Chronic Pain Case

[Noyac]

I don't know how this will go over here but here goes.

My group was consulted to assist with pain control on an inpt with new onset rectal cancer undergoing radiation and chemo after having a diverting colostomy. He is otherwise healthy but has some psych issues which have not been fully determined. Middle aged, 5'10" 180lbs. No home meds. No allergies on admission. Fentanyl was added as an allergy after admission because of hallucinations. Pain meds tried are fentanyl patch, dilaudid (works best), MS, Ativan, oxycodone and hydrocodone with Tylenol.
The consult asks, please help us in managing this pts pain while he is admitted and receiving radiation therapy.
What's your plan?
I am posting this because as we are pushed out of the OR by midlevels and administrations across the nation, we need to show our worth on staff. Other physicians will occasionally consult you when they have exhausted all resources and if you bring something to the table then maybe just maybe you we will survive.
Also, I want to drive home to the residents out there the importance of doing some pain management rotations while in residency. You don't need a fellowship to know how to manage pts like this.

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[deleted171991]

Ketamine gtt, ketorolac q6h, tylenol q6h, well-titrated dilaudid PCA, ativan PRN.

Pain rules; I love it almost as much as CCM. Pity the procedures are sham, and the patients are psych.

 

[Planktonmd]

I don't know how this will go over here but here goes.

My group was consulted to assist with pain control on an inpt with new onset rectal cancer undergoing radiation and chemo after having a diverting colostomy. He is otherwise healthy but has some psych issues which have not been fully determined. Middle aged, 5'10" 180lbs. No home meds. No allergies on admission. Fentanyl was added as an allergy after admission because of hallucinations. Pain meds tried are fentanyl patch, dilaudid (works best), MS, Ativan, oxycodone and hydrocodone with Tylenol.
The consult asks, please help us in managing this pts pain while he is admitted and receiving radiation therapy.
What's your plan?
I am posting this because as we are pushed out of the OR by midlevels and administrations across the nation, we need to show our worth on staff. Other physicians will occasionally consult you when they have exhausted all resources and if you bring something to the table then maybe just maybe you we will survive.
Also, I want to drive home to the residents out there the importance of doing some pain management rotations while in residency. You don't need a fellowship to know how to manage pts like this.

The consult is for:
1- Managing the acute pain in an opiate naïve patient, while he is in the hospital, and receiving radiation therapy,
2- Come up with a transition plan to pain management as an outpatient since the patient is likely to suffer of pain related to the effects of radiation to the pelvic area.
It all depends on how bad the acute pain is and on the discharge plan:
So if the pain is intolerable , I would be compelled to place and epidural for a few days then gradually transition to PO meds.
If the pain is at least partially manageable by the current opiates, I would start an IV PCA of Hydromorphone and transition gradually to PO Opiates.
In addition to those modalities you need to address insomnia, anxiety and depression secondary to the underlying psych issue mentioned and the recent diagnosis of cancer.
We can add a Benzo and an SSRI, or involve Psychiatry to get a better evaluation of the "undetermined psych issues"

 

[Noyac]

Ketamine gtt, ketorolac q6h, tylenol q6h, dilaudid PCA (PRN only), ativan PRN.

Pain rules; I love it almost as much as CCM. Pity the procedures are sham, and the patients are psych.

Did you see the comment about the "hallucinations"?

 

[Robotic Wis-Hipple]

Well, a sprinkling of Ketamine probably isn't the board answer here but I still may use it as second line/escalation if necessary (with versed/Ativan).

Scheduled Tylenol, scheduled oxy. I think toradol works great for a short term as well. Depending on floor/nursing rules or experience you could add IV lido and Mg. I'm not convinced neurontin does anything other than snow patients but I'd imagine there's some evidence for it in post radiation pain so I'd probably try it with up-titration qpm.

As far as interventional adjuncts I'd think an epidural is the way to go while in house. But the real issue is finding a home regimen that will work, which I'm going to guess will be multimodal and benefit from some psych evaluation/coping strategies.

 

[deleted171991]

Extra points for what I missed/misunderstood and Plankton noticed (hint: it's not the hallucinations).

 

[deleted171991]

Did you see the comment about the "hallucinations"?

Yep. Never stopped me from giving analgesic-level ketamine.

