Please review the handout "Acute Pain Management" prior to completing this case.

An otherwise healthy 33 year-old woman is scheduled for total colectomy and ileal reservoir construction for ulcerative colitis. You are consulted for preoperative recommendations regarding her postoperative acute pain management.

Side effects of opioids include all of the following except:

a) Respiratory depression

b) Cough suppression

c) Nausea

d) Muscle weakness

e) Smooth muscle spasm

Advantages of patient controlled analgesia (PCA) in this patient include:

a) Avoidance of opioid side effects

b) Absolute safety from overdosage

c) Reliable analgesia despite interpatient variability in dose requirements and minimum effective analgesic concentration

d) The ability to administer much higher bolus doses of narcotics than when the intramuscular (IM) route is selected

e) Minimal need for patient monitoring

Advantages of postoperative epidural opioid analgesia include:

a) Intense analgesia with lower overall opioid doses than with IV PCA or IM narcotics

b) Minimal respiratory depression

c) Decreased pruritis compared to IV PCA

d) Similar onset time and duration of analgesia regardless of the choice of opioid

e) Sensory and motor blockade which decrease opioid requirements

The addition of local anesthetic to an epidural opioid infusion:

a) Produces profound sympathetic blockade which is the main cause of hypotension in the postoperative period

b) May decrease narcotic side effects by decreasing the total amount of opioid needed to achieve analgesia

c) Results in motor blockade which prohibits patient ambulation

d) Increases the risk of respiratory depression by causing diaphragmatic paralysis

e) Allows the epidural catheter to be placed farther from the spinal level corresponding to the surgical site

The patient initially requests an IV PCA. You order:

a) Fentanyl 100 mg bolus with a 5 minute lockout interval

b) Morphine 1 mg bolus with a 10 minute lockout and a 10 mg/hr basal infusion

c) Morphine 10 mg bolus with a 5 minute lockout

d) Hydromorphone 0.2 mg bolus with a 5 minute lockout

e) Hydromorphone 2.0 mg bolus with a 5 minute lockout

Wait. The patient changed her mind and wants an epidural. You place an epidural catheter at the T 8-9 interspace and administer a 5 mg bolus of preservative free morphine at the beginning of the case. An infusion of bupivicaine 0.1% and morphine 50 mg/ml is run at 7 cc/hr beginning in the recovery room and running into the postoperative period.

When monitoring this patient for respiratory depression you must remember:

a) The depression may be biphasic, with early and late components

b) Respiratory depression frequently occurs in the absence of other opioid side effects

c) The risk of delayed respiratory depression is greatest with lipid soluble drugs such as fentanyl

d) Respiratory depression may be treated with naloxone 400 mg boluses without affecting analgesia

e) The risk of respiratory depression is not significantly increased if intravenous opioids are administered along with the epidural infusion because the two work by different mechanisms

Naloxone:

a) Has a long half-life, exceeding that of most commonly used opioids

b) Is the drug of choice for managing mild pruritis associated with epidural opioids

c) Should be administered in small incremental boluses whenever possible

d) Is the only effective treatment for nausea associated with epidural opioids

e) Cannot be administered as an infusion because of the rapid development of tolerance