Help needed/pain management case

[cfdavid]

First, I just got done with a pretty elaborate case review of this patient, but somehow it got deleted when I hit send.....

So, let me bottom line this case.

I need to achieve good pain control as an outpatient in an 84 yo with a Rt. 1st toe stage 4 ischemic ulcer (ABI <4 and not a candidate for bypass or stenting).

Basically, this guy has severe PAD and we're spinning our wheels. Should be amputated according to vascular sx. Podiatry is with us doing beside debridements and WC. Expensive alternatives (bariatric tx/wound vac) that are not so well proven in these cases are out of the question.

Goal is to DC him to extended care facility with follow up to vascular or podiatry. ****BUT, we need an outpatient pain control plan for this guy.

PMH: CAD, HTN, DM, PAD, decubs/ischemic ulcers. Stage 4 (as mentioned) and Stage 2 saccral. Also, dementia 2/2 chronic ischemia

Currently, we're using Lortab 2.5-167/5ml (given in 15 ml) Elixir Q4hrs, with Morphine 2mg Q3 for breakthrough. (which is inadequate for him)


What can we do for adequate OP pain control until a decision to either amputate, or go strictly palliative (not mutually exclusive I know)is made by the family??

PCA?? Fentanyl patch?? He can be DC'd with a PICC line. Also, PO is an option as he can swallow.

Any help would be greatly appreciated.

CF

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[cfdavid]

I should clarify. This is a hypothetical case. This is a strictly academic, learning oriented topic. Not real life medical consultation.

Again, any help would be appreciated.

cf

 

[2ndyear]

I would keep it simple, he's not on mega-dose narcotics. You're not maxed out on the Lortab but it has acetominophen in it and that's 1g/day now. You could go up by a factor of 4. But the FDA met this summer and voted to lower the maximum daily dose of APAP from 4g to...well they didn't exactly come up with a number. So I wouldn't get too aggressive with pushing that one.

Opiate rotation is probably in order. Pick your favorite long acting extended release po narcotic. Give it as a scheduled dose. Then pick your favorite short acting narcotic for breakthrough. Titrate both up as needed. If you would rather go with a patch for extended release instead of po that's fine as well. I like to stick with single agents (ie, not combined with tylenol). Pick one and go up. Basically it comes down to MS Contin or Oxycodone. Methadone potentially, but I would want to see a good regimen fail first, and this really does require a pain specialist as it's not a benign drug and someone is going to have to write for it on the outside. I see lots of these patients and someone has done the pea soup pain med approach. They're on a low dose duragesic patch, MS Contin, Dilaudid and Percocet for breakthrough. And Lyrica because they did a nice lunch presentation on how good it is for pain. Instead of going up on one thing they just keep adding crap. Keep it simple. Non narcotic analgesics are probably in order. I would stay with tylenol and nsaids in appropriate doses if there are no contraindications.

Big picture though, sounds like vascular is right. You have a demented 84 yo. What is the downside of the amputation?

 

[Jeff05]

1. i would not give standing nsaids to someone with clear CAD.

2. tylenol is going to do next to nothing for this patient.

3. start lyrica, low dose. you can titrate it up quickly. he clearly has a neuropathic component to his pain.

4. convert 75% of his lortabs/morphine 24 hr intake into fentanyl patch

5. take the remaining 25% divide by 5 and make that a q4-6 hr prn - use something without metabolites - dilaudid would work.

6. pca is not an option for demented patients.

7. if all else fails, someone may take pity and put an intrathecal pump into this guy.

 

[cfdavid]

Thanks guys. I really appreciate the input.

cf