Good ED docs use ketamine+midaz to calm down drunk and disorderly. So no, I am not a big believer in ketamine-induced "hallucinations" in an awake patient.

Also, many people underestimate the delirium-inducing qualities of a hospital stay and/or pain in elderly (not really the case if middle-aged).

 

[Noyac]

The consult is for:
1- Managing the acute pain in an opiate naïve patient, while he is in the hospital, and receiving radiation therapy,
2- Come up with a transition plan to pain management as an outpatient since the patient is likely to suffer of pain related to the effects of radiation to the pelvic area.
It all depends on how bad the acute pain is and on the discharge plan:
So if the pain is intolerable , I would be compelled to place and epidural for a few days then gradually transition to PO meds.
If the pain is at least partially manageable by the current opiates, I would start an IV PCA of Hydromorphone and transition gradually to PO Opiates.
In addition to those modalities you need to address insomnia, anxiety and depression secondary to the underlying psych issue mentioned and the recent diagnosis of cancer.
We can add a Benzo and an SSRI, or involve Psychiatry to get a better evaluation of the "undetermined psych issues"

Sorry, I could have given a bit more information.
The pt is currently on IV PCA.
His hallucinations have not been narrowed down to the actual medication that caused it. Basically, the hospitalization are guessing that it is fentanyl but he had fentanyl for the colostomy without any issues.
His pain is described as 5-10/10 always. He can't sit down. He can't sleep well. The rectum is constantly sloughing material presumedly from the radiation.
He claims zero benefit from opioids.

Yes, Psychiatry is scheduled to visit but he needs some pain control.

 

[pgg]

In addition to whatever acute stuff you settle on, consider starting him on methadone. Like ketamine you get some NMDA agonism, but unlike ketamine he can go home with it.

 

[deleted171991]

Sorry, I could have given a bit more information.
The pt is currently on IV PCA.
His hallucinations have not been narrowed down to the actual medication that caused it. Basically, the hospitalization are guessing that it is fentanyl but he had fentanyl for the colostomy without any issues.
His pain is described as 5-10/10 always. He can't sit down. He can't sleep well. The rectum is constantly sloughing material presumedly from the radiation.
He claims zero benefit from opioids.

Yes, Psychiatry is scheduled to visit but he needs some pain control.

My money is on hallucinations/delirium from pain + inpatient + drugs, not psych.

I would still stick to my plan, minus Ativan, plus/minus regional, plus/minus @pgg's methadone instead of ketamine (always forget about it because I don't have it IV, and ketamine is much easier to titrate for uncontrolled pain).

Anyway, great thread to remind us of what we see so frequently: surgeons suck at pain management (huge opportunity for karma for the anesthesia group).

 

[Noyac]

Yep you guys are on the right track. As usual.
I have recommended methadone t this group of docs before but for some reason they are afraid of it. Plus, I don't really think it will handle his acute pain well.
I tried a few things before going to what was ultimately his best option. I tried Demerol, since I find it frequently covers acute pain in combination with the dilaudid pretty well and gave him a Mg++ infusion. This seemed to work fairly well subjectively. But I was obvious it wasn't going to cut it. I also switched the Ativan to Valium. Which was better for some reason and I don't really have a great explanation for it.

But none of this was enough, so I placed an epidural. He is scheduled to be in house for at least a couple more weeks.
What's your plan?
How effective is an epidural for rectal pain? What level will you place it? He needs to be able to ambulate.

 

[Planktonmd]

Sorry, I could have given a bit more information.
The pt is currently on IV PCA.
His hallucinations have not been narrowed down to the actual medication that caused it. Basically, the hospitalization are guessing that it is fentanyl but he had fentanyl for the colostomy without any issues.
His pain is described as 5-10/10 always. He can't sit down. He can't sleep well. The rectum is constantly sloughing material presumedly from the radiation.
He claims zero benefit from opioids.

Yes, Psychiatry is scheduled to visit but he needs some pain control.

Epidural Then gradually multimodal PO regimen.

 

[deleted171991]

But none of this was enough, so I placed an epidural. He is scheduled to be in house for at least a couple more weeks.
What's your plan?
How effective is an epidural for rectal pain? What level will you place it? He needs to be able to ambulate.

O Captain Ketamine! My Ketamine!

