Pain Management — MCQs

Pain Management Indian Medical PG Practice Questions and MCQs

Question 51: True about epidural opioid are all except:

A. Act on dorsal horn substantia gelatinosa
B. Can cause Itching
C. Can cause respiratory depression
D. Function of the intestine is not affected (Correct Answer)

Explanation: **Function of the intestine is not affected** - **Epidural opioids** can indeed cause **constipation** and other gastrointestinal side effects by affecting opioid receptors in the **gut wall**, thus disturbing normal intestinal motility. - The phrase "not affected" is incorrect because **opioids inherently reduce gastrointestinal motility**, leading to common side effects such as nausea, vomiting, and constipation. *Act on dorsal horn substantia gelatinosa* - This statement is true; **epidural opioids work primarily by binding to opioid receptors** in the **substantia gelatinosa** of the dorsal horn of the spinal cord. - This binding **inhibits the release of neurotransmitters** like substance P, thus preventing the transmission of pain signals. *Can cause Itching* - **Pruritus (itching)** is a very common side effect of **epidural opioids**, often concentrated around the face and trunk. - It results from the **activation of opioid receptors** in the central nervous system and the release of histamine. *Can cause respiratory depression* - **Respiratory depression** is a serious and potentially life-threatening side effect of **epidural opioids**, particularly with higher doses or systemic absorption. - It occurs due to the **suppression of the medullary respiratory centers** in the brainstem.

Question 52: A patient after undergoing thoracotomy complains of severe pain. The BEST method of pain control in this patient would be:

A. Oral morphine
B. Diazepam rectal suppository
C. Intercostal cryoanalgesia (Correct Answer)
D. IV fentanyl

Explanation: ***Intercostal cryoanalgesia*** - **Intercostal cryoanalgesia** involves applying extreme cold to the intercostal nerves, leading to temporary nerve denervation and prolonged pain relief. This technique is particularly effective for **post-thoracotomy pain** due to its targeted action and reduced systemic side effects compared to opioids. - The goal is to provide **long-lasting pain control** specifically at the surgical site, allowing for better respiratory mechanics and early mobilization. *Oral morphine* - Oral morphine can provide systemic pain relief, but its onset of action is slower, and it carries the risk of significant **sedation** and **respiratory depression**, which are major concerns in a patient who has just undergone thoracotomy. - While effective, it may not provide optimal local pain control for incisional pain and often requires higher doses to achieve adequate relief, increasing the risk of adverse effects. *Diazepam rectal suppository* - Diazepam is a **benzodiazepine** primarily used for anxiety, muscle spasms, and seizures, not for severe acute surgical pain. It has **no significant analgesic properties**. - Its sedative effects would be contraindicated after thoracotomy due to the risk of respiratory depression and masking potential neurological changes. *IV fentanyl* - IV fentanyl is a potent opioid with a rapid onset and short duration of action, making it useful for breakthrough pain or during immediate post-operative periods. However, it requires **continuous monitoring** and frequent re-dosing. - Like other opioids, it carries risks of **respiratory depression**, nausea, and sedation, making it less ideal for sustained primary pain control immediately after thoracotomy where lung function is critical.

Question 53: Site of action of epidural analgesia

A. Anterior horn
B. Substantia gelatinosa (Correct Answer)
C. Ventral horn
D. Sensory nerve endings

Explanation: ***Substantia gelatinosa*** - Epidural analgesia primarily acts on the **substantia gelatinosa** (Rexed lamina II) within the **dorsal horn** of the spinal cord. - This area is crucial for processing and modulating **pain signals**, which are inhibited by local anesthetics and opioids administered epidurally. *Anterior horn* - The **anterior horn** (ventral horn) primarily contains **motor neurons** responsible for skeletal muscle control. - While local anesthetics can block motor fibers if they diffuse sufficiently, the primary target for analgesia is sensory. *Ventral horn* - The **ventral horn** is synonymous with the **anterior horn** and is mainly involved in **motor function**. - Its role is not directly related to the primary analgesic effect of epidural medications on pain transmission. *Sensory nerve endings* - **Sensory nerve endings** are located in the periphery, such as the skin, muscles, and organs. - Epidural analgesia acts within the **spinal canal** and does not directly target peripheral sensory nerve endings.

