How To Treat Severe Post-Op Pain

Many patients with non-healing ulcers are already in significant pain prior to surgery. Many of these patients will require escalating doses of pain medications following surgical debridement and grafting. Some will already have developed tolerances to pain medications. So, what do we prescribe to control their pain? More importantly, what can we prescribe and still maintain a level of comfort in writing the prescription?
With these questions in mind, Robert Snyder, DPM, engaged in a Q&A session with Andrew J. Goldberg, MD, the Director of the Northwest Pain Management Center in Margate, Fla.

Q: Do all of these patients require aggressive pain medications?
Clearly not. As we know, the majority of patients do well with routine pain medications, like Percocet, Vicodin and Darvocet, that we typically prescribe.

Q: When do we need to explore other options of pain medications?
This should be considered when we face certain clinical scenarios. Perhaps the patient is already taking large doses of narcotics (i.e. 10 to 12 Percocet per day) prior to surgery, or maybe the recovery room informs us the patient is in severe pain despite large does of parenteral narcotics (i.e. intramuscular Demerol or morphine), or we find the surgery to be much more extensive then we expected.

Q: Now that we have recognized the difficult patients, which drug do we choose?
Before you can choose what post-op pain medication to use in a challenging patient, you need to know where the patient will receive post-op care, whether it’s in an in-patient hospital setting, a skilled nursing facility/in-patient rehabilitation or a home/assisted living facility. The location of the patient’s post-op care will determine what options we have for pain medication.

Q: Many of my patients are already admitted to the hospital, so what would you recommend in this setting?
That’s easy. I feel a Patient Controlled Analgesia (PCA) infusor would be the best choice. This technique allows the patient to regulate his or her own use of the narcotic. In addition, this would eliminate nursing response time to administer pain medications. Typically, morphine and Demerol are the agents used. Many wound care surgeons may not know how to order such a device. Well, there is no need to worry. Chances are the work has most likely already been done for you by the anesthesia department.
In most hospitals, prewritten PCA order forms are already in existence and can be found in the recovery room. Simply check off the box of the medication you want to use. The dosages and settings are already written in. The guidelines for monitoring and patient education are also already found on the order forms. My usual algorithm for PCA is the following:
a) My first choice is PCA morphine, demand dose of 1mg, lockout of 6 minutes, 4-hour limit of 24mg, with no basal rate.
b) If the patient is allergic to morphine or cannot tolerate it, my second choice would be PCA Demerol, demand dose of 10mg, lockout of 6 minutes, 4-hour time limit of 240 mg, with no basal rate.
c) If the patient cannot tolerate the Demerol or has a history of seizures, my third choice would be PCA fentanyl, 12.5 microgram demand dose, 6 minute lockout, 4-hour time limit of 240 micrograms, and no basal rate.

Q: Are there any other options for an in-patient?
Yes, I find intravenous Toradol quite useful. This central acting nonsteroidal antiinflammatory drug has analgesia properties equivalent to morphine without the worries of respiratory depression. A routine dose would be 30mg IV q 6h, either standing or prn pain. Either way, it should not be used for more than five days.
Keep in mind that you should not prescribe this drug for patients with the following medical problems: renal insufficiency, significant liver dysfunction, coagulopathy or a history of a GI bleed. If you still have difficulty in controlling the pain level despite the above modalities, take advantage of the patient’s in-patient status by calling a pain management consultation through the anesthesiology department.

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