72 M, acute femoral fracture. History of hip, knee OA. Uses Tylenol, ibuprofen. Used Norco in the past very infrequently. Keeps an old bottle in the.

Pain Management Common pitfalls

Jamie Capasso, DOUCI Hospitalist

Palliative Medicine

Case 1

72 M , acute femoral fracture. History of hip, knee OA. Uses Tylenol, ibuprofen.

Used Norco in the past very infrequently. Keeps an old bottle in the medicine chest.

Poor baseline pain control, function is limited due to pain, slowly declining over time prior to admission

Fentanyl 50mcg IVP PRN. Pain well controlled.

Case 1

Patient is delighted-Never experienced such relief! Only used it 3 times total over 2 days.

Long term plan/discharge med(s)?› A. Fentanyl patch 50mcg q72 hours› B. PO PRN Norco q4 hours› C. PO Scheduled Norco q4 hours› D. PO Dilaudid 2mg q4 hours› E. PCA pump at home with home health

Fentanyl

Fentanyl is an opioid with high lipid solubility, suitable for intravenous, spinal, transmucosal and transdermal administration.

After placement of a fentanyl patch, serum fentanyl concentrations gradually increase during the first 14 h and stay relatively constant from 14 to 24 h. The increase in plasma fentanyl concentration is slower in elderly people.

Fentanyl

Fentanyl

Case 2

53 F with acute gallstone pancreatitis admitted for pain, ERCP.

Nausea, vomiting, poor PO intake, miserable with pain

At home, uses PO PRN Dilaudid 2mg maybe 1x a week for OA pain.

Treatment: NPO, IVF, antiemetics and PCA for pain control.

Case 2

PCA medication and settings?› A. Fentanyl 50 mcg q10 mins PRN› B. Fentanyl 50mcg basal and 50mcg q10

mins PRN› C. Dilaudid 1mg q15 mins PRN› D. Dilaudid 1mg basal and 1mg q15 mins

PRN› E. Morphine 2mg basal and 3mg q20 mins

PRN

Basal on PCA= No safety net

Somnolence in response to opiate therapy occurs BEFORE respiratory depression.

DO THE MATH!!› Example: our patient doesn’t even take

ANY opiates on most days. Basal of1mg Dilaudid/hr=24mg/day= 480mg

PO morphine. Would you administer MScontin 200 PO

BID to this patient?

Case 3

38 M with ESRD on HD, DM1, HTN, CHF, anxiety, hyperlipidemia and hx CVA.

Admitted for severe diabetic foot ulcer that progressed to necrotizing fasciitis. Pain out of control.

Has chronic neuropathy for which he uses PRN Norco.

Case 3

To surgery, now has a fasciotomy, just arrived back to the floor and RN would like to know:

How should we control his pain?› A. PRN Norco q4 hours › B. MScontin 15mg PO BID with PRN Norco› C. PCA Morphine 2mg basal, 2mg q15 min PRN› D. PCA Dilaudid 2mg basal, 2mg q15 min PRN› E. PCA Dilaudid no basal, 0.5mg IV q10 min

PRN

Renal failure and pain NOT recommended:

› Morphine› Codeine › Demerol

Use with CAUTION› Oxycodone› Hydromorphone

SAFEST› Fentanyl› Methadone

Neuroexcitatory effects

Build up of 3-glucuronide metabolite implicated

Myoclonus – the uncontrollable twitching and jerking of muscles or muscle groups – usually occurs in the extremities, starting with only an occasional random jerking movement.

Progresses to delirium-> +/- hyperalgesia

-> seizure->coma->death.

Case 4

69 F with severe DJD, recent fall, vertebral fracture causing acute spinal cord impingement on top of chronic stenosis. Uses PRN PO Dilaudid daily at home.

Severe pain, OR planned tomorrow. How can we make him comfortable now

AND address his chronic poorly controlled back pain from underlying disease?

Case 4› A. Start Methadone 5 PO BID, PCA Dilaudid

(bolus only) + Ketamine +Neurontin +Effexor

› B. Start Methadone with Dilaudid breakthrough

› C. Start Ketamine and Neurontin to add to home Dilaudid

› D. Start a PCA Dilaudid (bolus only) › E. Start Morphine and increase his Dilaudid

Hint: PO Dilaudid already tried… Only “took the edge off” Still excruciating!

Case 4 Breakdown

Types of Pain: Acute post traumatic and chronic› Inflammatory from the fall/trauma› Neuropathic from the cord impingement

Why does his PO Dilaudid only “take the edge off?”› Neuropathic pain is opiate refractory by

definition!

Case 4- Correct answer

A. Start Methadone 5 PO BID, PCA Dilaudid (bolus only) + Ketamine +Neurontin +Effexor

WHY all the meds: Dilaudid and Ketamine will exert analgesic

effect within seconds to minutes, one with primarily NON Neuropathic use, and one for Neuropathic

Methadone: hours to days Neurontin and Effexor: days to weeks

Case 4

The 5 drugs we chose represent most of the major categories of medications used for neuropathic pain:› Methadone: Opiate agonist, NMDA receptor

antagonism› Ketamine: NMDA receptor antagonist› Effexor: SNRI antidepressant› Neurontin: antiepileptic (although not used

as such in practice)

Summary Opiate naïve patients need to be handled

with care=Low doses of short acting medication.

Basal infusion on PCA is the exception, rather than the rule. Again, NOT for naïve patients.

Morphine is a poor choice in renal failure. Neuropathic pain is difficult to control and

frequently needs a multi-drug regimen