A Guide To Pain Management In Wound Care
- Volume 25 - Issue 11 - November 2012
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For inpatients at his hospital, Dr. Suzuki always starts with IV hydromorphone (Dilaudid, Purdue Pharma) for moderate and severe pain. He reserves meperidine (Demerol, Sanofi Aventis) for the selected patients who are truly allergic to morphine or hydromorphone. Moreover, Dr. Suzuki always tries to use subcutaneous or intravenous routes to administer parenteral analgesics because intramuscular pain medication has erratic absorption and consequently erratic pain relieving effects.
The answer for Dr. Lullove depends on the patient’s experience with pain relief. Sometimes, he says it is necessary to ascertain blood levels of narcotic-type medications before initiating therapy to determine dosing. Dr. Lullove also notes that some wound care patients may have kidney dysfunction, which can alter the amount needed to dispense. Either way, Dr. Lullove says assessing a starting point must be patient-dependent. He uses the American Academy of Pain Management guidelines for acute and chronic pain management.
After identifying the etiology of pain, Dr. Brill initiates treatment. He will generally start patients with painful neuropathy on gabapentin (Neurontin, Pfizer) and titrate the dosing as needed. In patients with ischemic pain, Dr. Brill uses hydrocodone combinations or tramadol (Ultram, Janssen Pharmaceuticals). He says local treatment with lidocaine patches frequently helps. In patients with wounds and inflammatory disease, his first line of treatment is an NSAID.
“Needless to say, treating the underlying cause is most important,” says Dr. Brill.
Do you use NSAIDs? Do you have a favorite kind of NSAID?
When patients have wounds with inflammatory disease as a cause of their wound-related pain, Dr. Brill uses naproxen (Naprosyn, Roche) or meloxicam (Mobic, Boehringer-Ingelheim). To those drugs, he will add an H2 receptor antagonist such as ranitidine (Zantac, Boehringer-Ingelheim).
Dr. Suzuki often prescribes celecoxib (Celebrex, Pfizer), noting it has a long half-life and one can prescribe it for acute pain at 200 mg bid or for osteoarthritis or less acute pain with 200 mg qd dosing. He likes other NSAIDs with a longer duration, such as naproxen sodium (250 to 500 mg PO q12h) and diclofenac sodium (50 mg PO bid-tid), which one can use in combination with the other drugs. Dr. Suzuki notes this combination may work synergistically.
Although NSAIDs have their place, Dr. Lullove says most geriatric patients have kidney and/or cardiac issues that may prevent the use of NSAIDs in the therapy of wounds for pain relief. He emphasizes the need to take a thorough medical and medication history to manage geriatric patients. For younger patients, NSAIDs can play a vital role but Dr. Lullove advises always balancing bleeding risk with wound management.
“I should mention that, with any other pain medications including NSAIDs, most of our patients have their own ‘favorite’ pain medications,” says Dr. Suzuki. “Asking them ‘what worked the best for you’ may help you in guiding your prescription since there are an overwhelming choice of medications and combinations for pain management.”
Do you utilize regional blocks prior to lower extremity surgery?
All three panelists use regional blocks. Dr. Suzuki has been requesting regional blocks to be administered by specifically trained anesthesiologists prior to most of his lower extremity surgeries. Since the post-op pain is most intense in the first 24 to 48 hours, he believes regional blocks are quite useful in controlling post-op pain and minimizing the use of heavy-duty opioids, which often cause constipation.
Dr. Lullove has found regional blocks to be very effective in lower extremity surgery, especially when the patient has serious comorbidities that can threaten the normal use of inhaled anesthesia or general anesthetic use. Regional blocks are great for the management of post-procedure pain and patients seem to tolerate them when applied, according to Dr. Lullove. He says one should keep in mind that regional anesthesia has inherent risks such as swelling, infection at the injection site, systemic toxicity (rare) and cardiac and/or pulmonary problems (rare).