f****o
发帖数: 2770 | 1 50 yo female w/ normal hepatic and renal function admitted post-op for
ovarian ca at 2100 (9PM)
Service: gyn onc
Allergie: morphine (hives)
CC: patient is in post-op pain and requires pain meds through non-oral route
Diet: NPO post-op x 24 hrs
Bed level: Med/Surg
IV dilaudid: patient refuses IV dilaudid d/t hallucination
IV oxymorphone: not on hospital formulary
IV methadone: reserved for pain/palliative team and burn patients
IV fentanyl: cannot be pushed on regular floor
Fentanyl PCA: due to shortage, reserved for pain/palliative team to order
only
IV meperidine: pain team discourages its use for pain, only for rigor
associated with chemotherapy
it's 9PM, all day shift people are gone, you are the moonlighter cross cover
.
what would you give this patient for acute pain management?
P.S. this is a real situation happened twice...
IV ketorolac? IV tylenol? |
A*******s
发帖数: 9638 | 2 Demerol 50-100 mg im once, then try fentanyl patch. |
s*******y
发帖数: 1739 | 3 我的疑问是，为什么没用普通的 Morphine？ |
s*******y
发帖数: 1739 | 4 我的疑问是，为什么没用普通的 Morphine？ |
f****o
发帖数: 2770 | 5 Allergie: morphine (hives)
【在 s*******y 的大作中提到】
: 我的疑问是，为什么没用普通的 Morphine？
|
l**********p
发帖数: 189 | 6 IV tramadol? Transdermal fentanyl is contraindicated for postoperative pain |
L****n
发帖数: 12932 | |
f****o
发帖数: 2770 | 8 IV tramadol is only available in Europe not US
pain
【在 l**********p 的大作中提到】
: IV tramadol? Transdermal fentanyl is contraindicated for postoperative pain
|
f****o
发帖数: 2770 | 9 will you give yourself this if ur in the same situation?
【在 A*******s 的大作中提到】
: Demerol 50-100 mg im once, then try fentanyl patch.
|
f****o
发帖数: 2770 | 10 i don't recall exactly, let's just say some surgery related to her cancer.
it's not minor but not an open-abdominal surgery either
【在 L****n 的大作中提到】
: What surgery?
|
|
|
M****a
发帖数: 577 | 11 啥是 major, not-open, ovarian cancer-related的手术啊？
【在 f****o 的大作中提到】
: i don't recall exactly, let's just say some surgery related to her cancer.
: it's not minor but not an open-abdominal surgery either
|
f****o
发帖数: 2770 | 12 因为我压根就没管她做了啥手术，我也不是学手术的。
她就是做了某我记不得的手术，术后PACU回来直接住在regular floor了（没去SICU什
么的）
然后NPO24小时
术后她就叫疼，给了针hydromorphone说有hallucination再也不要了，要别的药。。。
我是负责verify你们医生发过来的order的药剂师。然后gyn/onc的一年级intern就给开
meperidine 12.5mg IV啊，护士还催呢。虽然不是最好的option，但是我真是想不出有
啥办法了。发了个email给pain team问问，他们也不给个答案，就说meperidine不让用
止痛。
这个事情都发生了两次了，我真是没辙了。
【在 M****a 的大作中提到】
: 啥是 major, not-open, ovarian cancer-related的手术啊？
|
m****g
发帖数: 42 | 13 Call allergist to do graded challenge to morphine. Most likely, the reaction
(hives) to morpine is not a true allergy (IgE mediated). A true allergy to
morphine is very rare. You can pre-med her with corticosteroid and
antihistamine and give morphine. But graded challenge by an allergist is the
safest way of course. |
a******a
发帖数: 57 | 14 Was the surgery open or laparoscopic?
What kind of pain did the patient complain: shoulder refer pain? Sharp
incisional pain? Or cramping pain?
How many hours out of the surgery?
A couple of things you may consider: give rectal Tylenol 1g, then Iv toradol
30mg.
I personally agree with short term usage of meperidine 25-50mg Iv q2-3h, and
put pt on fentanyl patch( It takes about 8-12 hours to reach desired level);
Iv ketamine could be another choice, 10-20mg Iv bolus.