 

[Hoya11]

I don't know how this will go over here but here goes.

My group was consulted to assist with pain control on an inpt with new onset rectal cancer undergoing radiation and chemo after having a diverting colostomy. He is otherwise healthy but has some psych issues which have not been fully determined. Middle aged, 5'10" 180lbs. No home meds. No allergies on admission. Fentanyl was added as an allergy after admission because of hallucinations. Pain meds tried are fentanyl patch, dilaudid (works best), MS, Ativan, oxycodone and hydrocodone with Tylenol.
The consult asks, please help us in managing this pts pain while he is admitted and receiving radiation therapy.
What's your plan?
I am posting this because as we are pushed out of the OR by midlevels and administrations across the nation, we need to show our worth on staff. Other physicians will occasionally consult you when they have exhausted all resources and if you bring something to the table then maybe just maybe you we will survive.
Also, I want to drive home to the residents out there the importance of doing some pain management rotations while in residency. You don't need a fellowship to know how to manage pts like this.

One thing to keep in mind is how likely is this the end for this guy? Assuming there is a reasonable chance of recovery and we are not heading towards hospice...



Tylenol 1g TID transition to BID.

These guys are usually already on steroids but if not put them on decadron..
I wouldnt do NSAIDs with steroids but if no steroids IV toradol 30 q6 sounds good or even PO celebrex, pick your NSAID.

Keep him on the dilaudid PCA with Oxycontin 40 BID in the background.
Then Get him off the PCA onto oxy 20/15/10 sliding scale.
He goes home on the oxy/oxy.

Neurontin 300, 300, 600. He goes home on it
Valium 5-10QHS for home too.

NO ketamine. I think ketamine, lido and Mg++ are a total scam. Ive seen them in real life many times and I feel strongly that they do nothing. Everyone has stories otherwise. All i can say is I dont. ANd I do indeed think ketamine could make an awake person hallucinate at any dose. The fancy drug I would prefer (if hes in the unit and in agony) would be precedex at 0.5 in addition to the above.

That would be the medical management...

For interventions your considering: Continuous epidural (probably the way to go) , Caudal block single shot (blind or under fluoro) , or a ganglion impar block (longest lasting, but not super helpful acutely). For the acute pain, if warranted, I would do an epidural catheter. Caudal would get good sacral coverage but no catheter (unless you want to get really fancy under fluoro). I would only go the caudal route if poor epidural relief. Ganglion impar as mentioned would be more for long term pain and I would offer it after the epidural came out prior to DC.

 

[deleted171991]

NO ketamine. I think ketamine, lido and Mg++ are a total scam. Ive seen them in real life many times and I feel strongly that they do nothing. Everyone has stories otherwise. All i can say is I dont. ANd I do indeed think ketamine could make an awake person hallucinate at any dose. The fancy drug I would prefer (if hes in the unit and in agony) would be precedex at 0.5 in addition to the above..

I have stories about going from 300 mg daily IV morphine and 10/10 screaming pain to analgesic ketamine infusion, toradol and barely touched dilaudid PCA with 0-1/10 pain in under 12 hours. Or treating opiate-"allergic" patient with CRPS flare (10/10 screaming) after hysteroscopy with almost anesthetic level ketamine (she needed 0.5 mg/kg/hr for 48-72 hours, total pain control achieved in 6 hours, went home with nothing). So yeah, big "belieber" here.

But those were not opioid naive patients like here (that was the part I had missed above).

Btw, what you say is pretty interesting coming from a pain doc.

 

[deleted162650]

How bout a caudal cath in lieu of an epidural? With careful dosing (low) you might be able to get better coverage without the leg weakness.

 

[Robotic Wis-Hipple]

And I think Mg works great. Lidocaine I'm less high on but I think it does something, even if it's just sedating like neurontin. But let's be honest, if there was good evidence based medicine for cancer pain/chronic pain we wouldn't be where we are now. It's definitely a bit of educated trial and error. I just don't think 20mg Ketamine or a low dose infusion is sending people into Pink Floyd land. Especially when he's already there "from fentanyl"....

But, I think pgg has the right answer, all the acute stuff +\- epidural (I'm definitely for it to gain acute control) and add methadone for mdma/outpt.

