ANESTHESIA & PAIN MANAGEMENT

Editors: Mercede Erikson, MD and Camille Adajar, MD
Faculty Editor: Brandon Pruett, MD

Acute Pain

Multimodal pain regimen suggestions

Always check patient's home meds/CSMD. Restart home regimen as able

Tylenol

  • Dose: 1,000mg PO Q8H (can reduce to 650mg based on age, weight <70kg, or comorbidities)
  • Indications: Analgesic and antipyretic
  • Contraindications: Cirrhosis – limit to 2000mg daily

Gabapentin

  • Dose: 300mg PO Q8H (reduce to 100mg, Q12H dosing, or hold based on renal function, age, or sedation level)
  • Indications: Neuropathic pain
  • Contraindications: ESRD
  • Side effects: sedation, respiratory depression

Robaxin

  • Dose: 500mg PO Q8H
  • Indication: muscle relaxant
  • Contraindication: IV formulation has preservative that is nephrotoxic

NSAIDs

(check for adequate renal function and GI contraindications) - Toradol 15-30mg IV Q6H x 3-5 days - Ibuprofen 600mg Q6H - Indications: analgesic, anti-inflammatory, antipyretic - Contraindications: CKD/AKI, ulcers, GI bleed

Opioids

  • Oxycodone 5mg PO Q4H PRN for moderate pain, 10mg PO Q4H for severe pain
  • Hydromorphone 0.5mg IV Q4H for breakthrough pain

Thoracic epidural catheter (TEC)

  • These are done and managed by the Acute Pain Service. With any issues or concerns, APS must be contacted.
  • Indications: pain relief in thoracic dermatome distributions (rib fractures, BOLTs, etc.)
  • Contraindications:
  • PLT <80-100, INR >1.5, coagulopathy
  • Hypotension
  • Positive blood cultures, fever, white count, etc.
  • TECs remain for 5-7 days, risk of infection increases beyond that point.
  • TECs run an infusion of Ropivacaine and Hydromorphone in the epidural space
  • Do NOT need to d/c anticoagulation to pull TEC
  • Pt can only be on 5000 units of Subq heparin
  • Pain service can pull TEC 4hrs after last SQH dose
  • They can NOT be on the weight adjusted 7500 units
  • No Lovenox/Enoxaparin while TEC in place

Chronic Pain

Suboxone/Buprenorphine management

  • Can restart home regimen if they have taken their suboxone in the last 48 hours
  • Look at CSMD to verify their home regimen
  • If re-initiation is needed, consult addiction psych
  • Important for patients taking suboxone to remain on the medication
  • If pain is an issue, continue their medication and consult either chronic pain or acute pain service and addiction psych
  • The most effective pain medication while on Suboxone is hydromorphone, oxycodone cannot overcome the receptor affinity of Suboxone

Methadone management

  • Patients need to be evaluated by addiction psychology service for methadone recommendations while inpatient (often requires QTc monitoring)
  • Patients should be continued on home regimen

Consulting Pain Services

Consulting Acute Pain Service (APS)

  • If refractory to multimodal pain regimen above, consider consulting APS for:
  • Acute pain due to surgery in the last 7-10 days
  • Acute pain due to new trauma
  • APS also provides services for patients who are receiving regional anesthetic techniques (nerve blocks, nerve catheters)

Consulting Perioperative Consult Service

  • Periop provides pain management and implements enhanced recovery after surgery (ERAS) for specific surgical patients on the ERAS pathway

Consulting Chronic Pain Service (CPS)

  • Service for patients with chronic pain and cancer-related pain
  • If a patient is having an acute flare of a chronic problem that is not related to surgery or trauma, consult CPS
  • Examples: IBD flare, chronic pancreatitis, sickle cell pain crisis
  • Consultation available Monday through Friday 7am-3pm
  • The Transitional Pain Service (TPS) is a division of CPS: evaluate chronic pain patients preoperatively in clinic or before hospital discharge for outpatient pain management recommendations after surgery