Center to Advance Palliative Care

Sounds like a really tough case. Im not up on intra-op literature for this issue, but will contact a colleague who should know. However, as a general rule, I think the following makes sense:

a) some opioid will need to be continued intra-op to avoid withdrawal, but the dose would really depend on the depth of anesthesia and use of the particular anesthetic agents, I doubt there is any kind of formula for this.
b) in the immediate post-op period, I would not restart the opioid at its' pre-surgery rate, you really run the risk of resp. depression for a couple of reasons: i) post op from a fracture repair you would expect markedly decreased analgesic requirement as the procedure itself should be analgesic, except of course for the post-op pain and ii) until the anesthetics get out of the system, the double whammy of anesthetics plus high-dose opioids can be quite dangerous--I've seen a number of mishaps in post-op pain management like this.
c) as a general rule, you want no basal, but sufficeintly high bolus dose, to manage post-op pain. For a pt on high-dose opioid pre-op, I would use a basal, but fairly low, but with sufficient bolus dose and short lock-out, to rapidly up-titrate the patient, as you did.
d) The key to all this, as you know, is close communication with the anesthesia team.

Regarding Narcan--the ordering of narcan is totally dependent on the goals of care, not the CPR/DNR status; in most hospitals, intra-op DNR suspension is the rule, and is reversed back to DNR either in the PACU or once the patient leaves the PACU--check with your hospital policy. You probably won't have much luck enforcing a do not give Narcan order in the PACU.

Hope this helps.

David E. Weissman, MD
Professor, Palliative Care
Medical College of Wisconsin
Palliative Care Leadership Center
Milwaukee, WI