1. Troubleshooting in APS Moderator: Dr Wan Rohaidah Date: 11/7/13

2. Content Case scenario Troubleshooting: PCA Troubleshooting: epidural Other pain management APS in chronic pain patient/ substance users Role of oxynorm

3. Case scenario 32 years old lady, G2P1 at 34 weeks. Presented with 1 episode of seizure and drop in GCS. CT scan noted brain aneurysm. Admitted to ASW for further management. In ward, patient had episodes of intermittent tachycardia and hypertension, most likely due to pain contractions. Patient conscious but not obeying command, not intubated. Referred to APS for pain control, to prevent labile BP which can lead to bleeding of the aneurysm. What is the best modality of APS to be used in this patient?

4. Content Case scenario Troubleshooting: PCA Troubleshooting: epidural Other pain management APS in chronic pain patient/ substance users Role of oxynorm

5. Troubleshooting: PCA Inadequate analgesia Nausea and vomiting Sedation Respiratory depression Pruritus

6. PCA: Inadequate analgesia Check pump (Demand and good) – If high Increase bolus dose by 50% Change types of opiods (opioid rotation) Add ketamine infusion (0.1mg/kg/hour)- dilute 200mg in 50cc NS Non opiods adjuvants (PCM, NSAIDs, tramadol, gabanoids) If bolus greater than standard (eg fentanyl 20mcg) and use of fentanyl > 200mcg/hr; – Consider adding ketamine

7. PCA: Inadequate analgesia – If low Nausea when presses button? Doesn’t understand how to use PCA – If cognitive impaired, change to NCA – If cognitive intact, encourage to use PCA

8. PCA: Inadequate analgesia (stepwise approach) Make sure patient on non opiod adjuvants (PCM, NSAID, tramadol, gabanoids) Ensure patient getting the most out of PCA Optimise PCA doseAdd ketamine infusionChange opioid

9. Nausea and vomiting Consider changing to other opiods Other aetiologies- bowel obstruction, dehydration PONV protocol

10. Nausea and vomiting (PONV protocol)

11. Nausea and vomiting Midazolam infusion – Give bolus 0.5mg or 1mg – Review after 30 mins – If improved, commenced and continue until PCA removed 10mg midazolam in 100cc NS, run at 0.5-1mg/hr

12. Sedation: PCA Monitor vital signs- RR, pulse oximetry, sedation score Ensure patient on oxygen Check usage of PCA –consider reducing dose Exclude other causes (intracranial pathology- trauma history/neurosurgical) Ensure patient not getting sedatives

13. Respiratory depression: PCA Monitor RR (if less than 6-8, be alarmed) Apply oxygen Check other signs of opiod toxicity- pupil size, rousability Stop PCA Naloxone – Dilute 400mcg (1 ampoule) in 10mls – Give 1ml at a time and wait 2-3 minutes each time

14. Pruritus Centrally (intrathecal, epidural)- naloxone, ondansetron IV,s/c,oral- antihistamine first choice Ondansetron or sc naloxone (100mcg 2 hourly prn) Change opioid Low dose naloxone infusion (0.2 mcg/kg/min)

15. Content Case scenario Troubleshooting: PCA Troubleshooting: epidural Other pain management APS in chronic pain patient/ substance users Role of oxynorm

16. Troubleshooting: Epidural Hypotension Inadequate analgesia Epidural haematoma/abscess

17. Epidural: hypotension Check other causes (haemorrhage, sepsis, cardiac event) Fluid loading Check epidural – Extent- adjust accordingly (adjust rate) – Check tip- ensure not intrathecal

18. Epidural: Inadequate analgesia Causes (bleeding, compartment syndrome, cardiac event) Level of catheter insertion Has it been effective at the first place? Epidural site- dislodged, leakage Extent of sensory block

19. No block/patchy block

20. Unilateral block

21. Block too high/ too low

22. Epidural haematoma/ abscess

23. Epidural abscess Routine inspection at epidural site D2 onwards If pain/erythema present, assess; – Extent, location, severity of pain – Extent of erythema – Neurological symptoms and signs – Recent or current pyrexia – Any predisposing factors (cancer, sepsis, immunosuppressed)

24. Epidural abscess

25. Content Case scenario Troubleshooting: PCA Troubleshooting: epidural Other pain management APS in chronic pain patient/ substance users Role of oxynorm

26. Other pain management:Ketamine infusion Useful for; Opiod tolerance (reduces tolerance) Pain that is poorly responsive to opioids (eg phantom limb pain) Neuropathic pain Starting rate 0.05-0.1mg/kg/hr maximum 0.5- 0.6mg/kg/hr Dilution: 200mg in 50cc NS

27. Content Case scenario Troubleshooting: PCA Troubleshooting: epidural Other pain management APS in chronic pain patient/ substance users Role of oxynorm

28. APS in Chronic pain patients and substance users Do not assume pain complaints stem from opiod tolerance, drug seeking, behavioural issues- can be genuine surgical complications. Ensure they are getting the usual opioid requirement (this is their background requirement) and be given along with PCA/regional Consider adding ketamine infusion or increase dose by 50%

29. Opiod conversion table

30. Opioid conversion table Eg: – Conversion of SC morphine to transdermal fentanyl patch, patient using 10mg 4 hrly= 60mg per day – Conversion factor: divide by 1.2 – 60 divide 1.2= 50mcg per hour

31. Case scenario 32 years old lady, G2P1 at 34 weeks. Presented with 1 episode of seizure and drop in GCS. CT scan noted brain aneurysm. Admitted to ASW for further management. In ward, patient had episodes of intermittent tachycardia and hypertension, most likely due to pain contractions. Patient conscious but not obeying command, not intubated. Referred to APS for pain control, to prevent labile BP which can lead to bleeding of the aneurysm. What is the best modality of APS to be used in this patient?