Key Clinical Questions
What are the goals of pain therapy?
How is the sensation of pain measured?
What are the types of pain?
How do patient comorbidities affect pain management?
What are the most appropriate and effective pain treatment options available?
A 76-year-old female with a history of dementia, hypertension, hypercholesterolemia, coronary artery disease, chronic obstructive pulmonary disease, and chronic low back pain suffered a right tibia fracture. The orthopedic surgery service surgically repaired her leg and transferred her to the primary service for management of multiple co-morbidities. On the second postoperative day, severe pain has limited her movement and ability to work with physical therapy or use the bathroom facilities. Home medications include atorvastatin, metoprolol, ramipril, hydrochlorothiazide, ipratropium, albuterol metered dose inhaler, and oxycodone controlled-release 20 mg twice a day. Her vital signs were: heart rate is 120 beats per minute, blood pressure 150/95 mm Hg, SpO2 95% on 2 L of oxygen, and temperature 37.2°C. Laboratory results were notable for a glucose level of 212 mg/dL. Her postoperative pain is managed by 2 mg of intravenous (IV) morphine every 3 hours. On this regimen she does continue to report severe right leg pain.
In managing the postoperative patient with dementia the goal is to minimize her opioid requirement (and side effect burden) by using NSAIDs and gabapentinoids as adjuncts. The patient has no history of renal insufficiency or gastric ulceration, and scheduled doses of ketorolac, ibuprofen, or celecoxib may be appropriate. However, this would require consultation with the operative surgeon due to associated bleeding risk and the possibility of impaired bone healing. In the absence of hepatic insufficiency, scheduled acetaminophen would also be appropriate. One may also consider starting low doses of pregabalin or gabapentin.
A peripheral nerve block using a femoral nerve catheter, a relatively low-risk intervention, may alleviate much, but not all of her pain. This would allow systemic anticoagulation with low-molecular-weight heparin without risk of an epidural hematoma. If a femoral nerve catheter does not sufficiently control her pain, an epidural placed in the low lumbar region may offer superior pain relief. This would require urinary catheterization, and appropriate precautions regarding anticoagulation. Either intervention may decrease or obviate the need for supplemental opioids. The ultimate goal with this patient is to improve functionality and have her out of bed and working with physical therapy. It is important to achieve a sensory blockade while maintaining motor function, decreasing her fall risk and improving her ability to work with physical therapy.
DEFINITION AND CLASSIFICATION
Pain is the leading cause of both adult outpatient and emergency department visits, impacting both inpatient and outpatient care for over 100 million Americans annually. The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.