Episode 253 — the Acute Pain Service With Drs. Segna, Rayaz, Jaremko and Barnhart
Highlights
- Ketamine for Depression: A Review
Key takeaways:
- Ketamine is well tolerated at lower doses, and typically starts at 0.10.2 mg/kg per dose.
- It is important to be aware of potential contraindications, such as active psychosis, and to titrate the dose accordingly.
Transcript:
Speaker 1
Has synergism with opioids for analgesia it does not increase your risk of not being able to breathe or having respiratory depression so that is a really important one and because it is used IV we can use it in patients that can't take anything right now there's some relative contraindications active psychosis is the number one reason why you should not start it and then because it is also metabolized by the liver if they have significant liver dysfunction or a new transaminitis we have to be careful in rare cases ketamine can cause a trans aminitis so this doesn't mean we can't try it in these patients but we need to be cognizant of starting a lower dose knowing that more may accumulate I'm trending those liver enzymes during that time other things that are relative contraindications are malignant arrhythmias or uncontrolled cardiovascular disease because it is a Sympathetic nervous system stimulant which actually puts additional strain on the heart so if they have a ischemic issue or they have arrhythmias this can worsen them so that's something we consider but overall it's very well tolerated at these lower doses and typically we start here at Hopkins between 0.1 and 0.2 makes percage and sort of depending on the patient you could titrate it up is there's a common misconception (Time 0:24:15)
- Muscle relaxants for pain relief
Key takeaways:
- Muscle relaxants can be helpful in treating pain caused by spasms and tightness in the muscles around the incisions made during surgery.
- There are only a few muscle relaxants that have an IV formulation, and they all have different mechanisms of action.
- Cyclobenzapine, bacliphine, methocarbomol, and tzazanidine are all centrally acting, meaning they work on the central nervous system (CNS) to relieve pain. Valium is a benzodiazepine, which is a type of medication that works on the brain to relieve pain.
Transcript:
Speaker 1
Um other medications that we consider muscle relaxants i think that's an area that we don't always think about or is not always included in ERAS protocols but we know that several surgeries that go through many layers of muscle these patients can have spasms and tightness that tugs on their incisions that squeezes nerves that are already agitated and so we do have a good benefit from including these as part of our regimen there are several different muscle relaxants i'll sort of list them and then there are only a few that we have IV formulations for they are centrally acting but the mechanisms are not always clear for these medications but overall they treat the skeletal muscles spasms tightness and cramping and so that's what i asked the patient are you having any of those symptoms and then also assessing where their incisions and injuries are if We think that muscles would be significantly contributing to their pain so the list of those are cyclobenzapine which also has a serotonin component important to note if you're starting them on a lot of serogenergic medications bacliphine which is traditionally used in spasm more spasmodic pain and back pain methocarbomol is another that has an IV formulation tzazanidine and valium is a benzodiazepine that had the long (Time 0:27:57)
- Epidural vs. Peripheral Nerve Catheter for Regional Anesthesia
Key takeaways:
- IV regional and topical medications are used to treat patients who do not have systemic infection or coagulopathy.
- IV muscle relaxants and topical lidocaine patches are also options.
- IV opioids are often used to treat pain.
Transcript:
Speaker 1
Are IV regional and topical so we would look at these patients to see if they're a candidate for regional if they don't have systemic infection or coagulopathy and could tolerate an epidural that certainly whenever our first choice is for large abdominal surgeries or large thoracic surgeries if that is contraindicated for any of those reasons we can look at peripheral nerve catheters that are more distal in the body or not in a place that we would be worried about bleeding with a coagulopathy systemic infection is always a risk for a catheter because then it will stick to any indwelling device so we avoid it there the other IV medications that i reach for are certainly ketamine infusion and or lidocaine infusion i wouldn't mix lidocaine infusion with an epidural or peripheral nerve catheter but if they can't get those i have done ketamine and lidocaine together And those have worked well IV muscle relaxant like we mentioned and topical lidocaine patches are always a possibility and then the IVs you can either have an IV push which means the nurse administers it and is something that the patient has to ask for or consider a patient controlled analgesia or PCA with those and our our opioids of choice for that is usually (Time 0:37:02)
- Epidural and peripheral nerve catheter placement: what to expect
Key takeaways:
- Peripheral nerve catheters are contraindicated in patients with a coagulopathy, systemic infection, or a history of falls.
- IV medications that are commonly used include ketamine, lidocaine, and opioids.
- Topical lidocaine patches are also possible.
- IVs can be administered with an injection or through a port in the arm.
Transcript:
Speaker 1
Contraindicated for any of those reasons we can look at peripheral nerve catheters that are more distal in the body or not in a place that we would be worried about bleeding with a coagulopathy systemic infection is always a risk for a catheter because then it will stick to any indwelling device so we avoid it there the other IV medications that i reach for are certainly ketamine infusion and or lidocaine infusion i wouldn't mix lidocaine infusion with an epidural or peripheral nerve catheter but if they can't get those i have done ketamine and lidocaine together and those have worked well IV muscle relaxant like we mentioned and topical lidocaine patches are always a possibility and then the IVs you can either have an IV push which means the nurse administers it and is something that the patient has to ask for or consider a patient controlled Analgesia or PCA with those and our our opioids of choice for that is usually fentanyl or delotted but sometimes morphine depending on the patient and what works for them and that allows them to have small doses that they control they have better patient satisfaction and if they get too sedated from the medication they fall asleep they don't press the button the downside is that it is fast on and off so if someone has (Time 0:37:21)
- What is the difference between fentanyl and morphine?
Key takeaways:
- Fentanyl is usually the preferred opioid for PCA in most cases.
- Buprenorphine is a good opioid for patients on buprenorphine who are seeking relief from opioid addiction.
