pain case

[Jeff05]

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45 year old male with history of UC presents for 4th abdominal surgery in 2 years (hemicolectomy with ileostomy). chronic abdominal pain managed by PCP. he takes oxycontin 120mg q8h, dilaudid 8mg q4 hrs prn, klonopin 1mg q12h, cymbalta 60mg qday. he appears anxious in holding.

what is your anesthetic plan?
what is your plan for postop analgesia?

 

[Fastrach]

45 year old male with history of UC presents for 4th abdominal surgery in 2 years (hemicolectomy with ileostomy). chronic abdominal pain managed by PCP. he takes oxycontin 120mg q8h, dilaudid 8mg q4 hrs prn, klonopin 1mg q12h, cymbalta 60mg qday. he appears anxious in holding.

what is your anesthetic plan?
what is your plan for postop analgesia?

Preop: Takes his scheduled full chronic pain/anxiety cocktail in the morning

Intraop: GETA + epidural, would probably also run low-dose ketamine; gonna still have to give this guy a generous helping of IV narcs & benzos so he doesn't w/d, would likely titrate these in based on how he looks at the end of the case

Postop: epidural (local + opioid + clonidine), consider throwing in a morphine/ketamine PCA until he's taking PO and can get back on his home meds

 

[BLADEMDA]

45 year old male with history of UC presents for 4th abdominal surgery in 2 years (hemicolectomy with ileostomy). chronic abdominal pain managed by PCP. he takes oxycontin 120mg q8h, dilaudid 8mg q4 hrs prn, klonopin 1mg q12h, cymbalta 60mg qday. he appears anxious in holding.

what is your anesthetic plan?
what is your plan for postop analgesia?

1) some low dose ketamine with propofol at induction. GA with tube

2) BIS (yes ketamine may falsely elevate the reading for the first 15-30 minutes). After induction keep the Volative Vapor at no less than 0.6 MAC preferably 0.8 MAC. (overdrive the vaporizer immediately and use Et gases)

3) Low thoracic epidural. bolus for case and run cont. infusion for postop pain. local anesthetic plus fentanyl.

4) some would add Lyrica or Neurontin

5) A few might run a lidocaine drip intraop to decrease pain

6) Midazolam in holding . 2 mg I.V. won't touch him

7) Even if he has zero post op pain with the epidural keep him happy with
pain killers. I would add PCA to replace his "missed" narcotics.

8) Consider Methadone P.O. once his bowels are working again

 

[OB1🤙]

1) Definitely agree with ketamine on induction.

2) Why BIS? Why preferably 0.8 MAC? Are you saying you think the presence of an epidural will result in hemodynamic compromise with a MAC of volatile? IMO I'd prefer to just run 0.8-1.3 MAC of vapor titrated to hemodynamics same as I would with any other patient, even with the epidural. If hypotensive, 0.8 MAC ought to prevent recall in and of itself without relying on BIS. Curious as to your thoughts on this.

3) Definitely epidural run intra and postop, and would consider using sufenta instead of fent for the narcotic (institutional norm for us with opiate-tolerant pts).

4) Cymbalta and lyrica should be considered as vital to this patient's well-being as oxygen.

5) Lidocaine gtt isn't something I'd consider, maybe I'm unaware of some convincing evidence about it? Seems like trying to put out a fire with a squirt gun (fire very much on my mind these days, sorry).

6) Agree with liberal versed. Pelosi-level liberal.

7) This is what's nice about sufenta in the epidural, so much systemic absorption that extra supplementation can possibly be kept minimal. I'd hate to add a PCA (that you're going to have to pry away from this patient with a crowbar) unless I really had to.

8) Would prefer to just resume home regimen once he's taking PO, but methadone in this population is always a good thing, what with the NMDA activity and all.

1) some low dose ketamine with propofol at induction. GA with tube

2) BIS (yes ketamine may falsely elevate the reading for the first 15-30 minutes). After induction keep the Volative Vapor at no less than 0.6 MAC preferably 0.8 MAC. (overdrive the vaporizer immediately and use Et gases)

3) Low thoracic epidural. bolus for case and run cont. infusion for postop pain. local anesthetic plus fentanyl.

4) some would add Lyrica or Neurontin

5) A few might run a lidocaine drip intraop to decrease pain

6) Midazolam in holding . 2 mg I.V. won't touch him

7) Even if he has zero post op pain with the epidural keep him happy with
pain killers. I would add PCA to replace his "missed" narcotics.

