Surgery EOR--Pain Medicine and Anesthesia

How is acute pain defined?

Sudden onset of discomfort, often associated with surgery, trauma, or acute medical conditions, typically lasting less than 3 months.

How is chronic pain defined?

Pain lasting longer than 3 to 6 months, persisting beyond normal tissue healing time, and often resistant to conventional treatments.

What are the main etiological factors of acute pain?

Combination of tissue trauma, local/systemic inflammation, and direct nerve injury.

What are common risk factors for acute pain?

Medical and psychological conditions

Concomitant medications

History of chronic pain

Substance use disorder

Previous postoperative treatment regimens

What factors contribute to chronic pain?

A combination of biological, psychological, and social factors.

What are the two main types of chronic pain?

Nociceptive pain (tissue damage) and neuropathic pain (nerve damage).

What are the characteristics of nociceptive pain?

Involves inflammatory, ischemic, infectious, or mechanical/compressive injury.

What are the characteristics of neuropathic pain?

Results from central and/or peripheral nerve disorders.

What are common symptoms of acute pain?

Sharp, stabbing, throbbing, burning pain in the affected area.

What are common physical signs of acute pain?

Guarding

Facial grimacing or frowning

Moaning or groaning

Restlessness or agitation

Sweating

What are common symptoms of chronic pain?

Persistent pain with varying intensity, often accompanied by functional limitations, mood disturbances, and sleep disruption.

How does somatic pain present?

Localized pain that worsens with movement.

What are common symptoms of neuropathic pain?

Tingling

Pins and needles sensation

Burning

Shooting/electric shock-like pain

Allodynia (pain from non-painful stimuli)

Hyperalgesia (increased sensitivity to pain)

What tool should be used to assess and track pain management effectiveness?

A validated pain assessment tool

Why is postoperative pain management important?

It facilitates recovery, improves mobility, and reduces complications like atelectasis and deep vein thrombosis (DVT).

What are nonpharmacologic treatments for acute pain

Patient education, compression, elevation, ice/heat as indicated.

What are first-line pharmacologic treatments for acute pain?

Nonopioid analgesics: Acetaminophen, NSAIDs, local anesthetic wound infiltration, regional anesthesia.

How is moderate acute pain treated?

Gabapentinoids, ketamine, lidocaine infusions, and opioids as needed.

How is severe acute pain treated?

Gabapentinoids, ketamine, lidocaine infusions, opioids (scheduled or as needed).

What are nonpharmacologic therapies for chronic pain?

Exercise, PT, ice/heat, TENS, massage, sleep hygiene, CBT, lifestyle modifications, acupuncture, spinal cord stimulation, nerve blocks, or targeted surgeries.

How is nociceptive chronic pain treated?

NSAIDs, acetaminophen, topical agents, and opioids if insufficient.

How is neuropathic chronic pain treated?

TCAs, SNRIs, gabapentinoids; acetaminophen, topical agents, or opioids if refractory.

What role does psychological support play in chronic pain management?

CBT, biofeedback, and pain specialists are often integral in managing chronic pain.

What is an important consideration in pain management over time?

Adjust the pain management plan based on adequacy of pain relief and adverse events.

What is the maximum daily dose of acetaminophen?

4 g/day

What are the indications for acetaminophen?

Preoperative, intraoperative, or postoperative pain

What is a major caution when using acetaminophen?

Avoid in patients with active liver disease

Name three common NSAIDs and their dosing schedules.

Ibuprofen: 600–800 mg PO q4–6 h

Celecoxib: 200 mg PO q12 h

Naproxen: 250–500 mg PO q12 h

What are the key cautions for NSAID use?

Use with caution in patients with renal dysfunction, cardiovascular disease, or peptic ulcer disease

What are the two gabapentinoids used for pain management?

Pregabalin and Gabapentin

What is a key safety concern with gabapentinoids when combined with opioids?

Increased risk of respiratory depression

What is the primary intraoperative use of ketamine?

Provides analgesia and reduces opioid requirements

What medication can be added to ketamine to mitigate adverse effects

Clonidine

100 mg of tramadol is equivalent to how much morphine?

10 mg morphine

What is the morphine equivalent for 10 mg of oxycodone?

15 mg morphine

What is the conversion ratio of fentanyl patches to oral morphine?

25 mcg/hr fentanyl patch ≈ 60 mg oral morphine per day

Why does methadone require ECG monitoring?

Risk of QTc prolongation

What opioid has a ceiling effect on respiratory depression?

Buprenorphine

What is the immediate-release dosing for oxycodone?

5-10 mg PO q3-4 h

What is a major caution for oxycodone use?

Dose adjust in kidney/liver disease, avoid abrupt discontinuation

What is the IV dosing of hydromorphone for breakthrough pain?

0.2-0.5 mg IV q15 min

Which opioid is commonly used for opioid dependence treatment?

Methadone

Why should fentanyl patches be avoided in opioid-naïve patients?

High risk of overdose and respiratory depression

Name two common preoperative findings in patients with SUD.

Delayed presentation for care

Signs of intoxication or withdrawal

What are two key perioperative concerns for patients with SUD?

Increased anesthetic risks due to altered drug metabolism

Higher likelihood of infection and wound healing complications

What screening tool is used for alcohol use disorder?

CAGE questionnaire

Name one lab test important for chronic alcohol use assessment.

