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Case Scenarios

Case Scenarios. Critical Thinking. Case 1.

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Case Scenarios

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  1. Case Scenarios Critical Thinking

  2. Case 1 • You get a call from your patient s/p TKA.  A 67 year old female. They complain of 9/10.  They have a femoral nerve catheter. It has a continuous infusion at 8 cc/hr of 0.25% bupivacaine. They have a PCA ordered with morphine: demand-1 mg, lockout-10 minutes, max-6mg.

  3. Case 1 • What further information would be helpful? • What further evaluation would be helpful? • What interventions are reasonable? • What side effects should we be cognizant of?

  4. Case 1 • What further information would be helpful? • Age of patient • Time of day • How many hours post op • What PT regimen and when • Pre op pain medication regimen • Co morbidities • What further evaluation would be helpful? • What interventions are reasonable? • What side effects should we be cognizant of?

  5. Case 1 • What further information would be helpful? • What further evaluation would be helpful? • Location of Pain (knee or other site, front or back) • Aching or Sharp • Dressing (too tight?) • How many demands pt attempted/received • Peripheral nerve catheter (connected/pump on) • Block in Femoral nerve distribution • What interventions are reasonable? • What side effects should we be cognizant of?

  6. Case 1 • What further information would be helpful? • What further evaluation would be helpful? • What interventions are reasonable? • Loosen dressing • Bolus through peripheral nerve catheter • Increase demand, or increase max allowed per hour • Other modalities-NSAIDs, Tylenol • What side effects should we be cognizant of?

  7. Case 1 • What further information would be helpful? • What further evaluation would be helpful? • What interventions are reasonable? • What side effects should we be cognizant of? • Increase morphine dose-pruritis, nausea/vomiting, urinary retention, somnolence, respiratory depression, cognitive impairment • bolus or increase LA infusion-toxicity from LA, arrythmias, agitation, somnolence, seizures • Bolus or increase LA infusion-extreme weakness in extremity>>falls • NSAID-kidney function, upper GI bleeding, liver problems.

  8. Case 2 • You are caring for a 72 year old female S/P TKA. She has a lumbar plexus catheter and a sciatic nerve catheter. The LP catheter is 0.125% bupivacain @ 10 mL/hr and the sciatic nerve catheter is 0.125% bupivacaine @ 3m mL/hr. She is POD 2, and has been doing well. Now she appears more lethargic, and when questioned answers with slurring speech and jumbled words. She has a percocet 1 5mg/500mg q4 hr ordered PRN.

  9. Case 2 • What further information would be helpful? • Co morbidities (previous demention) • Time of day or night this started • How much percocet can you verify she received • Any other symptoms? • What further evaluation would be helpful? • What interventions are reasonable? • What side effects should we be cognizant of?

  10. Case 2 • What further information would be helpful? • What further evaluation would be helpful? • Are her vital signs changed? • Pulse oximeter? • Are pumps functioning appropriately? • What interventions are reasonable? • What side effects should we be cognizant of?

  11. Case 2 • What further information would be helpful? • What further evaluation would be helpful? • What interventions are reasonable? • Stop possible offending medications-LA • Close follow up of patient • Avoid giving additional percocet • What side effects should we be cognizant of?

  12. Case 2 • What further information would be helpful? • What further evaluation would be helpful? • What interventions are reasonable? • What side effects should we be cognizant of? • Block may regress if infusion d/c’d for too long-pain • LA toxicity could result in seizures or even cardiac arrest.

  13. Case 3 • A 75 year old male POD 0 s/p cholecystectomy calls the nurse complaining of weakness. You come to the room and notice a patient who is breathing heavily and sweating profusely. He says that he doesn’t feel well. • VSS-BP 110/80, HR-130, sats 97%- Temp 99F RR 22. • Med list: insulin R (SSI), metoprolol, lisinopril, zofran, meperidine pca demand 20 mg, lock out 5 minutes, max dose 100 mg/hr. • H/o DM II, S/P CABG x 10 years ago, HTN, and prostate ca.

  14. Case 3 • EKG

  15. Case 3 • What history would help us determine most likely cause for patients sx. • What could account for his symptoms. • How could this be prevented or risk reduced.

  16. Case 3 • Cardiology consulted, echo showed EF of 30%, and chest xray showed mild pulmonary edema. Pt given lasix 40 mg IV times one. • HR controled with metoprolol 5mg IV Q 4 hr. • Pt HR decreases, ST depression improves, Enzymes come back negative pt improves. • POD 1. Pt still experiencing significant pain, hitting demand Q 6 min getting max demerol each hour. • POD 1 8pm, Pt is agitated, shouting, and appears to be suffering from acute auditory & visual hallucinations.

  17. Case 3 • What is cause? • Why? • What lab value could give us a clue to etiology? • BUN/Cr-40/2.5 >>ARF

  18. Case 3 • Summary • Meperidine synthesized in 1939 as an anti-cholingergic (atropine like med). Implications! • Metabolism-liver to normeperidine-active metabolite-renal elimination. Will accumulate in renal dysnfuntion. Can result in seizures or other CNS excitatory symptoms. • Thought to inhibit serotonin (5-HT) reuptake and NE reuptake-can lead to an excitation syndrome known as serotonin syndrome in pts on other medications that inhibit reuptake of serotonin.

