Pain Management Common pitfalls Jamie Capasso, DO UCI Hospitalist Palliative Medicine
Dec 31, 2015
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