1. Which of the following best describes a pre-emptive analgesic strategy?
A. Administration of 800mg IV ibuprofen bolus over 30 minutes during induction of anesthesia
B. Administration of 30mg IV ketorolac in the post anesthesia care unit for sternal pain after cardiac surgery
C. Administration of gabapentin 300mg twice daily in the trauma ICU for neuropathic pain associated with phantom limb pain after leg amputation.
D. Instillation of bupivacaine 0.5% @ 3ml/hr via wound catheter
2. Which of the following best describes a multimodal analgesic strategy?
A. Rotating from morphine to hydromorphone patient controlled IV PCA therapy
B. Single shot ropivicaine joint infiltration, followed by bupivacaine via continuous peripheral nerve catheter
C. Standing Ibuprofen 600mg Q6hrs, Acetaminophen 650mg Q6hrs, with hydromorphone IV PCA therapy
D. Changing from clinician controlled as needed hydromorphone to IV PCA therapy
3. Which of the following therapeutic approaches should be considered for all surgical procedures in the 2012 American Society of Anesthesiologists practice guidelines?
A. Around the clock subcutaneous opioids
B. Around the clock acetaminophen, NSAID, or COX-II inhibitor
C. Neuraxial opioids
D. Patient controlled IV opioid analgesia
4. Which of the following therapeutic approaches for acute perioperative pain management is recommended in the 2012 American Society of Anesthesiologists practice guidelines?
A. High dose continuous infusion opioids
B. Long-acting or extended-release opioids
C. Subcutaneous opioid therapy as needed
D. Multimodal analgesic techniques
5. Your institutional pain committee is creating policies and guidelines related to the use multimodal analgesics regimens using local anesthetics. In your policies, the use of intrathecal, epidural, and peripheral nerve blocks should be restricted to which of the following providers?
A. Surgeons
B. Anesthesiologists
C. Psychiatry
D. Neurology
6. Which of the following is a barrier to implementation of multimodal analgesia in the perioperative setting?
A. Insufficient access or availability of institutional guidelines and policies on perioperative pain management
B. 24 hour availability of anesthesia or pain specialist
C. Established institutional multidisciplinary pain committee
D. Smart pump technology for patient controlled analgesic modalities
7. Patient X is a 62 year old female admitted to the PACU postoperatively s/p total knee replacement. She is continued on her home duloxetine 60mg QD for neuropathic pain, fentanyl 25mcg patch for chronic hip and back pain, as well as diazepam 2.5mg BID for muscle spasms. She is currently experiencing 10/10 pain despite escalation of her hydromorphone PCA, with settings of 0.6 mg every 6 minutes, no lockout. Which of the following changes would you make to her regimen?
A. Initiate IV ketamine infusion at 0.1 mg/kg/hr
B. Increase fentanyl patch to 50mcg dosing
C. Administer intra-articular methylprednisolone to the repaired knee
D. Initiate a weekly clonidine 0.1mg patch
8. Which of following perioperative complications is associated with inadequately treated pain?
A. Somnolence
B. Hypoglycemia
C. Shivering
D. Tachycardia
9. All of the following drugs exert their analgesic mechanisms by reducing inflammation locally at the surgical site EXCEPT:
A. NSAIDS
B. COX-II inhibitors
C. Clonidine
D. Corticosteroids
10. Non-pharmacological therapies that have been shown to improve perioperative analgesia include all of the following EXCEPT:
A. Music
B. Transcutaneous electrical nerve stimulation (TENS)
C. Local infiltration techniques
D. Acupuncture
11. Adverse drug reactions to acetaminophen include all of the following EXCEPT:
A. Qtc prolongation
B. Rash
C. Metabolic acidosis
D. Liver dysfunction
12. Genomic alteration of this metabolic pathway may be responsible for rapid metabolism of codeine to morphine?
A. CYP 2C9
B. CYP 2C8
C. CYP 2D6
D. Glucoronidation pathways
13. Multimodal analgesia is best defined as:
A. Administration of two or more analgesic modalities with similar mechanism of action in order to improve pain control
B. Administration of analgesics with a long mechanism of action prior to surgical incision
C. The use of non-pharmacological methods to improve pain control
D. The use of any combination of two or more analgesic modalities with differing analgesic mechanisms that may have synergistic effects in managing acute pain
14. Which of the following strategies can be used to treat opioid induced hyperalgesia?
A. Rapid opioid discontinuation
B. Switching to an intrathecal pump to achieve higher CNS opioid concentrations
C. Administration of an NMDA antagonist
D. Administration of a systemic corticosteroid
15. Use of meperidine in the perioperative setting should be limited to
A. Patients with creatinine clearance < 30mL/min
B. Shivering
C. Elderly patients
D. Intrathecal administration
16. Which of the following is true of IV ketorolac in the perioperative setting?
A. Its recommended to be given preemptively before incision
B. Single doses greater than 60mg are common
C. Is contraindicated perioperatively for coronary artery bypass patients
D. Lower incidence of GI side effects compared to celecoxib
17. Use of alpha 2 agonists in the perioperative setting may be limited by:
A. Increased risk of bradycardia and hypotension
B. High incidence of pruritis
C. Increased risk of shivering
D. Increased risk of delirium
18. For patients experiencing life threatening cardiovascular local anesthetic systemic toxicity (LAST) which of the following agents could be used adjunctively for attempted reversal of symptoms?
A. Intravenous propofol
B. N-acetylcysteine
C. Intravenous lorazepam
D. Intravenous Intralipid® 20% weight based dosing
19. Risk factors for acute perioperative pain include all of the following EXCEPT:
A. Early age
B. Prior opioid use
C. Orthopedic or thoracic surgery
D. Pre-operative anxiety
20. For patients on acetaminophen, caution on prescribing, dosing, and monitoring is needed for all of the following EXCEPT:
A. Patients with a creatinine clearance less than 30ml/min
B. Patients with history of liver dysfunction
C. Patients with history of heart failure
D. Patients on concomitant warfarin therapy