8) Consider Methadone P.O. once his bowels are working again

 

[pgg]

In addition to what's above, I would add
- a dose of IV methadone at the start of the case, perhaps 20 mg
- both ketamine and lidocaine infusions

I'd also give some thought to placing the epidural the day before surgery and running some 0.2% ropivacaine overnight if practical.


Just curious, what would Oxycontin 120 mg q8h cost the patient (or insurer) these days? My guess is that it's well over $1000/month. The hospital where I did my residency more or less quit using Oxycontin and replaced it with MS Contin for both cost and diversion reasons.

 

[Fastrach]

Curious if anyone has given Marinol to pts like this. I've given it once, for a lady who had been on truck loads of methadone, and despite us throwing the kitchen sink at her she just wasn't happy- until she got the Marinol... and from that point on, she was feelin' the love....

 

[drccw]

1) Make sure he takes his oxycontin on morning of surgery. I hate starting the day behind the eight ball..
2) Low thoracic epidural pre-op. i would use liberal doses of midazolam and fentanyl for placement. Oh, and I would definitely make sure to test it to make sure it was working perfectly. This isn't a guy I would want a half-***** TEP in...
3) Ketamine with induction (I typically use 0.5 mg/kg) and then again right before skin incision (usually another 0.5 mg/kg).
4). I prefer to run an infusion of local anesthetic intra-operatively. I usually use 0.25% bupivicaine.
5) Post operatively I would advocate for just a plain local anesthetic infusion, likely Bupivicaine 0.1%. This guy is going to need systemic opiods, no matter how much opiod gets slammed into the epidural space. Might as well just provide the opiods via the systemic route to avoid any sort of confusion with two opiod infusions...
6) IV PCA. Hydromorphone. And I wouldnt be stingy.
7) as soon as possible restart his oxycontin.

 

[aredoubleyou]

1) Make sure he takes his oxycontin on morning of surgery. I hate starting the day behind the eight ball..
2) Low thoracic epidural pre-op. i would use liberal doses of midazolam and fentanyl for placement. Oh, and I would definitely make sure to test it to make sure it was working perfectly. This isn't a guy I would want a half-***** TEP in...
3) Ketamine with induction (I typically use 0.5 mg/kg) and then again right before skin incision (usually another 0.5 mg/kg).
4). I prefer to run an infusion of local anesthetic intra-operatively. I usually use 0.25% bupivicaine.
5) Post operatively I would advocate for just a plain local anesthetic infusion, likely Bupivicaine 0.1%. This guy is going to need systemic opiods, no matter how much opiod gets slammed into the epidural space. Might as well just provide the opiods via the systemic route to avoid any sort of confusion with two opiod infusions...
6) IV PCA. Hydromorphone. And I wouldnt be stingy.
7) as soon as possible restart his oxycontin.

👍
pretty much exactly what I would think. Would keep the opiod out of the epidural to keep things simple as well. Not so sure the ketamine really makes a difference, but then again, why not.

The big question tho is: from my understanding if you run an epidural during the (majority of the) case its part of your intra-op anesthetic and you CANNOT bill for it for post-op pain control - whereas if you bolused and started it near the end you get full reimbursenet for your intra-op anesthetic AND full reimbursment for your post-op pain control.

 

[2ndyear]

👍
pretty much exactly what I would think. Would keep the opiod out of the epidural to keep things simple as well. Not so sure the ketamine really makes a difference, but then again, why not.

The big question tho is: from my understanding if you run an epidural during the (majority of the) case its part of your intra-op anesthetic and you CANNOT bill for it for post-op pain control - whereas if you bolused and started it near the end you get full reimbursenet for your intra-op anesthetic AND full reimbursment for your post-op pain control.

Not quite. It has to do more with what the primary anesthetic was. If you did the whole case with just epidural and sedation then you are correct. The case (ex lap) was not possible without the epidural, hence that is your primary anesthetic. You can still bill 01996 on subsequent days of post op pain management, but you can't bill for the epidural placement.

In the case of placing an epidural for the main purpose of post op pain control, you bill separately for epidural placement (and NOT as part of the anesthesia time) does not matter what you do with it in the OR. Again you bill for post op management each day you see the patient. Think of it like an interscalene block. Do them before, bill for them, mainly used for postop pain, but very nice to have on board in the OR as well. Opposed to say an axillary or a Bier block for a hand case. Both can be used as a primary anesthetic. If you do the case with either it doesn't matter that the ax block will provide post op pain relief, you did the case with it and therefore only bill anesthesia time.

In any of these a separate note documenting 'surgeon requests epidural/block for post op pain control' and then your procedure are necessary to get paid.

