Table 3:
Exemplar of a Perioperative Multimodal Pain Management Plan
| Phase | Pharmacological plan | Rationale |
|---|---|---|
| Preoperative | Develop patient centered postoperative pain management plan. | Set realistic goals. |
| Tylenol 1000mg PO | ||
| Celebrex 300mg PO | ||
| Neurontin 150mg PO | ||
| Morphine 5mg Intrathecal | ||
| Intraoperative | Fentanyl – titrate to effect | Manage pain intraoperatively with choice of opioid. |
| Morphine – titrate to effect | ||
| Postoperative | Opioid rotation from oral opioids to IV morphine | The open bowel resection requires the patient to be NPO after the surgery. |
| 1. Patient taking oxycodone 200mg and tramadol 50mg. | ||
| ○ Hydrocodone 120mg daily ➔ 120 × 1= 120mg morphine | The conversion of oral morphine to IV morphine is 3:1. | |
| ○ Oxycodone 30mg daily ➔ 30 × 1.5 = 45mg morphine | ||
| ○ Total MEDD = 120 + 45 = 165 MEDD | 27.5mg IV morphine is the baseline rate that will be used to prevent withdrawal and manage chronic pain symptoms. | |
| 2. 165mg of oral morphine is equivalent to 55 mg IV morphine. | ||
| 3. Decrease the dose by 50% due because of incomplete tolerance ➔ (50% of 55mg = 27.5mg). | ||
| 4. Infuse 27.5 mg over 24 as the basal rate of PCA (27.5/24 = 1.15mg). | 1mg IV bolus helps manage acute postoperative pain | |
| ○ Run baseline PCA at 1 to 1.25mg per hour | ||
| ○ Program 1mg bolus as needed with a 4-hour lock time | ||
| Postoperative day 1: Summary of opioid consumption | A summary of the last 24 hours opioid consumption is used to determine the discharge opioid requirement. | |
| - 24mg morphine from the infusion | ||
| - 3 mg in boluses | ||
| - Total daily IV use = 27 mg | ||
| Postoperative day 2: Discharge orders | The importance of teaching the patient about the need to reduce opioid consumption cannot be overemphasized. | |
| - Gabapentin 600 mg two times a day | ||
| - Convert IV morphine to oral equivalence ➔ 27 × 3 = 81mg | - Some patients may rationalize their opioid dependence by requesting the same opioid. Good knowledge of pharmacogenetics would enhance patient teaching. | |
| - 81 mg of oral MEDD ➔ 81/4 = 20mg oral Hydromorphone | ||
| - Hydromorphone extended-release 8 mg by mouth 2 (or 3 depending on assessment) times a days | ||
| - Increasing the dose of non-opioid analgesics should help decrease opioid requirements. |
Notes: PCA= patient controlled analgesia; IV = intravenous; NPO = nothing by mouth; MEDD= morphine equivalent daily dose; PO = oral