2.  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.

3.  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

4.  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.

8.  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.

9.  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

10.  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?

11.  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.

12.  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

13.  NOT recommended: › Morphine › Codeine › Demerol  Use with CAUTION › Oxycodone › Hydromorphone  SAFEST › Fentanyl › Methadone

14.  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.

15.  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?

16. › 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!

17.  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!

18.  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

19.  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)

20.  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