CAPA Pharmacology & Pain Management 2 — Questions and Answers
Question 1: A patient in the PACU reports pain rated 7/10 after ambulatory knee arthroscopy. They received fentanyl intraoperatively. Which multimodal analgesic agent is MOST appropriate to add first?
- IV hydromorphone 1 mg
- Ketorolac 15-30 mg IV (Correct answer)
- Morphine 4 mg IV
- Meperidine 25 mg IV
Correct answer: Ketorolac 15-30 mg IV
Ketorolac is a first-line NSAID adjunct in multimodal analgesia that reduces opioid requirements without causing respiratory depression.
Question 2: Which opioid characteristic makes methadone particularly challenging to use for acute postoperative pain management in the ambulatory setting?
- Short half-life requiring frequent dosing
- Prolonged and unpredictable half-life up to 150 hours (Correct answer)
- Lack of analgesic efficacy
- Inability to cross the blood-brain barrier
Correct answer: Prolonged and unpredictable half-life up to 150 hours
Methadone's prolonged and variable half-life (24-150 hours) creates risk for delayed respiratory depression, making it unsuitable for ambulatory acute pain.
Question 3: A patient is prescribed gabapentin 300 mg preoperatively as part of a multimodal analgesia protocol. What is the PRIMARY mechanism by which gabapentin reduces postoperative pain?
- Inhibition of COX-1 and COX-2 enzymes
- Blockade of voltage-gated calcium channels reducing neuronal excitability (Correct answer)
- Antagonism of NMDA receptors
- Activation of mu-opioid receptors
Correct answer: Blockade of voltage-gated calcium channels reducing neuronal excitability
Gabapentin binds to the alpha-2-delta subunit of voltage-gated calcium channels, reducing presynaptic neurotransmitter release and central sensitization.
Question 4: A 65-year-old patient with renal impairment (CrCl 25 mL/min) requires analgesia after ambulatory cataract surgery. Which analgesic choice is MOST concerning?
- Acetaminophen 650 mg PO
- Tramadol 50 mg PO
- Ketorolac 30 mg IV (Correct answer)
- Oxycodone 2.5 mg PO
Correct answer: Ketorolac 30 mg IV
Ketorolac is contraindicated in significant renal impairment because NSAIDs reduce prostaglandin-mediated renal perfusion and can precipitate acute kidney injury.
Question 5: During PACU assessment, a patient shows signs of opioid-induced pruritus after morphine administration. Which agent is MOST effective for treating this side effect while minimally reversing analgesia?
- Naloxone 0.4 mg IV
- Diphenhydramine 25 mg IV
- Nalbuphine 2.5-5 mg IV (Correct answer)
- Ondansetron 4 mg IV
Correct answer: Nalbuphine 2.5-5 mg IV
Nalbuphine, a mixed agonist-antagonist, treats opioid-induced pruritus by antagonizing mu receptors while preserving analgesia via kappa receptor agonism.
Question 6: A patient scheduled for ambulatory surgery is taking buprenorphine (Suboxone) for opioid use disorder. What is the BEST perioperative management strategy?
- Discontinue buprenorphine 72 hours preoperatively
- Continue buprenorphine and use high-dose full agonist opioids as needed
- Switch to methadone the morning of surgery
- Continue buprenorphine and maximize non-opioid multimodal analgesia (Correct answer)
Correct answer: Continue buprenorphine and maximize non-opioid multimodal analgesia
Current guidelines recommend continuing buprenorphine perioperatively while maximizing non-opioid analgesics, as abrupt discontinuation risks relapse.
Question 7: Which local anesthetic has the LONGEST duration of action and is most appropriate for a single-injection peripheral nerve block intended to provide overnight analgesia after ambulatory shoulder surgery?
- Lidocaine 1.5%
- Mepivacaine 1.5%
- Bupivacaine 0.5% (Correct answer)
- Chloroprocaine 3%
Correct answer: Bupivacaine 0.5%
Bupivacaine has the longest duration (8-16+ hours) among commonly used local anesthetics, making it suitable for prolonged postoperative analgesia via peripheral nerve block.
CAPA Pharmacology & Pain Management 2
A patient in the PACU reports pain rated 7/10 after ambulatory knee arthroscopy.
They received fentanyl intraoperatively.
Which multimodal analgesic agent is MOST appropriate to add first?