Week Two: Analgesia Quiz
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DCLissa17
May 11, 2011, 4:27:56 AM5/11/11
to ACCES Study Group
Week One participants: Linda Ness and Melissa Hoemann
Here is the quiz on Analgesia that was given out at the Tuesday study
group and served as our talking points for the evening:
ACCES Study Group - Week Two: Analgesia
Analgesia Quiz
1. Which of the following analgesia options will not prevent windup
from occuring?
A. Administering an epidural pre-op to a hindlimb amputation patient
B. Applying a Fentanyl patch immediately after surgery
C. Giving subsequent doses of analgesics before the expected duration
of action ends on previous doses
D. Using a morphine/ketamine CRI intra-operatively
Correct answer: B. Applying a Fentanyl patch immediately after
surgery. Wind up is a phenomenon whereby stimulation of the NMDA
receptors in the spinal cord causes pain and prolonged bombardment of
these receptors (such as during surgical manipulation or chronic pain)
results in amplification of the signals. Hyperalgesia results, a
condition where spinal neurons are more easily stimulated by lower
levels of stimulation. Then allodynia follows, a state where even non-
painful stimulus is perceived as painful. This is collectively termed
windup. It is most evident at the end of anesthesia when a patient
regains consciousness if appropriate analgesia was not provided pre-
or intra-op and during the immediate post-operative period. Ketamine
is a NMDA antagonist so it is very good at counteracting and
preventing wind-up when combined with another analgesic such as an
opioid. Fentanyl patches have a delayed onset of action (6-24 hours)
so applying one in the post-operative period will provide no analgesic
effect or prevention of windup.
2. Which analgesic will be most suitable for a patient with severe
pancreatitis?
A. Fentanyl
B. Rimadyl
C. Butorphanol
D. Dexmedetomidine
Correct answer: A. Fentanyl. Fentanyl is one of the most potent
analgesics available and is excellent for severe visceral pain. It can
be provided as a patch (most effective for post-operative management)
or a CRI which is easily titrated depending on patient response and
pain level. Rimadyl is an NSAID and a good component of multimodal
analgesia, though not appropriate for a pancreatitis patient.
Butorphanol is only good for mild pain. Dexmedetomidine can be a good
additional to an opioid when administered at a low-dose CRI but by
itself does not provide sufficient analgesia.
3. What is the onset and duration of action for an IV injection of
buprenorphine?
A. 1-2 minutes, 2-4 hours
B. 1-2 minutes, 6-12 hours
C. 15-30 minutes, 4-8 hours
D. 15-30 minutes, 6-12 hours
Correct answer: D. 15-30 minutes, 6-12 hours. Buprenorphine is a
partial agonist and stimulates the mu receptors only. It avidly binds
to the mu receptors and partially stimulates them. It has a delayed
onset of action, and it has an extended duration of action because it
has slow dissociation from the receptors. Due to the fact that it only
partially stimulates the receptors, it does not provide as high of
analgesia as pure agonists such as morphine and is only good for mild-
moderate pain, not severe pain.
4. A patient has a Fentanyl patch placed to provide analgesia but is
having strikethrough pain. Which additional analgesic should be
avoided as it may partially reverse the action of the Fentanyl?
A. Hydromorphone
B. Dexmedetomidine
C. Metacam
D. Buprenorphine
Correct answer: D. Buprenorphine. Because buprenorphine so avidly
binds to the mu receptors, it can be used to partially reverse the
effects of other agonists such as Fentanyl. Therefore, if additional
pain control is needed for a patient on an agonist, buprenorphine
should not be used. Because of the avid binding, it can be very
difficult to override the buprenorphine by giving additional opioids
if needed.
5. Your patient is experiencing severe dysphoria after administration
of oxymorphone - panting, vocalization, thrashing. It is desired to
reverse the effects of the oxymorphone and yet keep some analgesic
activity. What drug will best accomplish this goal?