If the patient has ivda history, then it is another scenario. |
M****a
发帖数: 577 | 15 1. 让妇科去问pain team
2. IV tylenol （不知道要不要pain team approval）
3. Toradol （有bleeding risk，不过很小）
【在 f****o 的大作中提到】
: 因为我压根就没管她做了啥手术，我也不是学手术的。
: 她就是做了某我记不得的手术，术后PACU回来直接住在regular floor了（没去SICU什
: 么的）
: 然后NPO24小时
: 术后她就叫疼，给了针hydromorphone说有hallucination再也不要了，要别的药。。。
: 我是负责verify你们医生发过来的order的药剂师。然后gyn/onc的一年级intern就给开
: meperidine 12.5mg IV啊，护士还催呢。虽然不是最好的option，但是我真是想不出有
: 啥办法了。发了个email给pain team问问，他们也不给个答案，就说meperidine不让用
: 止痛。
: 这个事情都发生了两次了，我真是没辙了。
|
f****o
发帖数: 2770 | 16 我做evening啊，we don't have clinical support like day shift
什么c/s team都回家了的说
原文我特地注明了晚上9点发生的故事
pain team不在，pain pharmacist不让我approve meperidine for pain
现在想想只能用iv tylenol+iv ketorolac了
fentanyl patch是给opioid tolerated 病人用的
ketamine也肯定是pain team才能order的
做晚班就是难做人啊 |
A*******s
发帖数: 9638 | 17 Can you provide me a link?
pain
【在 l**********p 的大作中提到】
: IV tramadol? Transdermal fentanyl is contraindicated for postoperative pain
|
A*******s
发帖数: 9638 | 18 I give demerol all the time. You have to know what is potential side effect
though.
【在 f****o 的大作中提到】
: will you give yourself this if ur in the same situation?
|
A*******s
发帖数: 9638 | 19 Are you a physician?
【在 f****o 的大作中提到】
: 我做evening啊，we don't have clinical support like day shift
: 什么c/s team都回家了的说
: 原文我特地注明了晚上9点发生的故事
: pain team不在，pain pharmacist不让我approve meperidine for pain
: 现在想想只能用iv tylenol+iv ketorolac了
: fentanyl patch是给opioid tolerated 病人用的
: ketamine也肯定是pain team才能order的
: 做晚班就是难做人啊
|
u***e
发帖数: 611 | 20 You can go ahead to give morphine. Give Benadryl if pt does develop hives. I
dont think its a real allergy. Meperidine increases risks for seizure, it's
rarely used. Fentanyl is also a good choice, not patch.
【在 f****o 的大作中提到】
: 我做evening啊，we don't have clinical support like day shift
: 什么c/s team都回家了的说
: 原文我特地注明了晚上9点发生的故事
: pain team不在，pain pharmacist不让我approve meperidine for pain
: 现在想想只能用iv tylenol+iv ketorolac了
: fentanyl patch是给opioid tolerated 病人用的
: ketamine也肯定是pain team才能order的
: 做晚班就是难做人啊
|
|
|
f****o
发帖数: 2770 | 21 "我是负责verify你们医生发过来的order的药剂师。"前文提到过了
【在 A*******s 的大作中提到】
: Are you a physician?
|
f****o
发帖数: 2770 | 22 http://www.accessdata.fda.gov/drugsatfda_docs/label/2005/19813s
他的意思是DURAGESIC® is indicated for management of persistent,
moderate to severe chronic pain
that:
• requires continuous, around-the-clock opioid administration for an
extended period of time, and
【在 A*******s 的大作中提到】
: Can you provide me a link?
:
: pain
|
u***e
发帖数: 611 | 23 Agree, I've never seen a pt who is really allergic to opiate. Normally they
will say dilaudid is the only thing works for me, I'm allergic to everything
else. By the way, can I also have some Benadryl? :)
reaction
to
the
【在 m****g 的大作中提到】
: Call allergist to do graded challenge to morphine. Most likely, the reaction
: (hives) to morpine is not a true allergy (IgE mediated). A true allergy to
: morphine is very rare. You can pre-med her with corticosteroid and
: antihistamine and give morphine. But graded challenge by an allergist is the
: safest way of course.
|
f****o
发帖数: 2770 | 24 mind if i ask, where do you practice? we know the potential side effect of
meperidine so we don't give it for pain when there are better options
effect
【在 A*******s 的大作中提到】
: I give demerol all the time. You have to know what is potential side effect
: though.
|
A*******s
发帖数: 9638 | 25 Why are you guys so scared of demerol? It does cause seizure because of its
metabolites but as long as you know what you are doing, it is safe.
I would never bother to use morphine if it causes hives.
Patch is good for chronic pain related to cancer.
I
's
【在 u***e 的大作中提到】
: You can go ahead to give morphine. Give Benadryl if pt does develop hives. I
: dont think its a real allergy. Meperidine increases risks for seizure, it's
: rarely used. Fentanyl is also a good choice, not patch.
|
L****n
发帖数: 12932 | 26 Without knowing what kind of surgery, there is no way to optimize pain
control. Npo 24hr would make me think this is not just a oophorectomy.