 

[dhb]

I'd do a continous spinal with heavy bupivacaine +-morphine in the spinal 0/10 pain garanteed

 

[divinemsm]

If he's on the end of life trajectory -why not a trial hypogastric plexus block to see if it helps ? Then do the definitive procedure if it does ?

 

[Planktonmd]

I'd do a continous spinal with heavy bupivacaine +-morphine in the spinal 0/10 pain garanteed

You might need to keep him in the sitting position all the time to keep the spinal confined to the sacral area, a little impractical IMHO!

 

[thinkorswim]

I'm a big fan of NMDA antagonists. In this patient, I agree that a low dose ketamine infusion would really be beneficial in addition to opioids and gabapentinoids.

I would also consider using tramadol for discharge -- it will lower total opioid use and may help with the depression.

 

[Noyac]

Well Hoya and Divine nailed it.
This guy described pain from rectum as most intense however he also had upper abdominal pain as well. So I placed an epidural at the upper lumbar location and started it with 0.625 ropiv with fentanyl. I fully expected it to not be enough but the guy was actually real comfortable. I ran it for 5 days and then pulled it. Then I brought him to our block room and did a hypogastic plexus block with a ganglion impar. He was continued on his oxycodone for maintenance.

I had never done either one of these blocks but I do lumbar sympathetic blocks occasion. The hypogastic is no different and the impar is about as simple as a block can be.

 

[Noyac]

Btw, ketamine is interesting as some of you have mentioned and I've done an infusion for pts with CRPSwith very good results. But as someone who has actually had ketamine before most recently last week I wouldn't advise using it in someone with hallucinations until a last resort. It's for real.

 

[Planktonmd]

Btw, ketamine is interesting as some of you have mentioned and I've done an infusion for pts with CRPSwith very good results. But as someone who has actually had ketamine before most recently last week I wouldn't advise using it in someone with hallucinations until a last resort. It's for real.

You had Ketamine last week?

 

[PainDrain]

From an interventional pain standpoint this guy could benefit from a superior hypogastric plexus or ganglion impar block. I would start by doing a block using local anesthetic then consider chemoablation if local provides relief. Rectal pain responds well to impar block and superior hypogastric for more pelvic pain.

You may want to add gabapentin or lyrica to help decrease the opiate doses. I would add ketamine low-dose infusion. Could also consider precedex, lidocaine and magnesium infusions to decrease opiate doses and provide pain relief.

 

[PainDrain]

Whoops, posted before reading Noys response.

 

[nimbus]

You guys are so smart. I've never even heard the word impar before. Had to look it up. Love SDN anesthesia.

 

[Noyac]

You had Ketamine last week?

Yep. I don't know how much but I could tell I had it. It's a weird feeling. I don't like it much.

 

[Noyac]

You guys are so smart. I've never even heard the word impar before. Had to look it up. Love SDN anesthesia.

Trust me, I'm not in the ballpark on this site when it comes to smart guys.
But I had what I believe was exceptional training from my institution and it wasn't an ivory tower type place. It's probably not on many people's top 10 list either. But it was a high volume place that did everything except transplants. No fellows except for pain and Peds
It's what I preach on this site from time to time. Leave the Ivory towers for those that want to stay in academics. Maybe go there for fellowship. But go to a well rounded high volume low fellow residency and do as many cases as possible. Stick your neck in all areas. If something really strikes you then do a fellowship but if you are happy with your training and you have enough cases under your belt to do just about anything out there with few exceptions then you might just find that you saved a year and you are ready to tackle PP.
Maybe times have changed, IDK. Good luck.

 

[deleted162650]

I could tell I had it

Are we talkin' medically or recreationally here?

John Drummond (authored a couple of the neuro chapters in Miller) and colleagues did a lot of the early work on how anesthetics affect SSEPs/MEPs on each other. He told me he didn't care for ketamine as he ended up staring at the corner of the room where the walls met the ceiling and got really irritated because he couldn't decide just exactly where the corner was.

 

[Noyac]

Medically and Dr Drummond describes it well.
I mostly felt looped. It cleared petty quickly but it was weird.

 

[dhb]

Drummond nailed it

 

[Noyac]

I would describe it sort like being at that point when you are really really drunk just before you black out. But you never really go over that edge with the ketamine since it's going away pretty quickly and you haven't really lost control of you faculties like with ETOH. it's like your head wants to spin but doesn't really go that far.