- There is a specific niche for fentanyl in certain roles, such as patients on buprenorphine.
Transcript:
Speaker 2
Great um Hassan while while we're talking to you i wonder if you could comment Kelly mentioned that you know that our common choice here and this may be true elsewhere as well for a PCA is usually going to be the fentanyl or delotted and then maybe occasionally morphine. Do you want to say a few words or anybody can about you know when you might pick one versus the other versus the other?
Speaker 4
Yeah so they're uh most of the time uh for uh a lot of this will be uh cultural within an institution delotted is uh or hydromorphone for you know if we're not going with brand names uh people go to very quickly because it has high efficacy it's very potent where i think it has a specific niche in a role and Kelly alluded to this is patients on buprenorphine coming in buprenorphine has a really high affinity for opioid receptors and out of our full agonists that (Time 0:50:17)
- The Different Roles of Opioids in the Treatment of Pain
Key takeaways:
- Opioid rotation is a useful way to manage patients who are resistant to opioid therapy,.
- Hydromorphone is a good choice for patients who are resistant to other opioids,.
- Fentanyl is a good choice for patients who are resistant to other opioids and are cyp 2d6 metabolizers.
Transcript:
Speaker 4
Yeah so they're uh most of the time uh for uh a lot of this will be uh cultural within an institution delotted is uh or hydromorphone for you know if we're not going with brand names uh people go to very quickly because it has high efficacy it's very potent where i think it has a specific niche in a role and Kelly alluded to this is patients on buprenorphine coming in buprenorphine has a really high affinity for opioid receptors and out of our full agonists that we use to treat pain hydromorphone is uh the choice to knock that buprenorphine molecule off the opioid receptor so that would be a first line choice to use that one in particular if they have renal dysfunction you know it's it's not quite uh morphine as far as metabolites and concern uh but it should be kind of in the Rolodex there uh and or i'm concerned about vulnerable populations geriatrics sleep apnea hepatorhenol like we talked about uh that's where i'll go fentanyl more often it's more of a cleaner medication from a side effect profile uh and that's it's more short acting but it can give us more there there may be a little bit more tacky phillaxis with fentanyl so you have to watch out for that i think for a lot of these patients rotating opioids instead of going up on the dose repeatedly um is useful great uh you know and the last the last thing i'll say is um there are certain things like there's a small percentage of Caucasian patients uh that are aren't great cyp 2d6 metabolizers and and that's delodage right if it's having no effect uh then it's probably good in those patients to rotate to something else so again Going along with that theme of rotating opioids instead of increasing doses great (Time 0:50:41)
- Methadone for Opiate Use Disorder: A Comprehensive Overview
Key takeaways:
- Methadone is a great pain medication because of its NMDA receptor antagonism and long halflife.
- It is also effective perioperatively, but can be risky if doses are stacked.
- Patients should be monitored carefully when starting and adjusting methadone dosing, as bispasic metabolism can vary.
Transcript:
Speaker 1
Thoughts that sure i can briefly go into that so i think the reason that methadone is such a great pain medication is because of the nmda receptor antagonism in addition to them uopioid receptors and also it has a very long half-life so it creates that background pain control without getting an extended release formulation on board and you can use that in the short term there's definitely efficacy perioperatively such as in spine surgeries using that because it does last a little bit longer the risk of using methadone is that it has this bispasic metabolism and that second phase can vary between i want to say 12 and 72 hours for the half-life and that is why when you have these patients where our subs team our substance use disorder team is treating the escalate very slowly so you really have to watch for what that person's Metabolism is going to be someone who's chronically been on it for pain or for opiate use disorder you kind of have an idea of what they can tolerate but in a new patient you don't know so stacking the doses can become slightly risky especially with changing metabolism now what we do know is that while once a day dosing is good for cravings and opioid use disorder every eight hours is the analgesic dose which correlates with that first phase of metabolism and the effects that you see so i think that it's certainly something i have used in patients patients that were really doing well on ketamine and then the ketamine came off and they're willing to do methadone i get a fair amount of pushback for patients that it's too stigmatizing now you can be prescribed methadone typically as a pill that can be picked up In a regular pharmacy and written by any of us as long as it's indicated for pain and that's the qa dosing there's some newer literature again i don't want to dive too deep in the palliative care world that even using a small amount of methadone even (Time 0:53:00)
- The benefits of using methadone for pain relief
Key takeaways:
- Opioid use disorder every eight hours is the analgesic dose which correlates with that first phase of metabolism and the effects that you see so i think that it's certainly something i have used in patients patients that were really doing well on ketamine and then the ketamine came off and they're willing to do methadone.
- There is some good evidence that using a small amount of methadone even as short as once a day can boost the advocacy of other opiates.
- We have to be very careful about metabolism, their qtc, and who is going to manage it as now patient great super.
Transcript:
Speaker 1
And opioid use disorder every eight hours is the analgesic dose which correlates with that first phase of metabolism and the effects that you see so i think that it's certainly something i have used in patients patients that were really doing well on ketamine and then the ketamine came off and they're willing to do methadone i get a fair amount of pushback for patients that it's too stigmatizing now you can be prescribed methadone typically as a pill that can be picked up in a regular pharmacy and written by any of us as long as it's indicated for pain and that's the qa dosing there's some newer literature again i don't want to dive too deep in the palliative care world that even using a small amount of methadone even as short as once a day almost works like um a little boost like we used to See with like a bilefi and an anti-depressants that it can actually boost the advocacy of other opiates and i think that's through the nmda receptor pathway but i'm not sure we fully figure that out yet so i think we can utilize it more but we have to be very careful about metabolism their qtc and who's going to manage it as now patient great super helpful um all right there's some go ahead that's not clear yeah uh like Kelly said uh there's some really good evidence (Time 0:54:12)