Pain Management in Hospital Medicine Daniel Burkhardt M.D. - - PDF document
u 10/26/2015 Pain Management in Hospital Medicine Daniel Burkhardt M.D. Associate Professor Department of Anesthesia and Perioperative Care University of California San Francisco daniel.burkhardt@ucsf.edu burkhardt.us/2015-10-15.pdf
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38 year old male with Sickle Cell Anemia in the ED with severe total body pain. Either moaning and screaming in "20
n Scale (0-10) n Various non-verbal pain scales (grimacing,
n Arousability (RASS in the ICU) n Splinting of the incision n Pupil size n Response to a trial of therapy
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"If you give fentanyl, and the blood pressure drops, then you haven't given enough fentanyl"
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By varying the opioid dose you can move between:
u Screaming in pain u Awake and comfortable u Nauseous, itching, somnolent u Dead (from respiratory depression)
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You can move up and down the spectrum by:
u Changing the opioid dose u Giving a reversal agent u Changing the pain intensity
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Match opioid fluctuation to pain fluctuation
n If the patient has stable vital signs, titrate low
u 40 - 80 mcg IV q1-5 min. n Naloxone doesn't cause pain, a naloxone
n Useful as a trial of therapy for altered mental
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u pulse oximetry
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u No good non-invasive test u ABG (must be drawn from an arterial line) u RR has a poor correlation with acidosis u Arousability (the “sedation scale”) is the best way
Gordon DB et al. Pain Manag Nursing 2005
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u 63% had RR > 12 u 48% had no sedation scores recorded u 65% of episodes occurred within 24 hours after
u Patients were older and received more concomitant
u No significant difference in opioid quantity or route
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Lee LA et al. Anes 2015
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Anesthesia Closed Claims Project
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357 acute pain claims between 1990 and 2009
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92 claims judged possible probable or definite
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77% severe brain damage or death
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88% within 24 hr of surgery
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97% preventable with better monitoring and response
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Contributing factors
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Multiple prescribers 33%
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Concurrent sedatives 34%
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Inadequate RN assessment 31%
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Time since last check <2hr in 42%, <15min in 16%
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Somnolence noted in 62% before event
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A normal oxygen saturation on room air rules out severe hypoxia AND hypercarbia.
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Alveolar Gas Equation: PaO2 = FiO2(713) - PaCO2(1.2)
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As your PaCO2 exceeds 80, you become hypoxic unless you are on supplemental oxygen
FiO2 PaCO2 PaO2 Normal 0.21 40 102 Opioid Respiratory Depression on Room Air 0.21 80 54 Opioid Respiratory Depression on Supplemental Oxygen 0.30 80 118
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u pH, pCO2, and HCO3 levels are related by a fixed
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u Acidosis can affect cardiovascular function u Hypercarbia causes somnolence and thus spirals
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Hypoxia rapidly causes permanent injury
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Acidosis in the absence of hypoxia is relatively well tolerated
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Oxygen may “buy you time” to detect and treat the problem before permanent injury occurs.
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If you can provide highly reliable continuous pulse oximetry (with rapid response to ALL alarms by trained personnel):
u Avoid prophylactic oxygen and use oxygenation as a surrogate
for ventilation
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If you are not willing to bet your patient’s life on continuous pulse
u Consider prophylactic supplemental oxygen to minimize and
delay hypoxia
u Regularly assess arousability and respiratory rate as surrogates
for ventilation
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Opioid induced constipation is iatrogenic
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Give laxatives BEFORE the problem happens
n Peripherally acting mu-opioid antagonists u Alvimopan (Entereg) PO u Methylnaltrexone (Relistor) SC n Centrally and peripherally acting mu-opioid
u Naloxone PO
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FDA approved only for opioid induced constipation in palliative care
u Trials in post-operative ileus have not consistently shown a
benefit
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8-12 mg SC QOD, use beyond 4 months not well studied
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Roughly 40-50% of patients in palliative care do not respond
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Possible increased risk of GI perforation: Health Canada Issues Notice August 2010
u Advanced illness and conditions associated with impaired
structural integrity of the GI wall (eg, cancer, GI malignancy, GI ulcer, Ogilvie's syndrome, concomitant use of certain medications including bevacizumab NSAIDs and steroids) may be at greater risk of perforation
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u Slow release theorized to avoid saturation hepatic
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Liu M Wittbrodt Eur J Pain Symptom Manage 2002
u 9 chronic opioid patients with constipation randomized to 0-2-4
mg PO TID
u All patients on active therapy had improvement in bowel
function
u 3 patients had increased pain
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Meissner W et al. Pain 2000
u 22 chronic pain patients with constipation placed on a dose
escalation 3 mg po tid then 6 mg then 9 mg then 12 mg
u Mean naloxone dose 17.5 mg/d u Mean number of days with laxation increased from 2.1 to 3.5 (p
< 0.01) in the 6 day study period
u No difference in pain scores
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u Cardiac Monitoring u Glycopyrrolate at the bedside
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Felden L et al. Brit J Anes 2011
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8 studies 1004 patients
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Dilaudid had better acute pain control (-0.4 NRS, p=0.006) but no difference for chronic pain
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NON-significant trend towards less N/V/itch
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Felden L et al. Brit J Anes 2011
Gular P et al. ASRA May 2015 Poster
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UHC Consortium data 10/2010 - 9/2013, 38 hospitals, patients treated with hydromorphone or morphine not both
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Medical Patients
u Hydromorphone up 17%, morphine down 6% u Rescue drug use higher for hydromorphone (1.11% vs 0.86%
p<0.01)
u LOS trend shorter for hydromorphone (5.68 vs 6.56 day) u Readmission trend higher for hydromorphone (10.15% vs. 6.54%)
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Actual conversion is not 0.2 mg = 1 mg morphine IV
u More like 0.15, but that isn’t what everyone uses
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u Lollipop / lozenge may be associated with
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u All have extended release versions
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u No pure immediate version commonly available
F Can't give acetaminophen separately ATC
u Combo agents rescheduled from DEA Schedule III to II
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Dose change takes several days to take effect
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PO to IV conversion -> cut in half
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Divide up TID for pain
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Comes as a liquid
u Give down a feeding tube
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QT interval prolongation
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u Almost hopeless now
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u Use methadone (only if experienced) u Use a fentanyl patch (and beware CMS) u (Even better for the short term) just give IR
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Interact with MAO-I inhibitors
u And possibly SSRI u MAO-I more common now with Parkinson's Pts.