Seems to me fentanyl patch is the best option. |
l**********p
发帖数: 189 | 27 You can compound it.
【在 f****o 的大作中提到】
: IV tramadol is only available in Europe not US
:
: pain
|
l**********p
发帖数: 189 | 28 It's stated in the prescribing information.
Transdermal fentanyl cannot be used for opioid naive patient as well.
【在 A*******s 的大作中提到】
: Can you provide me a link?
:
: pain
|
z***0
发帖数: 153 | 29 如果在国内，术后吗啡过敏的患者，我会给芬太尼家族的。术后的IV镇痛泵，我们可以
选morphine, fentanyl, or sufentanil，患者对sufentanil的反映最好，当然这个也
最贵，有次美国某医院麻醉医生来我们医院交流时，很羡慕我们可以用sufentanil，因
为太贵了他们医院不让用。 |
a**********2
发帖数: 3726 | 30 Lol, re this.
At that time, the intern should go to the floor to do IV fentanyl push if
floor nurse does not do it. Then turn over to the day team about pain
management consult and allergy/immunology consult for morphine allergy eval
and possible desensitization. Except morphine,dilaudid, fentanyl, other pain
management should leave to specialist, not general internist or general ob/
gyn doctor.
For demerol, if never used it before, it is definitely inappropriate to use
it as a night float doctor.
For hives caused by morphine, although we know most likely it won't cause
serious reactions other than hives, go get a consult from a&i is the best
next step. Do not practice beyond your limit. Specialists are there for a
reason.
they
everything
【在 u***e 的大作中提到】
: Agree, I've never seen a pt who is really allergic to opiate. Normally they
: will say dilaudid is the only thing works for me, I'm allergic to everything
: else. By the way, can I also have some Benadryl? :)
:
: reaction
: to
: the
|
|
|
L****n
发帖数: 12932 | 31 ？ what do u mean by "opoid naive"?
【在 l**********p 的大作中提到】
: It's stated in the prescribing information.
: Transdermal fentanyl cannot be used for opioid naive patient as well.
|
L****n
发帖数: 12932 | 32 you never seen one doesn't mean there is none. For patient listed Hive
reaction to Morphine, then morphine is not appropriate - unless you have
good enough reason to use it, meaning the benefit will out weight the risk.
ie, the patient is likely to die without it. obviously this is not the case.
they
everything
【在 u***e 的大作中提到】
: Agree, I've never seen a pt who is really allergic to opiate. Normally they
: will say dilaudid is the only thing works for me, I'm allergic to everything
: else. By the way, can I also have some Benadryl? :)
:
: reaction
: to
: the
|
L****n
发帖数: 12932 | 33 sufentanil is 1000 time more potent than morphine, while fentanyl is about
10 times as potent, The former is only used intra-op or ICU when the patient
is vented or closely monitored. Liberal usage of sufentanil on floor is way
too risky, whether you can afford it or not.
【在 z***0 的大作中提到】
: 如果在国内，术后吗啡过敏的患者，我会给芬太尼家族的。术后的IV镇痛泵，我们可以
: 选morphine, fentanyl, or sufentanil，患者对sufentanil的反映最好，当然这个也
: 最贵，有次美国某医院麻醉医生来我们医院交流时，很羡慕我们可以用sufentanil，因
: 为太贵了他们医院不让用。
|
L****n
发帖数: 12932 | 34 In this case, the best pain management is probably an epidural placed before
surgery - if she had a anesthesiologist who is good with epidural placement
handling her case. If the patient is on anticoagulant for some reason and
epidural is off limit, a single injection of intrathecal duramorph can be
considered. If none can be done, a low strength fentanyl patch can be used
for this patient. |
L****n
发帖数: 12932 | 35 to A+: Demerol, ie meperidine, is the weakest among all narcotics. it's
generally not enough for post pain. mostly given for shivering - which is
very effective. |
A*******s
发帖数: 9638 | 36 In your case, there are not many options available.
I have seen seizures from meperidine PCA but never seen a single seizure
from a single or double dose.
75 mg of IV meperidine has an analgesic potency equal to that of 10 mg of IV
morphine or 100 microgram of IV fentanyl. Believe it or not, a lot of
patients claim only demerol is effective to their pain. I used Demerol 75
mg dose a lot but how many of you use morphine 10 mg often?
