++
Chapter 71. Multimodal Analgesia: Pharmacologic Interventions and Prevention of Persistent Postoperative Pain
++
++
++
A 36-year-old woman with history of Crohn’s disease is complaining of pain in the post-anesthesia recovery unit following ileocecal resection for small bowel obstruction. Which agent would be most appropriate to treat her pain symptoms?
++
++
++
A. Oral hydrocodone/acetaminophen 10/325 mg
++
++
B. Rectal acetaminophen 650 mg
++
++
C. Intravenous acetaminophen 1000 mg
++
++
D. Intravenous ketorolac 30 mg
+
++
C is correct. Intravenous acetaminophen has a rapid time to meaningful analgesia less than 30 minutes following administration.
++
A, B, and D are incorrect. An intravenous medication would be appropriate following abdominal surgery. NSAIDs can increase the risk of anastomotic leak and would best be avoided.
++
++
++
When combined with acetaminophen, which of the following substances has been proven to have a synergistic effect?
++
++
++
++
++
++
++
++
++
+
++
D is correct. The synergism between nonsteroidal antiinflammatory agents and acetaminophen is well-described.
++
A, B, and C are incorrect. There is no such description of synergism between local anesthetics, anticonvulsants, or ketamine with NSAIDs.
++
++
++
Nociceptor sensitization occurs following tissue damage and cyclooxygenase (COX) production of which ligand?
++
++
++
A. Prostaglandins (PEs) PGE1 and PGE2
++
++
B. Histamine and bradykinin
++
++
++
++
D. Calcitonin gene-related peptide
+
++
A is correct. PGE1 and PGE2 are the byproducts of cell membrane metabolism by cyclooxygenase. They are responsible for sensitizing nociceptors to painful and nonpainful stimuli.
++
B is incorrect. Bradykinin is an inflammatory mediator involved in pain signaling and can cause vasodilation. Histamine is a molecule that acts as a neurotransmitter in the central nervous system and peripherally it is involved in a number of other physiologic processes.
++
C is incorrect. Substance P is an excitatory neurotransmitter involved in the transmission of signals; it is thought to be one of the first chemicals released in response to pain.
++
D is incorrect. Calcitonin gene-related peptide is released in the dorsal horn of the spinal cord and is involved in the pain pathway.
++
++
++
Despite escalating the dose of gabapentin from 300 mg three times daily to 600 mg three times daily, a 56-year-old man fails ...