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Goals

Goals. Discuss possible pain intervention for CRIT case Describe opioid side effects Initiate opioid therapy, convert from iv to po and calculate breakthrough dosing. Case. Mrs. HH. is an 84-year old woman admitted with perforated diverticulitis, awaiting surgery.

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Goals

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Presentation Transcript

  1. Goals • Discuss possible pain intervention for CRIT case • Describe opioid side effects • Initiate opioid therapy, convert from iv to po and calculate breakthrough dosing

  2. Case Mrs. HH. is an 84-year old woman admitted with perforated diverticulitis, awaiting surgery. How do you treat her pain?

  3. Opioid initiation In opioid naïve patient: • Max. effect iv morphine: 5 min • Max. effect sc morphine: 30-60 min • Max. effect po morphine: 1 hour Once you have steady state: T ½ is 4-6 hours for short acting opioids

  4. Opioid side effects • Constipation • Fatigue/Drowsiness/Sedation • Nausea/Vomiting • Pruritus • Hypotension • Confusion/Delirium • Urinary retention • Myoclonus • Respiratory depression

  5. Opioid conversion and breakthrough dosing • 2mg/hour x 24 hours = 48 mg/day iv (for ease of calculation let’s assume 50mg/day) • Conversion iv:po Morphine: 1:3 • 50 mg/day iv = 150 mg/day po • MS Contin is 12 hourly formulation (divide daily dose by 2) = 75 mg MS Contin bid • Breakthrough (10-20% of daily dose): 15-30 mg q 4h PRN breakthrough pain

  6. Pearls • Treat acute pain with short-acting medication until you achieve pain control, then convert to long-acting • Keep it simple (use same opioid for scheduled and PRN) • Demented/delirious patients don’t ask for pain medication: if you think they have pain, schedule the analgesia and avoid PRN only

  7. Pearls • Patients with renal insufficiency become toxic easily – better opioid choices for them are oxycodone and hydromorphone • Do not forget to treat constipation • Do ask your pharmacist for help if you worry about conversions • NEVER use Propoxyphene or Meperidine

  8. Summary • Treat pain adequately, ideally by mouth and scheduled • Keep it simple • Monitor and treat side effects • Educate families

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