I am more concerned about demerol drug interaction, and usually use morphine
or dilaudid. In your case, I would not leave this poor lady in pain while
waiting for consult from an allergist.
http://www2.kumc.edu/druginfo/pharmkey/Meperidine%20pharmacy%20
【在 f****o 的大作中提到】
: mind if i ask, where do you practice? we know the potential side effect of
: meperidine so we don't give it for pain when there are better options
:
: effect
|
A*******s
发帖数: 9638 | 37 I hear you.
Potency is not everything, it is just a matter of dosage.
But safety is above all.
【在 L****n 的大作中提到】
: to A+: Demerol, ie meperidine, is the weakest among all narcotics. it's
: generally not enough for post pain. mostly given for shivering - which is
: very effective.
|
l**********p
发帖数: 189 | 38 It means the patient is not opioid tolerant.
According to FDA, opioid tolerant patients are those who have received daily
opioid analgesics for one week or longer, and doses of at least: 60 mg oral
morphine/day, 25 mcg transdermal fentanyl/hour, 30 mg oral oxycodone/day, 8
mg oral hydromorphone/day, 25 mg oral oxymorphone/day, or an equianalgesic
dose of another opioid.
The fentanyl patch is contraindicated in the management of post-operative
pain, mild pain, or intermittent pain (e.g. use on an as needed basis)
because of the risk for serious or life-threatening respiratory depression.
Fatalities from fentanyl overdose have occurred in these situations.
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInforma
【在 L****n 的大作中提到】
: ？ what do u mean by "opoid naive"?
|
l**********p
发帖数: 189 | 39 Fentanyl is 100 times more potent than morphine
patient
way
【在 L****n 的大作中提到】
: sufentanil is 1000 time more potent than morphine, while fentanyl is about
: 10 times as potent, The former is only used intra-op or ICU when the patient
: is vented or closely monitored. Liberal usage of sufentanil on floor is way
: too risky, whether you can afford it or not.
|
l**********p
发帖数: 189 | 40 Duramorph is still morphine which might cause allergies.
Iontophoretic fentanyl would work for postoperative pain, however Ionsys was
pulled off the market because of some design defects.
before
placement
【在 L****n 的大作中提到】
: In this case, the best pain management is probably an epidural placed before
: surgery - if she had a anesthesiologist who is good with epidural placement
: handling her case. If the patient is on anticoagulant for some reason and
: epidural is off limit, a single injection of intrathecal duramorph can be
: considered. If none can be done, a low strength fentanyl patch can be used
: for this patient.
|
|
|
A*******s
发帖数: 9638 | 41 Naive, never been exposed.
Regarding that contraindication, it only means fentanyl patch could cause
respiratory depression. What opioid does not do that? Nil.
When you are out of options, you have to use what you think is the best for
the patient. You are not supposed to leave CANCER patient in pain.
daily
oral
8
equianalgesic
.
【在 l**********p 的大作中提到】
: It means the patient is not opioid tolerant.
: According to FDA, opioid tolerant patients are those who have received daily
: opioid analgesics for one week or longer, and doses of at least: 60 mg oral
: morphine/day, 25 mcg transdermal fentanyl/hour, 30 mg oral oxycodone/day, 8
: mg oral hydromorphone/day, 25 mg oral oxymorphone/day, or an equianalgesic
: dose of another opioid.
: The fentanyl patch is contraindicated in the management of post-operative
: pain, mild pain, or intermittent pain (e.g. use on an as needed basis)
: because of the risk for serious or life-threatening respiratory depression.
: Fatalities from fentanyl overdose have occurred in these situations.
|
l**********p
发帖数: 189 | 42 Fentanyl is way more dangerous than other opioids like morphine. Besides the
contraindication, transdermal fentanyl is difficult to dose due to slow
skin absorption and variable patient responses. It could take 12 hours to
begin pain relief so you would need some other pain medications to titrate
up. The steady state of plasma conc is not reached until end of the second
patch. When stopping the patch, fentanyl continues to release to the blood
from the skin depot for another 24 hours. It's not a good option for acute
pain management.
for
【在 A*******s 的大作中提到】
: Naive, never been exposed.
: Regarding that contraindication, it only means fentanyl patch could cause
: respiratory depression. What opioid does not do that? Nil.
: When you are out of options, you have to use what you think is the best for
: the patient. You are not supposed to leave CANCER patient in pain.
:
: daily
: oral
: 8
: equianalgesic
|
A*******s
发帖数: 9638 | 43 I could not understand why you think one opioid is way more dangerous than
the other? They are all dangerous in terms of respiratory suppression. It
only depends what the dose you are going to use and how.