Liver function tests

What medication can help prevent opioid withdrawal in surgical patients with opioid use disorder?

Methadone

What is a critical step in long-term management of SUD patients postoperatively?

Referral to treatment programs and psychiatric care

What are the symptoms of ethanol toxicity?

CNS depression, ataxia, dysarthria, odor of ethanol

How do you treat ethanol toxicity?

Give time to wear off; benzodiazepine (lorazepam) if needed

What substances can cause anticholinergic toxicity?

Atropine, antihistamines, antipsychotics

What is the classic mnemonic for anticholinergic toxicity symptoms?

"Mad as a hatter, blind as a bat, red as a beet, hot as a hare, dry as a bone"

How do you treat severe anticholinergic toxicity?

Sedate with benzodiazepine; physostigmine if severe

What are common causes of cholinergic toxicity?

Organophosphates, carbamate insecticides

What are the symptoms of cholinergic toxicity?

Diaphoresis, defecation, urination, miosis/mydriasis, bradycardia

What is the antidote for cholinergic toxicity?

Atropine

What substances cause opioid toxicity?

Heroin, morphine, codeine

What are the key symptoms of opioid overdose?

CNS depression, respiratory depression, bradycardia, miosis, hypothermia

What is the antidote for opioid overdose?

Naloxone

What substances cause hallucinogenic toxicity?

LSD, psilocybin, mescaline

What are the symptoms of hallucinogen intoxication?

Hallucinations, dysphoria, anxiety

How do you manage agitation from hallucinogens?

Benzodiazepines

What substances cause sympathomimetic toxicity?

Amphetamines, cocaine

What are the symptoms of sympathomimetic overdose?

Agitation, tachycardia, hypertension, hyperpyrexia, diaphoresis, seizures, acute coronary syndrome

How do you treat sympathomimetic toxicity?

Benzodiazepines; avoid beta-blockers

What substances cause sedative/hypnotic toxicity?

Benzodiazepines, barbiturates

What are the symptoms of sedative overdose?

CNS depression, ataxia, respiratory depression

How do you treat sedative overdose?

Taper; flumazenil for benzodiazepines

What substances can cause NMS?

Antipsychotics

What are the symptoms of NMS?

Lead-pipe muscle rigidity, bradyreflexia, hyperpyrexia, altered mental status, autonomic instability, diaphoresis, mutism, incontinence

What is the treatment for NMS?

Supportive care, cooling

What substances cause hypoglycemia?

Sulfonylureas, insulin

What are the symptoms of hypoglycemia?

Altered mental status, diaphoresis, tachycardia

How do you treat hypoglycemia?

Administer glucose

What substances cause salicylate toxicity?

Aspirin, oil of wintergreen

What are the symptoms of salicylate overdose?

Altered mental status, tinnitus, metabolic acidosis, tachycardia

What is the treatment for salicylate overdose?

Dextrose in LR/NS; correct potassium deficits

What substances cause serotonin syndrome?

SSRIs, MAOIs, amphetamines

What are the symptoms of serotonin syndrome?

Altered mental status, hyperreflexia, hypertension

What is the treatment for serotonin syndrome?

Cyproheptadine

What patient history factors increase anesthesia risk?

Chronic pain, opioid use, comorbidities (cardiovascular, pulmonary, renal diseases), psychological factors (anxiety, depression).

What are key physical exam components in anesthesia risk assessment?

ASA classification, airway assessment (Mallampati score, neck mobility), cardiopulmonary status, neurologic evaluation.

What laboratory and imaging studies are useful for preoperative risk assessment?

ECG, chest X-ray (CV/pulmonary disease), coagulation profile (on anticoagulants), renal function tests (medication dosing).

How does obesity or liver disease affect drug metabolism?

Can alter drug clearance and necessitate dose adjustments.

What anesthesia techniques help reduce systemic opioid use?

Nerve blocks and neuraxial techniques (epidurals, spinals).

What are key monitoring parameters during surgery?

Vital signs, end-tidal CO₂, oxygen saturation, advanced hemodynamic monitoring in high-risk patients.

What anesthetic agents can be used as opioid alternatives for pain control?

Dexmedetomidine, ketamine.

What is the preferred pain management strategy postoperatively?

Multimodal analgesia with opioids reserved for breakthrough pain.

What complications should be monitored postoperatively?

Respiratory depression (especially in sleep apnea patients), PONV, urinary retention, delirium.

What protocols enhance postoperative recovery?

Enhanced Recovery After Surgery (ERAS) protocols.

What are signs of respiratory depression and how is it managed?

Decreased respiratory rate, hypoxia; managed with oxygen and monitoring.

What cardiovascular events can occur due to anesthesia?

Hypotension, arrhythmias.

What is malignant hyperthermia, and how is it treated?

A life-threatening hypermetabolic state triggered by anesthetics; treated with dantrolene.

What are common opioid-related side effects?

Nausea, vomiting, constipation, tolerance.

How is neuropathic pain managed postoperatively?

With gabapentinoids or tricyclic antidepressants.

How does multimodal analgesia improve pain control?

Reduces opioid use and associated side effects.

Why is patient communication about pain expectations important?

Why is patient communication about pain expectations important?

How does continuous monitoring during and after surgery improve outcomes?

Prevents severe anesthesia-related complications.

What is the ASA Physical Status Classification System used for?

It is a standardized method used to assess a patient's overall health status before anesthesia and surgery, helping predict perioperative risks.