includes numbness, paraesthesia and senstivity

Risk factors
-radiotherapy
-younger age (possibly confounded by more aggressive cancers and higher rates of reoccurance)
-pre operative breast pain
-intensity of post operative pain
-surgical
-major reconstructive surgery (Mastectomy + prosthesis, 53% → chronic pain; Mastectomy alone, 31% → chronic pain )
-intercoastal nerve injury,
-psychosocial distress

Differentials
-cancer reoccurance
-brachial plexus neuropathy from cancer or radiotherapy
-cervical radiculopathy

Prevention
1. Preincision paravertebral block reduced prevalence and intensity of pain 12 months after surgery

2. Perioperative use of gabapentin reduces risk of neuropathic pain at 6 months

3. EMLA appears to be protective.

4. Other : earlier detection, breast-conserving treatment, nerve preservation techniques

Treatment
-multidisplinary
-multimodal : anti-depressants, anticonvulsants, opioids, NMDA antagonists, mexilitine, topical lidocaine, cannabinoids, topical capsaicin, and glycine antagonist.

Front 32

AP28 ANZCA version [2001-Apr ] Q74, [2003-Apr] Q77, [2003-Aug] Q72, [2005-Apr] Q70, [Mar06]

Chronic post-operative pain

A. in a phantom limb is reduced in incidence by administration of chemotherapy

B. after thoracotomy has an incidence of approximately 50%

C. following thoracotomy does NOT have its severity predicted by the severity of acute post-operative pain

D. following mastectomy combined with implantation of a prosthesis is LESS likely to occur than following mastectomy alone

E. following cholecystectomy is MORE likely if there is a history of classic gallbladder pain pre-operatively

Back 32

ANSWER B

A - False: "Administration of chemotherapy increases the incidence of phantom limb pain."

B - True: "Long-term pain after thoracotomy, the postthoracotomy pain syndrome (PTPS), may have an incidence of more than 50%."

C - False, this is the only predictor: "The intensity of acute postoperative pain is a statistically significant predictor of post-thoracotomy pain syndrome (PTPS) (36 vs. 56% PTPS for minor vs. moderate to severe acute pain)."

D - False: "......found that mastectomy combined with implantation of a breast prosthesis yielded a higher incidence of pain (53%) than did mastectomy alone (31%)."

E - False, has not been adequately investigated "A history of classic gallbladder attack symptoms is associated with reduced risk of chronic pain and symptoms."

Front 33

AP38 ANZCA Version [2006-Mar] Q113

Correct statements regarding tricyclic antidepressant drugs used in the treatment of chronic pain include each of the following EXCEPT

A. are more effective if they have predominantly noradrenergic effects

B. block alpha-adrenergic and NMDA receptors

C. block neuronal reuptake of serotonin and noradrenaline

D. enhance descending inhibitory actions on the spinal cord

E. should be used with caution in patients with abnormalities of cardiac conduction

Back 33

ANSWER A

A: false, and therefore correct answer "It is thought by many that mixed reuptake inhibitors such as amitriptyline are more effective than selective agents, emphasising the importance of both serotonergic and noradrenergic pathways in pain perception." CCEACP article

B: true "However, their efficacy is generally thought to be related to central blockade of central nervous system (CNS) monoamine uptake, specifically serotonin and/or norepinephrine, in addition to other neurotransmitters. They may alter nociceptive processing by prolonging synaptic activity of these monoamines, thereby enhancing descending inhibitory action in the spinal cord in addition to monoaminergic effects elsewhere in the CNS. The drugs also, to varying degrees, block a number of other receptor types involved in pain processing including a-adrenergic, H1-histaminergic and N-methyl-D-aspartate (NMDA) receptors." CCEACP article

C: true (see above)

D: TRUE (see B above)

E: TRUE Side-effects (which commonly limit their use) include sedation and anticholinergic effects, particularly dry mouth. Constipation and urinary retention are less common but well documented. The drugs have a number of effects on the heart including slowing of atrioventricular and intraventricular conduction. Cardiac side-effects are important as they may preclude the use of these drugs in patients with cardiac conduction disturbances or recent infarction.

