Pain rotation help

[dp101]

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Hi,
Im a pgy1 and recently started on the pain service and need some help. How do I manage these pain meds? For example, how do i know whether to start the patient on morphine, oxy, fentanyl, tylenol, nsaids, increasing the local anesthetic if they have a cath? All of these r used for pain, but whats a good way to learn how to play with all the drugs?

 

[nimbus]

Start here. But really you should be getting some introductory didactics from your attendings and fellows.

Equianalgesic - Wikipedia

 

[ZzzPlz]

Hi,
Im a pgy1 and recently started on the pain service and need some help. How do I manage these pain meds? For example, how do i know whether to start the patient on morphine, oxy, fentanyl, tylenol, nsaids, increasing the local anesthetic if they have a cath? All of these r used for pain, but whats a good way to learn how to play with all the drugs?

I'd prescribe them all and let the patient figure out what works best

 

[zizzer]

Equianalgesic apps are helpful. Read about non opioid adjuncts (Barash has a great section on it in its acute pain chapter). As for opioids, don't get too carried away when starting on opoid naive patients. Dosing I see a lot includes oxycodone 5-10mg PRN with morphine 2-4mg IV PRN or hydromorphone 0.2-0.5mg PRN for breakthrough pain. You'll get used to it. Also, keep in mind that genetic polymorphisms exist, causing for some variability between patients in which ones work for them.

 

[Aether2000]

Times are changing. In the past it seemed we started patients on the highest doses of all the medications combined, then gradually reduced the dosage until they began breathing again. Now times are far more complex with attorney generals and judges prefer people continue breathing. All kidding aside, for both acute and chronic pain titrate from a low dose initially, and for chronic non-malignant pain do not exceed 90-100 MED. Higher doses will only make things worse. For acute pain, early escalation under strict monitoring is indicated then rapidly reduce the dosage to zero. Combinations of multiple sedating drugs are more dangerous than single drugs. Combinations of benzodiazepines or alcohol with opioids are inherently dangerous. There is no book that can teach all the changing nuances in pain medicine nor can immerse you in the fires of history that have killed hundreds of thousands and destroyed many physicians. Go easy, go light with opioids. Use them when necessary, but never in excess.

 

[Hoya11]

Hi,
Im a pgy1 and recently started on the pain service and need some help. How do I manage these pain meds? For example, how do i know whether to start the patient on morphine, oxy, fentanyl, tylenol, nsaids, increasing the local anesthetic if they have a cath? All of these r used for pain, but whats a good way to learn how to play with all the drugs?

Think about all the different classes of pain medicines that currently exist (here are a few):

Opioids: so many (usually a combo of a long acting and short acting but depends on situation)
Anti-inflammatories: Nsaids, tylenol, steroids
Neuropathic agents: neurontin, lyrica
Local Anesthetics
Others: Alpha-2, NMDA

Make sure all those receptors are being hit with at least one drug.
That is multi-modal analg

 

[pgg]

Hi,
Im a pgy1 and recently started on the pain service and need some help. How do I manage these pain meds? For example, how do i know whether to start the patient on morphine, oxy, fentanyl, tylenol, nsaids, increasing the local anesthetic if they have a cath? All of these r used for pain, but whats a good way to learn how to play with all the drugs?

😱

Ask your resident or the attending for help.

You're on day 3 of internship and shouldn't be figuring this out with the help of an internet forum. This is a complex topic with plenty of room for things to go horribly wrong. Don't wing it with trial & error.

 

[anbuitachi]

Inpatient pain or outpatient chronic pain? Very different services.
Outpatient chronic pain, your attending should be going over things as it can be pretty complicated. There's also a lot of interventions and evaluating whether they need them or not.

In patient acute pain service, PCA for everybody.

Just remember unless you have a lot of co morbidities like bad CAD, you arent dropping dead from pain. But you can easily drop dead from narcotic OD. so go easy in the beginning

Also remember the US has 5% of the global population but use 80% of the opioids. So you dont have to go straight to opioids..

 

[deleted59964]

https://www.openanesthesia.org/who_analgesic_ladder/

 

[McPoyle]

Outpatient Chronic Pain: check patient's insurance and tailor treatments to match fee schedule.

Inpatient Pain: up on concentration for denser block, up on rate for more spread. Use adjuncts like gabapentin, Tylenol, ketorolac, etc. and PCAs are good.


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