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Pain Rounds 27 April 2011

Pain Rounds 27 April 2011. How much is too much? or “You will find medical culture different in Australia to the USA”. Jodie 48 yrs American Announced via warning e mail 2/52 pre Christmas 2010. Arriving from USA in several days on high dose IV opioids and Ketamine

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Pain Rounds 27 April 2011

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  1. Pain Rounds27 April 2011 How much is too much? or “You will find medical culture different in Australia to the USA”

  2. Jodie 48 yrs American Announced via warning e mail 2/52 pre Christmas 2010 • Arriving from USA in several days on high dose IV opioids and Ketamine • Many pages of previous medical history • Recurrent renal stones & fibromyalgia • HT • Diabetes type 2 • Migraine • GORD • Obesity • Self catheterisation – atonic bladder • Subclavian line sepsis

  3. Initial HIPS contact • Hayes/Nickerson appointment 2/7 after arrival in Australia • Analgesic medication: • Subclavian line regime - past 3 or 4 mths • IV hydromorphone 20mg/hr + boluses = daily oral morphine equivalent 5500mg • IV ketamine 20mg/hr + boluses • IV ketorolac 30mg boluses • Pregabalin 300mg tds • Nortriptyline 25 mg mane, 75mg nocte

  4. Initial HIPS contact • IV antibiotics for line sepsis (Merepenem) • Other medication: • Lorazepam 0.5 mg prn, Zolpidem 10mg • IV phenergan • Atenolol, Lisinopril • Pramipexole • Sumatriptan, ondansetron, metoclopramide • Lantus insulin 10units nocte, Metformin 1g bd • IV fluids to prevent dehydration

  5. Discussion with pharmacy • Jennie MacDonald cost estimate $80K yearly • Choice • Initial maintenance of regime over Christmas+ Or • Admission to rationalise medication

  6. Establishing priorities …

  7. Admission 17 December 2011 • Dr Rob Pickles • Intermittently drowsy, clammy, sweaty & complaining of poor analgesia • Metabolic acidosis - thought to be related to anti-inflammatory • Thrombocytopaenia - thought to be related to antibiotic

  8. Discharge 24 December 2011 • Analgesic regime: • IV ketamine/hydromorphone tapered & ceased • Norspan 20mcg/hr + Temgesic 0.2mcg x3/d • Clonidine cover 100mcg tds • Daily oral morphine equivalent 5500mg to 60mg • IV ketorolac ceased • Pregabalin switched to gabapentin 300mg tds

  9. Discharge 24 December 2011 • Metabolic acidosis - thought to be related to anti-inflammatory • Thrombocytopaenia - thought to be related to antibiotic • Sepsis • UTI klebsiella – ciprofloxacil 500mg bd during admission and for 1/52 • Central line left in situ, merepenem ceased • Medication for HT, diabetes, GORD continued

  10. What is going on?Diagnoses • Tolerance/ opioid induced hyperalgesia • Other adverse effects • Medical co-morbidities • Factitious ?

  11. Discharge 24 December 2011 • CT KUB clear of stones • Patient anxious ++ when jar of renal stones temporarily misplaced during admission

  12. Corroborative medical history • GP in USA • Mayo Clinic input • confirmed stones in early years • Multiple lithotripsies • One percutaneous stone removal • Palliative care physician input • Infected intrathecal pumps x2 • Escalation of opioid & other medication doses

  13. Progress – Jan/Feb 2011 • Maintaining boundaries • Dr A Powell + HIPS nursing staff

  14. Multidisciplinary assessment • 11 March 2011 – Pols, Daunt, Hayes • Pain History • 1st kidney stones in early 20’s • Increased formation rate since mid 30’s • 14 lithotripsies, multiple ureteric basket removals & 1 percutaneous surgery • Initial pain pattern typical of renal colic

  15. Multidisciplinary assessment • Pain History • Change 6 years ago with development of more generalised pain syndrome - fibromyalgia • Medically unexplained symptoms • Negative investigation for MS • Atonic bladder & bowel • Numbness & tingling R side of body • Shivers & sweats

  16. Multidisciplinary assessment • 2 years ago – input from palliative care physician • Intrathecal pumps x2 infected • Central line infected, removed then reinserted • Current pain • Total body pain syndrome with muscle tenderness • Intermittent waves of bilateral loin pain – patient related to passage of stones

  17. Multidisciplinary assessment • Activity • Intensive CBT program in 2009 • “learned some skills but no significant overall change” • Much of day resting in bed

  18. Multidisciplinary assessment • Life story • Married to Daniel for 20 years, clergyman • 2 teenage children • Work conflict 6 years ago – aggravation of pain • Difficult childhood with sustained sexual abuse 5-18 years. “Mum did not protect me” • Jodie unable to confront her mother about this prior to the mothers death • Coping via sporting/outdoor activity • Worked in Girl Guides & disability sector – last work 2 years ago

  19. Overall Assessment • Persistent pain in the context of medical co-morbidities and a traumatic developmental history • Sensitised nervous system rather than structure • Possible gravel formation ?? • Opioid situation improved • Low physical activity • Possible factitious disorder

  20. Whole Person Management: reprogramming old patterns Actions Retrain the brain Awareness Biological Thoughts Lifestyle Restore the tissues Story Choosing

  21. Management Strategy • Understanding – mindbody connection • Biological • Rotate Oxycontin 10mg bd, Endone 5mg x3/d prn • In future alternate between oxycodone and hydromorphone • GP support re opioid boundaries • Dr A Gillies review – central line, IV fluids, stones • Nutrition - “Nutrition & Pain” • Activity – Moving with Pain offer • Story – “My Story”, Dr M Pols review

  22. Time for a break …

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