  19. Case 4- • Patient is s/p ORIF of ankle after a fall. She is 44 years old. • PMH sig for HTN, chronic pain, and recent fainting spells for which she has not been evaluated. • Med list-methadone 120 mg/day, percocet 10/500 for breakthrough pain (6 pills per day).

  20. Case 4 • Comes to floor after surgery with PCA orders of basal rate of 0.25 mg/hr dilaudid, demand of 1 mg, lockout of 10 minutes and max 1 hour dose of 6 mg. • What concerns do you have with this pt? • What do you expect to find with this pt? • What if order was Demand of 0.5 mg, lockout 10 min. with max 1 hour limit of 2mg?

  21. Case 4 • Need to consider appropriate dose for someone on chronic methadone: Conversion tables or web based calculators • http://www.globalrph.com/narcotic.cgi • Use calculator above, estimated dose is 11.25 mg/day of dilaudid just to get baseline methadone covered. Basal is only 6 mg. • This doesn’t include Percocet’s she takes. • Equivalent dilaudid daily dose is 2.24 mg. • Probably best to restart their regular methadone regimen for background, and add opioids to this as needed.

  22. Case 4 • If the dose Rx is too low in this pt, what symptoms are we going to see? • Piloerection • Mydriasis • Abdominal pain • Tachycardia • Diaphoresis and fevers +/- chills • Achy joints

  23. What pain medications could cause the symptoms just discussed? • Pentazocine (Talwin) • Nalbuphine (Nubain) • Butorphanol (Stadol) • Buprenorphine (Buprenex) • Tend to be antagonists at μ-receptor, but agonists at the κ receptor

  24. Case 4- • Rare cases of prolonged QTc and Torsades de Pointes • female sex, • hypokalemia, • high-dose methadone, • Drug interactions, • underlying cardiac conditions, • unrecognized congenital long Q-T interval syndrome, and predisposing DNA polymorphisms.

  25. Case 5 • A 63 M s/p ex lap and colon resection for diverticulitis. He has a h/o THA and is currently scheduled to undergo THA of the other hip. During his previous THA his pain control was inadequate. For the last 2 months he has been on SR morphine 30 mg and Percocet 5mg/500mg.

  26. Case 5 • What factors in this pt’s history may impact on his expected post op pain control? • Some studies suggest that pre operative pain levels predict severity of post operative pain. • Psychiatric state (depression, anxiety, fear, sense of helplessness) can be a marker for greater post operative pain. • Pre operative quantitative sensory testing (QST) may predict up to 54% of the variance in post operative pain. This is superior to other predictors. • Opioid tolerance from his pre operative use of SR morphine and percocet. Also consider OIH • Genetic factors

  27. Case 5 • What organ systems might be adversely affected by inadequate pain control after this surgery? • Lungs-small Vt and no cough atelectasis, hypoxemia • Pain EPI, NE tachycardia, vasoconstriction ischemia, dysrhythmias, HTN • GI-decreased motility, ileus • Urinary-increased urinary bladder sphincter tone • Endocrine-increased catabolism & neg nitrogen balance • Coagulation-increased coagulobility from stress response • SSI-Chang, Chuen-Chau; Lin, Hsiu-Chen; Lin, Hui-Wen; Lin, Herng-ChingAnesthesiology. 113(2):279-284, August 2010. Pts with regional anesthesia reduced SSI by ½.

  28. Case 6 • 48 M S/P I&D septic knee joint. • PMH-RA, UC s/p colectomy w/ colostomy, IgA nephropathy, CAD, Restless leg syndrome • Surgeries-Multiple back surgeries, Colectomy with colostomy, and I&D knee jt x 2. • Meds: • Hospital-vanc, zosyn, lyrica, requip 2mg tid, Dilaudid 1 to 2 mg q 2 to 3 hrs prn, zofran, lovenox, flomax, phenergan, Demerol • Home-IV ig, tylenol, phenergan , albuterol, pulmicort, flonase, nortiptyline, plaquenil, Diluadid BID, Opana ER • Allergies-Morphine, oxycodone, reglan, flagyl, fentanyl patch • Current pain level-7/10 both at surgical site and in back.

  29. Case 6 • Dilaudid PCA: Demand 1 mg, LI 10 minutes, Max 1 hr dose 3 mg. • Dilaudid to Morphine equivalency • Varies tremendously in literature- from 5 to 10 times. • Lehmann-found potency of Dilaudid to be 3 to 4 times Morphine in PCA study.

  30. Case 6 • NCA vs PCA

  31. Case 6-PCEA vs. CEI

  32. Case 6 • Risk factors for Respiratory depression • Background infusions • Nurse-physician controlled analgesia • Concomitant administration of hypnotics or sedatives • Renal, hepatic, pulmonary or cardiac impairment • OSA and/or obesity

  33. Case 7 • 62 M in holding for surgery for SBO. • PMH-severe PVD w/ B AKA, DM, hypothyroidism, renal insuficiency, previous alcoholic (quit 16 yrs ago), HTN, smoker, COPD, Chronic pain • Meds-Norco tid, metformin, glyburide, synthroid, albuterol, lisinopril • Pt c/o pain 7/10 in holding area. Surgery won’t start for another 45 minutes.

  34. Case 7 • What would you do? • I asked RN to give Fentanyl-response, “we can’t do that it is not safe”. I asked for their recommendation- • Toradol • Morphine • Demerol

  35. Treating acute pain-safer

  36. Safest?

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