PAD Launch Day - Don Griesdale

Download PAD Launch Day - Don Griesdale

Post on 15-Jul-2015

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Airway pager programWhats Pain Got to Do With It? PAD Launch DayMarch 30th, 2015Donald Griesdale MD MPH FRCPCAssistant ProfessorDepartment of Anesthesiology, Pharmacology & Therapeutics Division of Critical Care MedicineUniversity of British Columbiadonald.griesdale@vch.ca1Case 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsObjectivesDisclosure52 year old female, previously healthyImmediate onset of pain and weakness in both handsImmobilized at scene and transferred to hospitalCC licence: Ludovic PeronCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsNeurology:Grade 1 2 motor strength in bilateral upper extremities4 5/5 strength in her legsDecreased sensation in her handsConservative managementTransferred to spine ICUCurrent pain management:Acetaminophen 975 mg PO q6h regularlyHydromorphone 2 4 mg q4h prn (used 16 mg in 24 hours)Case 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsDescribes 2 types of painNeck pain (NRS 2 3 / 10)Burning, electrical shocks in both arms and handsNRS 8 10 / 10Opioids dull the pain slightly, but dont help muchUnable to sleepEven the sheets touching her arms cause excruciating painCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsWhat type of pain does she describe?https://www.polleverywhere.com/multiple_choice_polls/wIssS8SPdKHo1EE7Case 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsAcute vs. chronicNeuropath: central vs. peripheralPatients with SCI can have both8Pain caused by a lesion or disease of the somatosensory nervous systemCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsClinical description (NOT a diagnosis)Requires a demonstrable lesion or disease that satisfies established diagnostic criteriaExamples: spinal cord injury, postherpetic neuralgia, trigeminal neuralgia, diabetes, MSAffect up to 20% of all chronic pain Allodynia9What would be your next option for treatment of this patient?https://www.polleverywhere.com/multiple_choice_polls/U6l1N8UPSOW3Z6s10Case 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsGabapentinStart at 300 mg / dayTitrate up to 4800 mg / daytidSE: dizziness, somnolence, nausea, rash, blurred visionPregabalinStart at 150 mg / dayTitrate up to 600 mg / daybidSimilar SE to gabapentinBetter bioavailabilityCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsInitially started on:Pregabalin 150 mg / dayNortriptyline 10 mg in AM and 25 mg qHSTopical amitriptyline ketamine creamOxycodone prnDespite increasing her pregabalin, her neuropathic pain worsenedRepeat MRI to ensure no obvious worsening pathologyStarted on ketamine IVTopiramate 25 mg BIDMethadone 1 mg PO TIDCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsRecognize and consider neuropathic painWhat is the etiology of neuropathic pain?Pharmacologic management is different than with nociceptive painEarly use of gabapentin / pregabalin and TCAsUse of topical agents for allodyniaReferral to a pain specialist for refractory neuropathic painCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home points27 year old male, belted driver in high speed MVCIntubated at the scene for respiratory distressIsolated flail chest with pulmonary contusionRib 4 9# on rightInitially managed on IV morphine and regular acetaminophenDamnsoft 09 at en.wikipediaCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home points"Pulmonary contusion" by Karim - http://www.trauma.org/index.php/main/image/32/Complications:Pneumonia & empyemaRespiratory failureChronic pain & long term disabilityPrimary goals:Excellent pain controlPulmonary volume expansionCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home points8 am the next day:Currently on PSV 5, PEEP 5 with FiO2 0.40You are now wanted to extubate this patientTry to wean his propofol infusion!Tachypneic, fighting ventilatorHypertensive, tachycardicRASS +2 to +3Case 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsBehavioural Pain ScaleBPS 7Case 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsICDSC ScoreAltered LOC1Inattention1Disorientation1Hallucinations delusions0Psychomotor agitation or retardation1Sleep/wake cycle disturbances0Symptom fluctuation1TOTAL5Case 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsOvernight pain management:Morphine total of 40 mg IV totalTylenol 975 mg NG q6hMethyltrimeprazine 20 mg IV totalPropofol infusion for sedation and ventilator synchronyReport: Either awake, agitated and confused or too sedatedCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsKeeping with PAD, what is the fundamental problem with this patient?https://www.polleverywhere.com/multiple_choice_polls/1o7Gptde4nhDval23Case 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsWhat would be your next pain management option?https://www.polleverywhere.com/multiple_choice_polls/NNTi3TezEnMAN0F25N Engl J Med 2010;362:1503Case 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsInfusion of local anesthetic & opioidCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsProsBetter pain control than PCAImprove respiratory functionMinimizes complications of systemic opioidsConsTechnically difficultComplicationsLocal HemodynamicInadequate blockCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsContraindications to epidural anesthesia:CoagulopathyAntiplatelet agents (e.g. Clopidogrel)LMW heparinElevated ICPLocal or systemic infectionCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsEpidural analgesia is a level1 recommendation for the management of severe blunt chest injuryCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home pointsPain scales may not be specificConsider the interactive effect of pain & deliriumAlternates to opioid analgesia where appropriateCase 1 Question 1 Question 2 Take home pointsCase 2 Question 3 Question 4 Take home points