A. Acepromazine
B. Naloxone
C. Atipamezole
D. Butorphanol
Correct answer: D. Butorphanol. Butorphonal is a agonist/antagonist
and as such, can partially reverse the effects of agonists such as
oxymorphone. The analgesic effect will also be partially reversed,
though butorphanol will provide some analgesia of its own. Naloxone
will also reverse the effects of oxymorphone, but it may fully reverse
the analgesic effect also, leading to more of the same symptoms, but
from pain. Butorphanol CAN be overridden by giving high doses of
agonists.
6. Which analgesic when given rapidly IV can cause a histamine release
resulting in an abrupt drop of blood pressure?
A. Lidocaine
B. Morphine
C. Propofol
D. Fentanyl
Correct answer: B. Morphine. Morphine if given rapidly as an IV bolus
to dogs, can cause a release of histamine which leads to a drop in
blood pressure, pruritis, and flushing. Careful IV administration can
be performed by slow titration of the injection over 5 minutes. It
should never be given IV to cats.
7. When talking about buprenorphine, what does the term "ceiling
effect" mean?
A. The maximum safe dosage
B. A description of the possible side effect of hyperexcitability,
ie. "that cat just hit the ceiling!"
C. The fact that buprenorphine has a limited effect for severe pain
D. A phenomenon where at a certain point, higher doses do not provide
additional analgesia and may actually provide less than at a lower
dose.
Correct answer: D. A phenomenon where at a certain point, higher doses
do not provide additional analgesia and may actually provide less than
at a lower dose.
8. Which of the following does not characterize a patient in pain?
A. A cat who is lying in the back of a kennel, acts depressed,
reluctant to get into litter box
B. A dog with increased heartrate and blood pressure, who is panting
C. A cat meowing at the front of the cage who will only eat when
someone is petting him
D. A dog who is licking compulsively at his bandage and flinches when
touched
Correct answer: C. A cat meowing at the front of the cage who will
only eat when someone is petting him. This patient is looking for
affection and is not experiencing pain.
9. All of the following are characteristic of NSAIDs except:
A. Decrease musculoskeletal pain
B. Antipyretic
C. Inhibit prostaglandin synthesis
D. Can be reversed with naloxone or buprenorphine
Correct answer: D. Can be reversed with naloxone or buprenorphine.
NSAIDs have no reversal agents so care must be taken with dosing and
and overdoses.
10. Which is the most accurate description of the potential side
effects of NSAIDs?
A. vomiting, panting, cardiac arrhythmias
B. respiratory depression, hypotension
C. GI ulceration, platelet inhibition, decreased renal perfusion
D. liver disease, hyperexcitability, bladder stones
Correct answer: C. GI ulceration, platelet inhibition, decreased renal
perfusion. Other side effects include: liver disease, vomiting, GI
bleeding, inappetance, diarrhea, gastrointestinal perforation
(ulcers), and acute renal failure
11. A dog has a severe laceration on his shoulder that needs to be
repaired. It is desired to provide local anesthesia in additional to
systemic anesthetics/analgesics. Which would be the most appropriate
choice?
A. A ring block of the area with bupivicaine
B. An epidural with morphine/lidocaine
C. A line block with lidocaine
D. A line block with morphine/bupivicaine
Correct answer: C. A line block with lidocaine. Lidocaine is excellent
for superficial and topical analgesia, while bupivicaine is excellent
for infiltration. A ring block describes a circumferential block of a
limb, such as for a declaw surgery. An epidural will provide analgesia
to the caudal half of the body, good for hind limb orthopedic
surgery.
12. Which category of drugs does Ketamine belong to?
A. Alpha2-agonist
B. Pure agonist
C. NMDA antagonist
D. Agonist-antagonist
Correct answer: C. NMDA antagonist. Alpha2-agonists include
dexmedetomidine, pure agonists are opioids such a hydromorphone, and
an agonist-antagonist is butorphanol.
13. Multimodal analgesia is:
A. Administration of different classes of analgesic drugs in the
same patient
B. Administration of one analgesic drug in several different ways in
the same patient
C. Using different drug protocols for each patient even if they are
having the same procedure
D. Accomplished by keeping the patient anesthetized for a period
after a surgical procedure
Correct answer: A. Administration of different classes of analgesic
drugs in the same patient. An example of this is a TPLO patient. He
may be given an epidural with morphine/bupivicaine, systemic analgesia
with hydromorphone, and an NSAID injection of metacam.