Question 54: Which of the following anesthetic agents have good analgesic property? a) Ketamine b) Nitrous oxide c) Thiopentone d) Propofol e) Midazolam

A. Ketamine and Nitrous oxide (Correct Answer)
B. Ketamine only
C. Nitrous oxide and Thiopentone
D. Ketamine and Propofol
E. Midazolam only

Explanation: ***Ketamine and Nitrous oxide*** - **Ketamine** is a dissociative anesthetic with potent **analgesic properties** secondary to its action as an **NMDA receptor antagonist**. - **Nitrous oxide** is an inhalational anesthetic known for its mild to moderate **analgesic effects**, making it useful for sedation and pain relief. *Ketamine only* - While **ketamine** has excellent analgesic properties, this option is incomplete as **nitrous oxide** also contributes significant analgesia among the choices. - Excluding other agents with analgesic properties makes this option less comprehensive than the correct answer. *Ketamine and Propofol* - **Ketamine** possesses strong analgesic effects, but **propofol** is a sedative-hypnotic agent with no significant intrinsic **analgesic properties**. - Propofol provides anesthesia and sedation but typically requires co-administration with opioids for pain control. *Nitrous oxide and Thiopentone* - **Nitrous oxide** provides analgesia, but **thiopentone** (a barbiturate) is primarily an anesthetic and sedative with **no significant analgesic properties**. - Thiopentone can induce unconsciousness rapidly but does not relieve pain. *Midazolam only* - **Midazolam** is a benzodiazepine primarily used for sedation, anxiolysis, and amnesia, with **no intrinsic analgesic properties**. - Its effects can reduce stress and perception of pain, but it does not directly act as an analgesic.

Question 55: The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for rating postoperative pain in children under one year excludes all of the following, EXCEPT:

A. Oxygen saturation
B. Torso
C. Verbal response (Correct Answer)
D. Cry

Explanation: ***Verbal response*** - The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) is designed for children **under one year of age**, who are typically pre-verbal. - While verbal complaints are not assessed, a child's **verbal response** (e.g., moaning, crying, or not making sounds at all) in relation to pain is a component of the scale, contributing to the interpretation of their comfort level. *Oxygen saturation* - **Physiological parameters** like oxygen saturation are typically not part of behavioral pain scales like CHEOPS, which focus on observable behaviors. - While low oxygen saturation can indicate distress, it is not a direct measure of pain for this scale. *Torso* - The CHEOPS scale assesses **pain-related behaviors** of extremities (e.g., legs, arms) and facial expressions, but does not specifically include observations of the "torso" as a separate category. - Behaviors like stiffening or arching of the torso might be implicitly considered under overall body tension, but it’s not a distinct domain. *Cry* - The **quality and intensity of crying** is a primary behavioral indicator of pain in pre-verbal infants and is a significant component of many pediatric pain scales, including CHEOPS. - A child's cry, along with other behaviors, helps differentiate between various levels of discomfort or pain.

Question 56: A patient with biliary duct stricture presenting with retching and vomiting was receiving 3mg epidural morphine daily. One day, 12mg of epidural morphine was mistakenly administered. Which of the following is NOT expected to occur with this morphine overdose?

A. Overstimulation of respiratory centre
B. Urinary retention (Correct Answer)
C. Itching
D. Increase vomiting

Explanation: ***Urinary retention*** - **Morphine** is known to cause **urinary retention** by increasing the tone of the urinary sphincter and detrusor muscle, leading to difficulty in urination or inability to empty the bladder. - This effect would be **expected** with an overdose of epidural morphine, not *unexpected*. *Overstimulation of respiratory centre* - **Opioid overdose** typically leads to **respiratory depression** due to direct effects on the brainstem respiratory centers, decreasing respiratory rate and tidal volume. - An **overstimulation** of the respiratory center is therefore not an expected finding. *Itching* - **Itching (pruritus)** is a common side effect of **epidural opioids**, including morphine, often due to histamine release or interaction with opioid receptors in the spinal cord. - This would be an **expected** symptom following a morphine overdose. *Increase vomiting* - **Opioids** can stimulate the **chemoreceptor trigger zone** in the brain, leading to **nausea and vomiting**. - An overdose would likely **exacerbate** this effect, leading to increased vomiting.

Question 57: A 45-year-old female with a history of chronic pain syndrome is scheduled for a hysterectomy. Which intraoperative anesthetic technique is most appropriate for pain management in this patient?

A. Multimodal analgesia (Correct Answer)
B. General anesthesia with opioids
C. Regional anesthesia with local anesthetics
D. Conscious sedation with opioids

Explanation: **Multimodal analgesia** - This approach combines **multiple analgesic agents** and techniques that act on different pain pathways, which is crucial for patients with a history of **chronic pain** and minimizes reliance on a single drug class. - It helps to achieve **synergistic pain relief**, reduce opioid requirements, and can improve postoperative outcomes, especially in individuals with altered pain perception. *General anesthesia with opioids* - While opioids are effective, relying solely on them can lead to **tolerance, hyperalgesia**, and increased postoperative side effects, especially in a patient with chronic pain. - This method alone may not adequately address the complex pain mechanisms involved in chronic pain syndrome, potentially leading to **breakthrough pain** postoperatively. *Regional anesthesia with local anesthetics* - Regional anesthesia is a valuable component of pain management but may not provide **complete analgesia** as a sole technique for a major surgery like hysterectomy in a chronic pain patient. - This option does not incorporate other pain-modulating agents or techniques, which are often necessary to manage the **central sensitization** seen in chronic pain. *Conscious sedation with opioids* - Conscious sedation is **inappropriate for a hysterectomy**, which requires a deeper level of anesthesia to ensure patient safety and comfort during the surgical procedure. - Although it involves opioids, it lacks the comprehensive pain management and surgical anesthesia required for an **intra-abdominal surgery**, and also carries risks of respiratory depression.