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Normeperidine causes seizures
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Weak opioid agonist
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Became DEA Schedule IV in August 2014
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? Some antidepressant effect
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May not add much coadministered with conventional
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u Difficult to crush/dissolve/snort
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u Naltrexone pellets pass thru gut intact if not
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u Form a viscous gel when dissolved that is
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u Not available yet
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Table must have dose intervals
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Cross tolerance imperfect
u Reduce answer by 50% u Don't use a conversion table
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Hit rate a marker of strength
u 1/hr is strong, 3/hr is weak u Can’t sustain more than 3 demand injections/hr u Demand dose must be big enough to work, or they won't hit
it
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Basal rates are not for pain
u Basal rates bad (mortality) u Ignore opioid dose need to "break" the crisis
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(J. Pain Sym. Man. 14:202-209, 1997)
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Results of 6000 patients utilizing PCA
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Retrospective chart review
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Overall incidence of “life threatening” complication = 0.28%
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When used with basal rate life threatening complications increased to 1%
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Hypoxemia = 6% (<90%)
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Respiratory depression = 2% (<8 b/m)
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u Split opioid out from tylenol
F Pure hydromorphone usually not available
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Cheap
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Not dependent on IV access
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No conversion needed for hospital discharge
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Guaranteed to get an arousability assessment before each dose
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No (real world) difference in speed of onset
u IV prn for procedures
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EXCEPT can't store at the bedside for oral PCA
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Don't need permission
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Don't get a hamburger and a PCA
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Don't hit your button unless you've taken your pill
u Make pill prn frequent (so they can stack) u Take button away if they aren't taking their pill
n Another advantage or oral opioids: can't get
u If they stay, they may actually need to stay
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You get "x" when you come to the hospital
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You agree to go back to orals at "y" rate
u Otherwise it is not a contract, it is just a recipe u Ok to delay conversion if they can't take PO's yet
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Only get meds from me
u Call me immediately if you get run over by a bus
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Agree to random drug tests
u Looking for other drugs u Looking for the drugs they are SUPPOSED to be taking
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If you are non-compliant you will be fired from my clinic
u "It isn't safe to prescribe these medications if you don't cooperate
with the safety measures"
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What "extra" do they have on hospital discharge because they weren't using it at home?
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Book quick outpatient visit so you don't have to prescribe much
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"Leftovers" at home
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Primary care doc familiar with the drug and it's titration
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Local pharmacy stocks it
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Insurance covers it
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u Cutting all PO combo agents to lower doses
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u $35++ per vial u Split the vial 500/500 u Insurance carve-out
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u Naprosyn better
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Trelle S et al. BMJ 2011
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31 RCT with 116K patients
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MI (Rate Ratio)
u Naprosyn 0.82 (0.37 to 1.67) u Ibuprofen 1.61 (0.5 to 5.77) u Rofecoxib 2.12 (1.26 to 3.56)
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Cardiovascular Death (Rate Ratio)
u Naprosyn 0.98 (0.41 to 2.37) u Ibuprofen 2.39 (0.69 to 8.64) u Rofecoxib 1.58 (0.88 to 2.84)
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Trelle S et al. BMJ 2011
Trelle S et al. BMJ 2011
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u Don’t have to load pregabalin as much u Gabapentin can start at 300 - 600 mg po TID as an
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u Sleep
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Mishriky BM et al. Brit J Anaes 2014
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55 RCTs with 4155 patients
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Significant reduction in
u Pain score at rest (-0.38) u Pain with movement (-0.47) u Morphine equivalents (-8.27 mg) u PONV (RR 0.62, 0.48-0.80) u Pruritus (RR 0.49, 0.34-0.70)
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Significant increase in
u Sedation (RR 1.46, 1.08-1.98) u Dizziness (RR 1.33, 1.07-1.64) u Visual disturbance (RR 3.52, 2.05-6.04)
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Exercise / PT
u Improve sleep
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The gold standard: cure the underlying disease
u Remove the painful stimulus
F Trach the intubated ICU patient F Remove foley, NG tube, etc. n
Separates the symptom management from the disease treatment
u Serve as a consult service: do not write orders if possible
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Interventional therapy
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Exotic non-opioid adjuncts
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Physical therapy
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Psych
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Support / Advice