The recreational users describe it well when they say, " I'm going down a K hole."

 

[dhb]

Well i would guess it depends on the dose if you go over the top or not.
A 250mg bolus would probably get you pretty high.
But or else yeah your brain keeps working alright.

 

[cleansocks]

Well Hoya and Divine nailed it.
This guy described pain from rectum as most intense however he also had upper abdominal pain as well. So I placed an epidural at the upper lumbar location and started it with 0.625 ropiv with fentanyl. I fully expected it to not be enough but the guy was actually real comfortable. I ran it for 5 days and then pulled it. Then I brought him to our block room and did a hypogastic plexus block with a ganglion impar. He was continued on his oxycodone for maintenance.

I had never done either one of these blocks but I do lumbar sympathetic blocks occasion. The hypogastic is no different and the impar is about as simple as a block can be.

How do you tend to perform these blocks (US, landmark, fluoro) and where did you learn them? Do you have a chronic pain background?

 

[deleted171991]

You guys are so smart. I've never even heard the word impar before. Had to look it up. Love SDN anesthesia.

+1.

Except that I remotely remember that most neurolytic blocks wear off in up to 6 months.

 

[deleted9493]

Yep you guys are on the right track. As usual.
I have recommended methadone t this group of docs before but for some reason they are afraid of it. Plus, I don't really think it will handle his acute pain well.
I tried a few things before going to what was ultimately his best option. I tried Demerol, since I find it frequently covers acute pain in combination with the dilaudid pretty well and gave him a Mg++ infusion. This seemed to work fairly well subjectively. But I was obvious it wasn't going to cut it. I also switched the Ativan to Valium. Which was better for some reason and I don't really have a great explanation for it.

But none of this was enough, so I placed an epidural. He is scheduled to be in house for at least a couple more weeks.
What's your plan?
How effective is an epidural for rectal pain? What level will you place it? He needs to be able to ambulate.

Methadone is a wonderful drug for acute pain. Its CNS equilibration half-time is similar to that of hydromorphone. If he was undergoing a general anesthetic, I'd load him with .2mg/kg and then start a maintenance infusion of .01mg/kg/hr into the postoperative period.

Outside of the surgical context, a slow load followed by continuous infusion as described here works well: https://www.ncbi.nlm.nih.gov/pubmed/2793918

I've used it quite a lot for pediatric pain management and love it.

 

[Noyac]

+1.

Except that I remotely remember that most neurolytic blocks wear off in up to 6 months.

With the Ganglion Impar block you can hope for 6 months of relief which by that time the tumor will have shrunk and the pain will have resolved or at least deminished tremendously.
I have done celiac plexus blocks with a neurolytic (phenol) and those last a lifetime. Unfortunately, that lifetime isn't 6 months so it's hard to know how long they last.
The Impar could be performed with a neurolytic in someone that isn't terminal to my understanding but I'm not sure if it returns or if it even matters. You would think that by 6 months the issue would be resolved or improved.
So I think your 6 month theory is really dependent. Again, IDK.

 

[Noyac]

How do you tend to perform these blocks (US, landmark, fluoro) and where did you learn them? Do you have a chronic pain background?

IT depends on the block. I do stellate ganglion blocks by landmark. Lumbar sympathetic with Fluoro I did hpthese two blocks with Fluoro. I do cervical epidurals with one or the other but I prefer Fluoro. Lumbar epidural steroid usually with Fluoro. It's just nice to be able to show the pt the contrast and print up an image for the chart.

I had a fantastic Pain attending, Steve Abrams. He taught us both landmark and Fluoro. Even CT guided for things like celiac plexus. All of this was available to us as residents. I ended up doing 6 months cardiac (including Ped's cardiac) and 6 months of pain in my last 18 months of residency. Our numbers were high.

 

[Planktonmd]

+1.

Except that I remotely remember that most neurolytic blocks wear off in up to 6 months.

they do my friend.

 

[deleted162650]

Well i would guess it depends on the dose if you go over the top or not.
A 250mg bolus would probably get you pretty high.
But or else yeah your brain keeps working alright.

At higher doses is where the dissociative aspect kicks in. It's been described as very similar to the "out of body" experience you get from a "near death" experience.

