Case Week 7 (w/c 14/11/11)
This week gasclass returns to elective theatres.
You have a 33 year old lady who is listed for a laparotomy for resection of small bowel strictures. She has had a previous colectomy and proctectomy for slow transit colon.
She wishes to discuss post op analgesia.
What is your default plan for post op-analgesia
The lady has previously had an epidural for her total colectomy which was required due to slow transit colon secondary to opioid use for back pain. This did not provide adequate analgesia, despite continuing her MST in conjunction with the epidural. For her proctectomy she did not want an epidural and had a PCA, this also did not give very effective analgesia. She is concerened that she is going to be in “agony”. She will accept whatever you decide but wants it to work.
How does this information influence your analgesic plan?
The failure of her epidural and PCA were related to confusion with her breakthrough dose of Oramorph for her back pain. Currently she is on a fentanyl patch 150mcg/hr and oramorph 10mg 4-6 hourly.
What will be your final decision for managing her post op analgesia? Why have you made that decision?
This weeks case covers a difficult but increasingly seen problem. The patient who will require management of acute pain who is already on opioids for a chronic condition.
The majority of people felt that an epidural would be their default choice for post operative analgesia when given the initial scenario. There are good reasons for this, epidural anaesthesia is felt to be the “gold” standard and has the potential provide complete analgesia following surgery. The epidural can also obutnd the stress response to surgery as well as reduce the incidence of post operative complications. Usually the epidural contains local anaesthetic and low dose opioid.
This approach is suitable in the majority of patients but in this case, there has been a previous attempt at epidural and pain relief was unsatisfactory, the alternative which is PCA was attempted on the second occasion and this also led to unsatisfactory pain relief.
With the additional information, the majority of responses switched from epidural to PCA. There are 2 approaches which can be used:
1) Continue with the current regimen (so long as this would be tolerated) and use the PCA for the additional pain
2) Convert all opioid to PCA
This lady was using a fentanyl patch and therefore this should be able to continue throughout the peri-operative period. As discussed a thorough history of additional opioid requirements pre-opertatively should be sought to allow this to be factored into the PCA bolus dose. It is likely that this patient will need close monitoring and intervention to obtain satisfactory analgesia due to her previous experiences.
The management of these cases is difficult there are no right or wrong answers however management should include early involvement of acute pain teams, these patients may require continuous opioid infusion in addition to a PCA bolus and should therefore be managed on a HDU post op.