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Blogs to Boards: Question 7


This is the seventh in a series of 41 posts from both GeriPal and Pallimed to get our physician readers ready for the hospice and palliative medicine boards. Every week GeriPal and Pallimed alternates publishing a new question, as well as a discussion of possible answers to the question (click here for the full list of questions).  


Question 7

JY, a 28 year old woman with advanced cystic fibrosis and Burkholderia cenocepacia colonization is hospitalized for a cystic fibrosis exacerbation. She has chronic chest wall pain from coughing and pleurisy, and recently broke 2 ribs from coughing. She is on IV glucocorticoids, IV ketorolac, IV ketamine prior to vest treatments, and lorazepam.

Prior to her hospitalization, she took oxycodone ER 30mg q12h. Currently she is on a hydromorphone IV PCA at 2mg/hour, with 2mg q30 minute boluses. She used 72mg of IV dilaudid in the last 24h. Despite this she is becoming drowsy, and reports her pain is minimally improved and still severe for most of the day: 7-8/10, and ‘nearly intolerable’ during vest therapy

The best next step is to:

a) Increase her PCA basal and ‘bolus’ doses by 50% and monitor for 24 hours. 
b) Add a 5% lidocaine patch to her chest wall over her rib fractures 
c) Discontinue hydromorphone and switch the patient to another opioid 
d) Advise the primary team to stop vest therapies 


Discussion:

Comments

Anonymous said…
I would change the agent and add the lidocaine TDP.Taht she is already drowsy without pain relief is discouraging.Hold the vest therapy for a day or two while changing the agent and see whether pain relief is better and sputum clearance any decreased and then decide on the frequency to as tolerated.
Bruce Scott MD said…
I guess we should try opioid rotation (IV fentanyl? methadone?)

Who is managing the ketamine? Was it working previously and now has stopped? If it is dosed properly, then it probably means that a rotation strategy to methadone will be less likely to be successful that we are otherwise used to. (Ketamine is a considerbly more potent NMDA recepter antagonist than methadone.)

I'd really be more inclined to increase the ketamine dose if she is not having side effects.

I agree with the first (anonymous) commenter that it is tempting to try skipping a day or two of the percussion vest therapy. I think that the primary team (or pulmonology) is unlikely to love this plan, however.

While topical lidocaine may not be terribly useful here, some might try IV lidocaine prior to vest therapy if the IV ketamine isn't working. My own sample size with IV lidocaine is small and results disappointing.
john.rich16 said…
I would keep all this in my mind while dealing with the patients so thanks to share this information here in your blog.

Home care

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