I found it interesting that the only drugs Drummond and friends all said (universally) were enjoyable were the barbiturates. Warm and fuzzy all over. They didn't like narcs, and Precedex f*cks with your sleep/wake cycle for days apparently.

 

[narcusprince]

I see a lot of folks prescribing Nsaids on someone with a fresh anastamosis now receiving radiation. I would start with Dilaudid PCA also starting methadone in house may have some utility as if he hallucinates it happens in house versus home. Agreed address sleep and depression with psych.

 

[lobelsteve]

IT depends on the block. I do stellate ganglion blocks by landmark. Lumbar sympathetic with Fluoro I did hpthese two blocks with Fluoro. I do cervical epidurals with one or the other but I prefer Fluoro. Lumbar epidural steroid usually with Fluoro. It's just nice to be able to show the pt the contrast and print up an image for the chart.

I had a fantastic Pain attending, Steve Abrams. He taught us both landmark and Fluoro. Even CT guided for things like celiac plexus. All of this was available to us as residents. I ended up doing 6 months cardiac (including Ped's cardiac) and 6 months of pain in my last 18 months of residency. Our numbers were high.

LESI without fluoro being done for pain mgmt is bogus. And next year you get your new code to separate from image guided epidurals.

 

[Noyac]

LESI without fluoro being done for pain mgmt is bogus. And next year you get your new code to separate from image guided epidurals.

I know what your talking about.
But I also know that not ever single LESI requires Fluoro.
I do very very few these days. Usually the ones that the PM&R guys can't or won't do. Therefore, I use Fluoro.
Bogus is strong statement. It's like saying you can't do regional without US. That's bull****.

 

[lobelsteve]

I know what your talking about.
But I also know that not ever single LESI requires Fluoro.
I do very very few these days. Usually the ones that the PM&R guys can't or won't do. Therefore, I use Fluoro.
Bogus is strong statement. It's like saying you can't do regional without US. That's bull****.

https://www.ncbi.nlm.nih.gov/pubmed/27288943

 

[Noyac]

Yep. I know the literature. Thanks.

You saw that I said usually with Fluoro, right?

 

[PainDrain]

So both blocks should be done with fluoro, or CT if available. The risk with a neuro lyric ganglion impar is bowel and possibly bladder incontinence; not a concern with someone with an ostomy. Also there is a risk of rectal perforation so I shoot dye whenever I do them so I ensure no perf and no vascular uptake. The sup hypogastric is fairly simple as well but I have found less effective overall.

Celiac plexus blocks are great for cancer pain, less so for chronic pancreatitis.

Also cancer is perhaps the only time I will consider doing an intrathecal pump. They can be very effective in the terminally ill who have exhausted all other options. MS spasticity treatment using baclofen is also an indication but baclofen can be a dangerous drug.

 

[lobelsteve]

Yep. I know the literature. Thanks.

You saw that I said usually with Fluoro, right?

It was tongue in cheek. look at the authors.

 

[Noyac]

It was tongue in cheek. look at the authors.

Ha ha. You got me. Well played my friend.

 

[sigrhoillusion]

Well Hoya and Divine nailed it.
This guy described pain from rectum as most intense however he also had upper abdominal pain as well. So I placed an epidural at the upper lumbar location and started it with 0.625 ropiv with fentanyl. I fully expected it to not be enough but the guy was actually real comfortable. I ran it for 5 days and then pulled it. Then I brought him to our block room and did a hypogastic plexus block with a ganglion impar. He was continued on his oxycodone for maintenance.

I had never done either one of these blocks but I do lumbar sympathetic blocks occasion. The hypogastic is no different and the impar is about as simple as a block can be.

So you were able to do a hypogastric and impar block under fluoro? I've never done one before. Would love to try one, but can't imagine doing one unless I had one of the chronic pain guys there helping out. How did you go about doing it? Use fluoro? And if so, how did you go about doing it resource wise?

Also, and a little off topic, just talked to a former colleague who did pain fellowship. She's up in Canada and they do 1 hour ketamine/lido infusions for chronic pain patients. They see them every 2 months. Bill $200/treatment, and patient pays $30. They do like 10-20/day. Damn... went into the wrong fellowship... haha.