CAPC Palliative Care Discussion Forum
General Operational Topics
Greetings, colleagues,
I am writing for practice advice on a patient that was being treated at our hospital, for whom I was consulted very late in a fairly disastrous case:
Mr. V was a 64yo man diagnosed with prostate CA 8/2006, underwent CTX and XRT, later with mets to liver, penis, bone, abdomen. He was under hospice care for pain management (family vehemently against pt being a DNR - despite full awareness of pt terminal stage of illness), and was receiving morphine via PCA pump at 22mg/h, with bolus of 4mg q10min prn pain, max 46mg/h. He came to the hospital for repair of right humerus fracture, and his PCA was discontinued immediately preoperatively. Unfortunately, his PCA was restarted postoperatively at a rate of 1mg/h basal, 1mg demand q6min. Then there was LOTS of chasing of tails, his PCA was again changed to 0 (zero) mg/h basal, 5mg q15min demand, 80mg 4hr limit. Needless to say, this man was in a pain crisis by the time I was called in on the case (again, demonstrating to me (an NP without the benefit of a palliative care physician for peer-to-peer discussion)that despite three years of teaching, marketing, and presence, my role is still misunderstood - but, that's another battlefield). I was able to titrate his morphine up quickly and improve his pain management, but am wanting evidence-based best practice if ever I run into this in the future. Unfortunately, my literature search is QUITE limited on the recommendations of intraoperative continuation of PCA, or resumption of postoperative PCA at this doseage.
My questions:
1. Do any of you have experience with continuing a PCA (or infusion), at baseline basal dose, during a surgical experience requiring general anesthesia? (I find lit on small dose morphine intraoperatively, but not this dose)
2. Do you restart basal dose of PCA immediately post-op? I assume in the PACU? Does this lengthen PACU stay?
3. Do you write orders for narcan if the patient is not an AND/DNR?
Any advice is appreciated, and any leads on literature is a Godsend. Seriously.
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PCA patient with surgical repair of fx humerus
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