 

[BLADEMDA]

1) Definitely agree with ketamine on induction.

2) Why BIS? Why preferably 0.8 MAC? Are you saying you think the presence of an epidural will result in hemodynamic compromise with a MAC of volatile? IMO I'd prefer to just run 0.8-1.3 MAC of vapor titrated to hemodynamics same as I would with any other patient, even with the epidural. If hypotensive, 0.8 MAC ought to prevent recall in and of itself without relying on BIS. Curious as to your thoughts on this.

3) Definitely epidural run intra and postop, and would consider using sufenta instead of fent for the narcotic (institutional norm for us with opiate-tolerant pts).

4) Cymbalta and lyrica should be considered as vital to this patient's well-being as oxygen.

5) Lidocaine gtt isn't something I'd consider, maybe I'm unaware of some convincing evidence about it? Seems like trying to put out a fire with a squirt gun (fire very much on my mind these days, sorry).

6) Agree with liberal versed. Pelosi-level liberal.

7) This is what's nice about sufenta in the epidural, so much systemic absorption that extra supplementation can possibly be kept minimal. I'd hate to add a PCA (that you're going to have to pry away from this patient with a crowbar) unless I really had to.

8) Would prefer to just resume home regimen once he's taking PO, but methadone in this population is always a good thing, what with the NMDA activity and all.

Good post. I chose to add BIS because we have the equipment and the strips. I rarely use BIS but this seems like the type of patient where it may be useful. This way we can titrate the volatile anesthetic to the appropriate level. My point about the 0.6 MAC was that at the beginning of the case the BIS is unreliable due to the Ketamine. Hence, we must rely on end tidal gases to avoid recall. The data supports an end tidal gas reading of 0.7 MAC or so. Thus, I would make sure my end tidal gas reading was as at least that amount or greater in this patient. But, as the Epidural kicks in to gear and the ketamine's affect on the BIS wanes (15-30 minutes at most) then begin to titrate the vapor based on the BIS reading.

http://content.nejm.org/cgi/content/short/358/11/1097?query=TOC


As for the lidocaine drip there was a nice study a few years back showing it reduced postop pain.

http://www.ncbi.nlm.nih.gov/pubmed/19138915

http://www.ncbi.nlm.nih.gov/pubmed/...inkpos=4&log$=relatedreviews&logdbfrom=pubmed

http://www.ncbi.nlm.nih.gov/pubmed/...nkpos=3&log$=relatedarticles&logdbfrom=pubmed

 

[BLADEMDA]

1: Anesth Analg. 2004 Apr;98(4):1050-5, table of contents. Links

Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery.

Koppert W, Weigand M, Neumann F, Sittl R, Schuettler J, Schmelz M, Hering W.
Department of Anesthesiology, University of Erlangen, Erlangen, Germany. [email protected]
Sodium channel blockers are approved for IV administration in the treatment of neuropathic pain states. Preclinical studies have suggested antihyperalgesic effects on the peripheral and central nervous system. Our objective in this study was to determine the time course of the analgesic and antihyperalgesic mechanisms of perioperative lidocaine administration. Forty patients undergoing major abdominal surgery participated in this randomized and double-blinded study. Twenty patients received lidocaine 2% (bolus injection of 1.5 mg/kg in 10 min followed by an IV infusion of 1.5 mg. kg(-1). h(-1)), and 20 patients received saline placebo. The infusion started 30 min before skin incision and was stopped 1 h after the end of surgery. Lidocaine blood concentrations were measured. Postoperative pain ratings (numeric rating scale of 0-10) and morphine consumption (patient-controlled analgesia) were assessed up to 72 h after surgery. Mean lidocaine levels during surgery were 1.9 +/- 0.7 microg/mL. Patient-controlled analgesia with morphine produced good postoperative analgesia (numeric rating scale at rest, <or=3; 90%-95%; no group differences). Patients who received lidocaine reported less pain during movement and needed less morphine during the first 72 h after surgery (103.1 +/- 72.0 mg versus 159.0 +/- 73.3 mg; Student's t-test; P < 0.05). Because this opioid-sparing effect was most pronounced on the third postoperative day, IV lidocaine may have a true preventive analgesic activity, most likely by preventing the induction of central hyperalgesia in a clinically relevant manner. IMPLICATIONS: The perioperative administration of systemic small-dose lidocaine reduces pain during surgery associated with the development of pronounced central hyperalgesia, presumably by affecting mechanoinsensitive nociceptors, because these have been linked to the induction of central sensitization and were shown to be particularly sensitive to small-dose lidocaine.