Question 58: Which technique is most appropriate for providing postoperative analgesia in a patient undergoing total hip replacement?

A. Intravenous patient-controlled analgesia
B. Spinal anesthesia
C. Femoral nerve block
D. Epidural analgesia (Correct Answer)

Explanation: ***Epidural analgesia*** - Provides **excellent pain control** for hip replacement surgery by blocking nerve signals from a wider area, offering superior analgesia compared to regional blocks for extensive procedures. - Allows for **titratable pain relief** and can reduce the need for systemic opioids, minimizing their side effects. *Femoral nerve block* - Primarily blocks pain from the **anterior thigh** and knee, which is not sufficient for comprehensive analgesia after a total hip replacement. - While it can be a part of multimodal analgesia, it often needs to be combined with other techniques to cover the full extent of surgical pain. *Intravenous patient-controlled analgesia* - Provides **systemic pain relief** but relies on the patient to activate the dose and carries a higher risk of **opioid-related side effects** such as respiratory depression, nausea, and sedation. - While commonly used, it is generally less effective and carries more side effects than well-implemented regional techniques for major orthopedic surgery. *Spinal anesthesia* - Provides excellent intraoperative anesthesia but its **duration is limited**, making it less suitable for sustained postoperative analgesia on its own. - While it can be combined with intrathecal opioids for extended effect, its primary role is intraoperative, and an epidural provides more flexible and prolonged postoperative pain management.

Question 59: What is the most common complication of a coeliac plexus block?

A. Hypotension (Correct Answer)
B. Diarrhea
C. Pneumothorax
D. Paresthesias

Explanation: ***Hypotension*** - **Hypotension** is the most common complication due to the **vasodilation** that occurs from the **sympathetic blockade** of splanchnic circulation, leading to blood pooling in the visceral bed. - This effect can be pronounced, particularly in patients who are dehydrated or have pre-existing cardiovascular compromise, requiring vigilance and fluid management. *Paresthesias* - While possible, **paresthesias** are less common than hypotension and are usually transient, resulting from temporary nerve irritation during needle placement. - They are typically not severe enough to be considered the most common or significant complication. *Diarrhea* - **Diarrhea** can occur as a side effect due to the unopposed **parasympathetic tone** following sympathetic blockade in the gut. - However, it is not as frequent or immediately life-threatening as hypotension. *Pneumothorax* - **Pneumothorax** is a serious but rare complication, primarily associated with an anterior approach to the coeliac plexus block, where the needle might inadvertently puncture the lung pleura. - It is avoided with careful needle placement and imaging guidance, making it far less common than hypotension.

Question 60: What is the primary use of the Visual Analogue Scale (VAS)?

A. Sleep
B. Sedation
C. Pain intensity (Correct Answer)
D. Depth of Anaesthesia

Explanation: ***Pain intensity*** - The **Visual Analogue Scale (VAS)** is a widely used psychometric response scale for subjective characteristics that cannot be directly measured, with **pain intensity** being its primary application. - Patients mark a point on a continuous line representing their perceived pain level, typically from "no pain" to "worst possible pain," allowing for a quantitative measure of a subjective experience. *Sleep* - While sleep quality can be assessed using scales, the **VAS is not the primary or most common tool** for measuring sleep. - The **Epworth Sleepiness Scale** or **Polysomnography** are more specialized for this purpose. *Sedation* - Sedation levels are usually assessed using scales like the **Ramsay Sedation Scale** or the **Richmond Agitation-Sedation Scale (RASS)**. - The **VAS is not specifically designed** for or widely used to quantify sedation. *Depth of Anaesthesia* - The **depth of anaesthesia** is typically monitored using objective measures like **EEG-based indices** (e.g., Bispectral Index Monitor - BIS) or clinical signs, rather than subjective scales. - A VAS would not provide the necessary **objective physiological data** to determine the depth of anaesthesia accurately.

Practice by Chapter

Pain Physiology and Pathways

Practice Questions

Acute Pain Management

Practice Questions

Chronic Pain Syndromes

Practice Questions

Neuropathic Pain

Practice Questions

Multimodal Analgesia

Practice Questions

Opioid Pharmacology

Practice Questions

Non-opioid Analgesics

Practice Questions

Adjuvant Analgesics

Practice Questions

Patient-Controlled Analgesia

Practice Questions

Interventional Pain Procedures

Practice Questions

Cancer Pain Management

Practice Questions

Perioperative Pain Management

Practice Questions

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