Here is the quiz on Analgesia that was given out at the Tuesday study
group and served as our talking points for the evening:
ACCES Study Group - Week Two: Analgesia
Analgesia Quiz
1. Which of the following analgesia options will not prevent windup
from occuring?
A. Administering an epidural pre-op to a hindlimb amputation patient
B. Applying a Fentanyl patch immediately after surgery
C. Giving subsequent doses of analgesics before the expected duration
of action ends on previous doses
D. Using a morphine/ketamine CRI intra-operatively
Correct answer: B. Applying a Fentanyl patch immediately after
surgery. Wind up is a phenomenon whereby stimulation of the NMDA
receptors in the spinal cord causes pain and prolonged bombardment of
these receptors (such as during surgical manipulation or chronic pain)
results in amplification of the signals. Hyperalgesia results, a
condition where spinal neurons are more easily stimulated by lower
levels of stimulation. Then allodynia follows, a state where even non-
painful stimulus is perceived as painful. This is collectively termed
windup. It is most evident at the end of anesthesia when a patient
regains consciousness if appropriate analgesia was not provided pre-
or intra-op and during the immediate post-operative period. Ketamine
is a NMDA antagonist so it is very good at counteracting and
preventing wind-up when combined with another analgesic such as an
opioid. Fentanyl patches have a delayed onset of action (6-24 hours)
so applying one in the post-operative period will provide no analgesic
effect or prevention of windup.
2. Which analgesic will be most suitable for a patient with severe
pancreatitis?
A. Fentanyl
B. Rimadyl
C. Butorphanol
D. Dexmedetomidine
Correct answer: A. Fentanyl. Fentanyl is one of the most potent
analgesics available and is excellent for severe visceral pain. It can
be provided as a patch (most effective for post-operative management)
or a CRI which is easily titrated depending on patient response and
pain level. Rimadyl is an NSAID and a good component of multimodal
analgesia, though not appropriate for a pancreatitis patient.
Butorphanol is only good for mild pain. Dexmedetomidine can be a good
additional to an opioid when administered at a low-dose CRI but by
itself does not provide sufficient analgesia.
3. What is the onset and duration of action for an IV injection of
buprenorphine?
A. 1-2 minutes, 2-4 hours
B. 1-2 minutes, 6-12 hours
C. 15-30 minutes, 4-8 hours
D. 15-30 minutes, 6-12 hours
Correct answer: D. 15-30 minutes, 6-12 hours. Buprenorphine is a
partial agonist and stimulates the mu receptors only. It avidly binds
to the mu receptors and partially stimulates them. It has a delayed
onset of action, and it has an extended duration of action because it
has slow dissociation from the receptors. Due to the fact that it only
partially stimulates the receptors, it does not provide as high of
analgesia as pure agonists such as morphine and is only good for mild-
moderate pain, not severe pain.
4. A patient has a Fentanyl patch placed to provide analgesia but is
having strikethrough pain. Which additional analgesic should be
avoided as it may partially reverse the action of the Fentanyl?
A. Hydromorphone
B. Dexmedetomidine
C. Metacam
D. Buprenorphine
Correct answer: D. Buprenorphine. Because buprenorphine so avidly
binds to the mu receptors, it can be used to partially reverse the
effects of other agonists such as Fentanyl. Therefore, if additional
pain control is needed for a patient on an agonist, buprenorphine
should not be used. Because of the avid binding, it can be very
difficult to override the buprenorphine by giving additional opioids
if needed.
5. Your patient is experiencing severe dysphoria after administration
of oxymorphone - panting, vocalization, thrashing. It is desired to
reverse the effects of the oxymorphone and yet keep some analgesic
activity. What drug will best accomplish this goal?
A. Acepromazine
B. Naloxone
C. Atipamezole
D. Butorphanol
Correct answer: D. Butorphanol. Butorphonal is a agonist/antagonist
and as such, can partially reverse the effects of agonists such as
oxymorphone. The analgesic effect will also be partially reversed,
though butorphanol will provide some analgesia of its own. Naloxone
will also reverse the effects of oxymorphone, but it may fully reverse
the analgesic effect also, leading to more of the same symptoms, but
from pain. Butorphanol CAN be overridden by giving high doses of
agonists.
