PAIN MANAGEMENT

Tips

• When the Acute Pain Service (APS) is following, we defer management to them. 
• IMPORTANT:  Anticoagulation, especially initiation of anticoagulants, should be discussed with the primary team and APS if there is an epidural in place.
• Recommend an adequate bowel regimen in place for patients on opiates.  (But—avoid suppositories post abdominal surgery—discuss with the primary team first)
• Hydromorphone is preferred in patients with renal failure because it has fewer active metabolites metabolized by the kidney compared with morphine or fentanyl.
• Avoid meperidine given the potential for toxicity and the availability of other effective agents.

Regional Anesthesia

• Neuraxial Anesthesia: 

      Epidural catheters:  (managed by Acute Pain Service)

• Thoracic or lumbar spine, used intraop and also postop generally less than 4 days. 
• Typically used in thoracic, abdominal, urologic, GYN, and lower extremity surgery. 
• Side effects include headache, hypotension, lower extremity numbness. 
• Foley catheters are typically NOT discontinued until a lumbar epidural is out or the epidural infusion discontinued. 
• Anticoagulation: 

Heparin 5000 units Q12H or Q8H	No restrictions
LMWH, prophylactic dose e.g. enoxaparin 40 mg subcut daily e.g. dalteparin 5000 units subcut daily	Wait 12 hrs after last dose before placing catheter (longer if renal insufficiency) Wait 6-8 hours after catheter placed to give a dose Wait at least 2 hrs after removing catheter to give a dose
LMWH, prophylactic high dose e.g. enoxaparin 30 mg subcut BID	DO NOT USE while catheter in place
Heparin, full dose Unfractionated or LMWH	DO NOT USE while catheter in place
Fondaparinux Prophylactic or full dose	DO NOT USE while catheter in place
Aspirin	No restrictions
Clopidogrel	DO NOT USE while catheter in place.  Stop for 7 days prior to placing catheter.
Warfarin	DO NOT USE while catheter in place.  INR should be < 1.5 prior to placing catheter.

      Spinal catheters:

• Similar to Epidural, but placed in the lumbar spine only, and used postop less than 24 hours.  Medication is infused directly into the CSF and typically requires very low doses.

• Nerve blocks:  Local injections near a nerve or nerve plexus.  Sites include interscalene, lumbosacral plexus, femoral nerve.  Interscalene blocks are sometimes used in shoulder / upper extremity surgeries—note they may be associated with plexopathy, bradycardia, hypotension, and phrenic nerve paralysis. 
• Peripheral nerve catheters:  Used with increasing frequency.  Instead of a single injection, a catheter is placed in the region attached to an infusion device that can remain postop for pain control. 

 

Reference:

1.         uwmcacc.org, last reviewed May 2011

Updated May 2011