Acute Perioperative Pain, Inpatient Pain Services, Multimodal Systemic Analgesia, and PCA — WACS Viva & Clinical Scenarios (Pre-Op & Pain Clinic Rotation)

Exam-style acute perioperative pain, inpatient pain services, multimodal systemic analgesia, and pca viva scenarios with examiner probes and model answers for…

Scenarios covered

• SCENARIO 1: A 38-year-old male undergoes an emergency exploratory laparotomy for peritonitis secondary to a perforated duodenal ulcer. He has a history of opioid tolerance due to chronic tramadol and codeine use for chronic back pain. On arrival in the post-anaesthesia care unit (PACU), he is in agony with a numerical rating pain score of 10/10, heart rate 125 bpm, and blood pressure 165/95 mmHg. How do you design and execute an acute multimodal systemic analgesic strategy for this opioid-tolerant patient, including PACU titration, IV PCA parameters, and non-opioid adjuncts?
• SCENARIO 2: You are called to the post-surgical ward by a nurse because a 60-year-old female who is receiving an intravenous morphine PCA pump (programmed at 1 mg bolus, 5-minute lockout, 1 mg/h background infusion) following open radical hysterectomy has become difficult to arouse. Her respiratory rate is 7 breaths per minute, SpO₂ is 88% on room air, and pupils are pinpoint. Detail your immediate emergency resuscitation, diagnostic evaluation, naloxone titration protocol, and subsequent reconfiguration of her pain management.
• SCENARIO 3: A 64-year-old male with severe baseline COPD undergoes an elective open upper abdominal gastrectomy for gastric cancer. A thoracic epidural catheter was inserted preoperatively at T7-T8 and an infusion of 0.125% bupivacaine with fentanyl 2 mcg/mL at 8 mL/h is running. On postoperative day 1, the patient complains of severe pain (visual analogue scale 8/10) localized to the right side of the incision, while the left side is completely numb. How do you systematically troubleshoot and manage this unilateral epidural block?
• SCENARIO 4: You have been tasked with establishing a formal Inpatient Acute Pain Service (APS) in a 500-bed West African university teaching hospital that currently relies on intermittent, as-needed intramuscular pethidine (meperidine) injections ordered by junior surgical residents. Outline your structured proposal, addressing organizational framework, nursing education, safety protocols, standard multimodal analgesic orders, and key quality indicators.