6. Which analgesic when given rapidly IV can cause a histamine release
resulting in an abrupt drop of blood pressure?
A. Lidocaine
B. Morphine
C. Propofol
D. Fentanyl
Correct answer: B. Morphine. Morphine if given rapidly as an IV bolus
to dogs, can cause a release of histamine which leads to a drop in
blood pressure, pruritis, and flushing. Careful IV administration can
be performed by slow titration of the injection over 5 minutes. It
should never be given IV to cats.
7. When talking about buprenorphine, what does the term "ceiling
effect" mean?
A. The maximum safe dosage
B. A description of the possible side effect of hyperexcitability,
ie. "that cat just hit the ceiling!"
C. The fact that buprenorphine has a limited effect for severe pain
D. A phenomenon where at a certain point, higher doses do not provide
additional analgesia and may actually provide less than at a lower
dose.
Correct answer: D. A phenomenon where at a certain point, higher doses
do not provide additional analgesia and may actually provide less than
at a lower dose.
8. Which of the following does not characterize a patient in pain?
A. A cat who is lying in the back of a kennel, acts depressed,
reluctant to get into litter box
B. A dog with increased heartrate and blood pressure, who is panting
C. A cat meowing at the front of the cage who will only eat when
someone is petting him
D. A dog who is licking compulsively at his bandage and flinches when
touched
Correct answer: C. A cat meowing at the front of the cage who will
only eat when someone is petting him. This patient is looking for
affection and is not experiencing pain.
9. All of the following are characteristic of NSAIDs except:
A. Decrease musculoskeletal pain
B. Antipyretic
C. Inhibit prostaglandin synthesis
D. Can be reversed with naloxone or buprenorphine
Correct answer: D. Can be reversed with naloxone or buprenorphine.
NSAIDs have no reversal agents so care must be taken with dosing and
and overdoses.
10. Which is the most accurate description of the potential side
effects of NSAIDs?
A. vomiting, panting, cardiac arrhythmias
B. respiratory depression, hypotension
C. GI ulceration, platelet inhibition, decreased renal perfusion
D. liver disease, hyperexcitability, bladder stones
Correct answer: C. GI ulceration, platelet inhibition, decreased renal
perfusion. Other side effects include: liver disease, vomiting, GI
bleeding, inappetance, diarrhea, gastrointestinal perforation
(ulcers), and acute renal failure
11. A dog has a severe laceration on his shoulder that needs to be
repaired. It is desired to provide local anesthesia in additional to
systemic anesthetics/analgesics. Which would be the most appropriate
choice?
A. A ring block of the area with bupivicaine
B. An epidural with morphine/lidocaine
C. A line block with lidocaine
D. A line block with morphine/bupivicaine
Correct answer: C. A line block with lidocaine. Lidocaine is excellent
for superficial and topical analgesia, while bupivicaine is excellent
for infiltration. A ring block describes a circumferential block of a
limb, such as for a declaw surgery. An epidural will provide analgesia
to the caudal half of the body, good for hind limb orthopedic
surgery.
12. Which category of drugs does Ketamine belong to?
A. Alpha2-agonist
B. Pure agonist
C. NMDA antagonist
D. Agonist-antagonist
Correct answer: C. NMDA antagonist. Alpha2-agonists include
dexmedetomidine, pure agonists are opioids such a hydromorphone, and
an agonist-antagonist is butorphanol.
13. Multimodal analgesia is:
A. Administration of different classes of analgesic drugs in the
same patient
B. Administration of one analgesic drug in several different ways in
the same patient
C. Using different drug protocols for each patient even if they are
having the same procedure
D. Accomplished by keeping the patient anesthetized for a period
after a surgical procedure
Correct answer: A. Administration of different classes of analgesic
drugs in the same patient. An example of this is a TPLO patient. He
may be given an epidural with morphine/bupivicaine, systemic analgesia
with hydromorphone, and an NSAID injection of metacam.
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