Front 34

AP36 ANZCA Version [Jul06] Q99, [Apr07]

In the treatment of phantom limb pain

A. calcitonin infusion is NOT effective

B. gabapentin reduces the pain

C. intravenous lignocaine reduces the pain

D. ketamine provides long-term pain relief

E. opiates are NOT effective

Back 34

ANSWER B

A. FALSE : calcitonin SC or intranasal is effective in treating acute phantom limb pain

B. TRUE

C. FALSE : IV lignocaine is effective for treatment of stump pain but not phantom limb pain

D. FALSE : periopertive ketamine may prevent severe phantom limb pain, but does not reduce the incidence of phantom limb pain

E. FALSE : Calcitonin, morphine, ketamine, gabapentin, amitriptyline and tramadol reduce phantom limb pain

Front 35

PN43a ANZCA Version [Jul06] Q147, [Apr07]

Which statement regarding the use of opiates for the management of acute pain is true?

A. in adults weight is the best predictor of opioid requirements

B. metabolism to codeine-6-glucuronide produces the analgesic effect of codeine

C. morphine produces more nausea and vomiting than pethidine

D. pethidine is superior to morphine in the management of renal colic pain

E. tramadol has a lower risk of respiratory depression than other opioids at equianalgesic doses

Back 35

ANSWER E

A. FALSE : age is the best predictor of opiods requirements

B. FALSE : codiene is metabolised to morphine via CYP2D6 (the main active metabolite)
-Caucasians 5-10% and Asians 2% deficient; less effective in these patients
-codeine-6-glucuronide produces some of its analgesic effect

C. False – pethidine induced more nausea and vomiting than morphine when used parenterally in the ED (level III-3) and in first 2 hours after gynaecological surgery (level II, APM 2010)

D. FALSE – not proven (level II, APM 2010)

E. TRUE

Front 36

SF84 [Apr07] Q112

Analgesic requirements during labour are reduced by each of the following except

A. Acupressure

B. Acupuncture

C. Hypnosis

D. One to one support by midwife

E. TENS

Back 36

ANSWER A

Analgesic requirements during labour are reduced by each of the following except:

* A. Acupressure - false: "Published in the Cochrane Library collection of evidence-based literature was a systematic review of complementary and alternative therapies for pain management in labor. This meta-analysis of 14 studies evaluated the efficacy of acupuncture, acupressure, audioanalgesia, aromatherapy, hypnosis, massage, and relaxation for labor analgesia. Only two therapies were found to be beneficial, acupuncture and hypnosis." (Macarthur, Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture, in Anesthesiology 2008; 108:777–85)
* B. Acupuncture - true: "Acupuncture decreases the need for analgesics" (ANZCA and FPM, Acute Pain Management: Scientific Evidence, 2E, 2005, p229)
* C. Hypnosis - true: "Hypnosis used in labour also leads to a decreased requirement for pharmacological analgesia" (ANZCA and FPM, Acute Pain Management: Scientific Evidence, 2E, 2005, p229)
* D. One to one support by midwife - true: "Continuous or one-to-one support by a midwife or trained layperson during labour reduces analgesic use" (ANZCA and FPM, Acute Pain Management: Scientific Evidence, 2E, 2005, p229)
* E. TENS - true but possibly dodgy evidence: "Randomised controlled trials provide no compelling evidence for TENS having any analgesic effect during labour. Weak positive effects in secondary (analgesic sparing) and tertiary (choosing TENS for future labours) outcomes may be due to inadequate blinding causing overestimation of treatment effects" (Carroll et al, Transcutaneous electrical nerve stimulation in labour pain: a systematic review, BJOG February 1997, Vol. 104, pp. 169-175)

Front 37

AC152 [Apr07] [Jul07]

Regarding Epidural Abcess - which is WRONG

A. Diagnosis is DEPENDENT on triad of back pain, fever, and paralysis

B. Occurs at a rate of 1:1000-3000 (OR 1:2000 - 1:5000)

C. Worse outcomes if advanced age

D. Usually gram positive cocci

E. Expectant management may be appropriate

Back 37

ANSWER A

A. Diagnosis is DEPENDENT on triad of back pain, fever, and paralysis - false and the ANSWER to CHOOSE: "The early signs and symptoms may be vague, the 'classic' triad of back pain, fever and variable neurological deficit occurred in only 13% of patients by the time of diagnosis, and contributed to diagnostic delay in 75%.

B. Occurs at a rate of 1:1000-3000 (OR 1:2000 - 1:5000) - true: "Estimating the true incidence of a rare complication from such disparate reports is not easy, but there is some suggestion that it might be of the order of 1 in 1000 in surgical, and 1 in 2000 in obstetric, patients.