For this patient, I just proposed demerol im as a bridge for acute pain
then considering her cancer status, a patch would be in her best interest if
she still remains NPO.
the
【在 l**********p 的大作中提到】
: Fentanyl is way more dangerous than other opioids like morphine. Besides the
: contraindication, transdermal fentanyl is difficult to dose due to slow
: skin absorption and variable patient responses. It could take 12 hours to
: begin pain relief so you would need some other pain medications to titrate
: up. The steady state of plasma conc is not reached until end of the second
: patch. When stopping the patch, fentanyl continues to release to the blood
: from the skin depot for another 24 hours. It's not a good option for acute
: pain management.
:
: for
|
a**********2
发帖数: 3726 | 44 Good learn thx
the
【在 l**********p 的大作中提到】
: Fentanyl is way more dangerous than other opioids like morphine. Besides the
: contraindication, transdermal fentanyl is difficult to dose due to slow
: skin absorption and variable patient responses. It could take 12 hours to
: begin pain relief so you would need some other pain medications to titrate
: up. The steady state of plasma conc is not reached until end of the second
: patch. When stopping the patch, fentanyl continues to release to the blood
: from the skin depot for another 24 hours. It's not a good option for acute
: pain management.
:
: for
|
L****n
发帖数: 12932 | 45 This is quickly becoming a board question.:-)
Intrathecal duramorph would not be first line choice of course. In a severe
post op pain patient who is allergic to morphine, has adverse reaction to
dilaudid, contraindicated to epidural, we have to take in the consideration
that true morphine allergy is extremely rare, vase majority comes from
preservative element in the regular morphine preparation. Placement of the
intrathecal injection is obviously done at the peri-operative area where
proper monitoring is available. Even if in a rare true allergic situation,
it can be treated promptly thus patients safety is ensured.
Fentanyl patch is not ideal either, like u said, it's slow to work. But
serum concentration don't fluctuate as much as IV injection. Patient usually
comes from PACU with pain under control and stable vitals. U will have a
little window in timing the placement of patch. I consider fentanyl patch
in this patient more because she obviously has chronic pain to begin with
and now compound it with acute pain. She has various reactions to different
narcotics - meaning she had been on different regimen before. Otherwise a
straight forward fentanyl PCA would work.
daily
oral
8
equianalgesic
.
【在 l**********p 的大作中提到】
: It means the patient is not opioid tolerant.
: According to FDA, opioid tolerant patients are those who have received daily
: opioid analgesics for one week or longer, and doses of at least: 60 mg oral
: morphine/day, 25 mcg transdermal fentanyl/hour, 30 mg oral oxycodone/day, 8
: mg oral hydromorphone/day, 25 mg oral oxymorphone/day, or an equianalgesic
: dose of another opioid.
: The fentanyl patch is contraindicated in the management of post-operative
: pain, mild pain, or intermittent pain (e.g. use on an as needed basis)
: because of the risk for serious or life-threatening respiratory depression.
: Fatalities from fentanyl overdose have occurred in these situations.
|
f****o
发帖数: 2770 | 46 感谢大家支招
当时那个intern order了meperidine 12.5mg-25mg IVP Q4hrs for overnight until
day shift people come in。我也让这个order过了。
我也没啥办法了(其实可以oxycodone rectally，估计病人也不会同意的)
但是pain pharmacist不让我以后approve meperidine for pain，说seizure has been
reported after single dose meperidine in patient with normal renal function
. 但是呢，她又不给我一个recommendation，我就想说以后又发生酱紫的情况咋办。
那个病人手术之前有没有take long acting opioid/有无chronic pain issue我已经不
记得了。fentanyl patch onset很慢，等onset了天就亮了day shift就来了也就没我的
事情了。
fentanyl IVP不是说nurse不能push on regular floor，而是不管是谁都不能push on
regular floor. hospital policy, IV halflife 2.5 minutes太短了。
Compound tramadol IV? from oral tablets? 这个academic medical center不是想干
嘛就能干嘛的。就算我compound出来了电脑系统也没有这个选项，一个一年级intern敢
order么。。。
PCA Fentanyl pump reserved for pain team to order only, and it's 9pm, nobody
is in house前面提过了。PCA sufentanil根本不在电脑系统里。
morphine allergy列出来了，一个一年级intern也不会冒险去order的。万一patient
complained他residency还做的下去么。。。
Epidural手术前没有做，晚上anesthesia team只有几个oncall不可能去做的。谁知到
她打了一针dilaudid杀出一个程咬金有了hallucination就不肯要了呢。。。 |