C. Worse outcomes if advanced age - true: With every decade increase in age, the likelihood of poor outcome doubled, presumably due to declining health and, possibly, reduced ‘plasticity’ of the spinal cord.

D. Usually gram positive cocci - true: "In the ‘developed’ world the organisms most frequently encountered are Staphylococcus aureus (57–93% of cases), Streptococci (18%) and a variety of Gram-negative bacilli (13%).

E. Expectant management may be appropriate - true: "It might be assumed that every patient with an epidural abscess should undergo surgery, but 11% of those identified in a major review did not, and another report identified 38 such individuals in case series and reports published between 1970 and 1990... The neurological deficit was unchanged or improved in all these patients except two, who died from sepsis syndrome, suggesting that the results of medical and surgical treatment are equivalent

Front 38

AP44 ANZCA version [Jul07] Q102 [Apr08] Q7

When used for treatment of neuropathic pain, the dose of gabapentin should be modified if the patient

A. has impaired hepatic function

B. has impaired renal function

C. is also receiving amitriptyline

D. is also receiving a proton-pump inhibitor

E. is also receiving fentanyl transdermally

Back 38

ASWERB

renal impairment will decrease clearance, and dose should be reduced

Front 39

ANZCA Version [Jul07]

Which of the following statements regarding the use of epidurally administered adjuvant drugs with epidural analgesia for acute postoperative pain is FALSE?

A. adrenaline added to the local anaesthetic improves thoracic epidural analgesia

B. clonidine added to epidural opioids improves analgesia

C. clonidine prolongs the effects of epidural local anaesthetics

D. ketamine added to opioid based epidural analgesia improves analgesia

E. neostigmine combined with an epidural opioid reduces the dose of opioid required

Back 39

ANSWER C

A: True (distinction between thoracic vs lumbar epidural)

B: True ("the addition of clonidine to PCEA with ropivacaine and morphine after total knee arthroplasty decreased opioid requirements and improved analgesia")

C: False (most of the info about clonidine is regarding intrathecal rather than epidural, and that seems to be the distinction here. It prolongs intrathecal block, but no reference made of effect on duration of epidural, so this option is false by a process of elimination as all others are true)

D: True ("Epidural ketamine...added to opioid-based epidual analgesia regimens improves pain relief")

E: True ("Epidural neostigmine combined with an opioid reduces the dose of epidural opioid that is required")

Front 40

Black bank April 2009

Young man on the ward post ORIF # tib/fib. On morphine PCA, high demands/bolus given ratio, used 40mg morphine in last 2 hours (or something else high). Is a bit drowsy but has severe constant leg pain.
Next step in management

A. admit to intensive care

B. increase bolus dose morphine PCA

C. decrease lockout interval of PCA

D. organise urgent orthopaedic review

E. give more morphine until comfortable (or something else rubbish)

Back 40

ANSWER D

Concerned that this is compartment syndrome.

Front 41

Black Bank August 2009

Q36. (NEW) Pain in 3 year old, best objective tool

a. FLACC (crying limbs activity consolability)

b. Wong baker Faces pain

c. Self reporting

d. Mum reporting

e. Nurse reporting

Back 41

ANSWER ?A

Communication aids and behavioural scales such
as the modified Faces, Legs, Activity, Cry and Consolability (FLACC) scale

Key Messages for patients with special needs

1. Regular assessment of pain leads to improved acute pain management (U) (Level III‐3).

2. There is good correlation between the visual analogue and numerical rating scales (U)
(Level III‐2).

*Self‐reporting of pain should be used whenever appropriate as pain is by definition a subjective experience (U).

* Scoring should incorporate different components of pain including the functional capacity
of the patient. In the postoperative patient this should include static (rest) and dynamic (eg pain on sitting, coughing) pain (U).

* Uncontrolled or unexpected pain requires a reassessment of the diagnosis and consideration of alternative causes for the pain (eg new surgical/ medical diagnosis,
neuropathic pain) (U).
* The pain measurement tool chosen should be appropriate to the individual patient; developmental, cognitive, emotional, language and cultural factors should be considered (U).

Front 42

Black Bank August 2009

67.(NEW) Ketamine for acute pain relief

A. an appropriate dose is 0.5 -1 mg/kg

B. Midazolam does not help in unpleasant dreams / delirium

C. Morphine is contraindicated

D. Hallucinations are common

E. Subcut is better than IV

Back 42

ANSWER D

A. FALSE

* Usual dose is 0.1 - 0.3mg/kg/hour (or as an initial bolus)

B. FALSE

* Midazolam is useful

C. FALSE

* Need an opioid for best effect

D. TRUE

* Don't know about it being common, but...

E. FALSE

* S/c is not better than; but can be used instead of IV. "however SC infusion is also used, especially in palliative care, with a bioavailability (similar to IM) of approximately 90% (Clements et al, 1982)." From APMSE

Front 43

TMP-Jul10-030

Regarding post craniotomy pain:


A. Local infiltration proven to reduce long-term pain

B. Local more painful than discrete nerve blocks

C. Local infiltration more efficacious than discrete nerve blocks

D. Local infiltration more efficacious than opioid analgesia

E. Local infiltration more efficacious with clonidine included

Back 43

ANSWER A and B

Cranial Surgery Key Messages

1. 70% of patients report moderate to severe pain D1 postop
-this is contrast to belief that intracranial surgery is not painful

2. Pain is more severe after intratentorial rather than supertentorial approach

3. Non‐craniotomy neurosurgery, for example trans‐sphenoidal surgery, seems to be associated with very limited pain and minimal morphine requirements

4. Paracetamol as sole analgesic agent is ineffective

5. NSAIDs are more effective than paracetamol in reducing PCA opiods requirements but with minimal benefits in regard to pain scores

6. Morphine is more effective than codeine and tramadol for pain relief after craniotomy
(MPCA better than PRN Morphine IM)
(MPCA better than TPCA)

7. Intraoperative remifentanyl may result in increased pain and increased analgesia post op

8. Local anaesthetic infiltration of the scalp provides early analgesia after craniotomy and reduces incidence of subsequent chronic pain

9. Local infiltration was no different to nerve blocks, IV morphine or IV fentanyl

10. Nerve blocks are less painful to administer than local infiltration.

11. Clonidine does not improve analgesia

Front 44

TMP-Jul10-031 A 60 year old female is undergoing hysterectomy. Gabapentin reduces postoperative:

A. Nausea

B. Vomiting

C. Sedation

D. Pruritus

E. Constipation

Back 44

ANSWER A

Perioperative gabapentinoids (gabepentin/pregabalin) reduce postoperative pain and opiods requirements and reduce the incidence of vomiting, pruritus and urinary retention but increase the risk of sedation.

Front 45

TMP-Jul10-032

Burns dressings. The following is proven to be of analgesic benefit:

A. Morphine gel

B. Biosynthetic dressings (the answer per pain book)

C. Dexmedetomidine IV

D. Lignocaine IV

E. Cognitive/Distraction technique

Back 45

ANSWER B

Acute Burn Injury Key Messages

1. Chronic pain reported 35-60% of burn patients

2. Immediately after injury : cooling, covering, elevating and immobilising may provide analgesia
-severe pain is best achieved by titration of IV opiods
-conversation to oral opiods is possible once normal GI function has returned

3. Opiods adjuncts
a. ketamine may reduce hyperalgesia
b. clonidine is opiods sparing
c. gabapentin reduces pain, is opiod sparing following acute burns and reduced neuropathic pain

4. The use of biosynthetic dressings is associated with a decrease in time to healing and a reduction in pain during burn dressings changes

5. Short‐acting opioids such as fentanyl administered via PCA or target‐controlled infusions

6. IN fentanyl was a viable alternative to oral morphine in children for burn dressings

7. N2O, ketamine and IV lignocaine infusions have also been used to
provide analgesia for burn procedures

8. PCA with a ketamine and midazolam mixture was effective and well‐tolerated when used for
analgesia and sedation during burn dressings

9. Augmented reality techniques virtual reality or distraction techniques reduce pain during burn dressings.

Front 46

TMP-Jul10-053

Complex regional pain syndrome. What proportion of patients have motor involvement ?

A. 0 %

B. 25 %

C. 50 %

D. 75 %

E. 95 %

Back 46

ANSWER D


Motor / trophic changes

- motor dysfunction 57-98%

- weakness 75-95%

- limited range of movement 80-88%

- incoordination 47%

- tremor 48%

- spasm 13%

- dystonia 14%

- myoclonus 4-20%