Pain Rounds 27 April 2011

How much is too much?or

“You will find medical culture different in

Australia to the USA”

Jodie 48 yrs American Announced via warning e mail 2/52 pre Christmas 2010

Arriving from USA in several days on high dose IV opioids and Ketamine

Many pages of previous medical history Recurrent renal stones & fibromyalgia HT Diabetes type 2 Migraine GORD Obesity Self catheterisation – atonic bladder Subclavian line sepsis

Initial HIPS contact

Hayes/Nickerson appointment 2/7 after arrival in Australia

Analgesic medication: Subclavian line regime - past 3 or 4 mths

IV hydromorphone 20mg/hr + boluses = daily oral morphine equivalent 5500mg

IV ketamine 20mg/hr + bolusesIV ketorolac 30mg boluses

Pregabalin 300mg tds Nortriptyline 25 mg mane, 75mg nocte

Initial HIPS contact

IV antibiotics for line sepsis (Merepenem) Other medication:

Lorazepam 0.5 mg prn, Zolpidem 10mg IV phenergan Atenolol, Lisinopril Pramipexole Sumatriptan, ondansetron, metoclopramide Lantus insulin 10units nocte, Metformin 1g bd

IV fluids to prevent dehydration

Discussion with pharmacy

Jennie MacDonald cost estimate $80K yearly Choice

Initial maintenance of regime over Christmas+

OrAdmission to rationalise medication

Establishing priorities …

Admission 17 December 2011

Dr Rob Pickles Intermittently drowsy, clammy, sweaty &

complaining of poor analgesia Metabolic acidosis - thought to be related to

anti-inflammatory Thrombocytopaenia - thought to be related to

antibiotic

Discharge 24 December 2011

Analgesic regime: IV ketamine/hydromorphone tapered & ceased Norspan 20mcg/hr + Temgesic 0.2mcg x3/d Clonidine cover 100mcg tds Daily oral morphine equivalent 5500mg to 60mg IV ketorolac ceased Pregabalin switched to gabapentin 300mg tds

Discharge 24 December 2011

Metabolic acidosis - thought to be related to anti-inflammatory

Thrombocytopaenia - thought to be related to antibiotic

Sepsis UTI klebsiella – ciprofloxacil 500mg bd during

admission and for 1/52 Central line left in situ, merepenem ceased

Medication for HT, diabetes, GORD continued

What is going on? Diagnoses

Tolerance/ opioid induced hyperalgesia

Other adverse effects

Medical co-morbidities

Factitious ?

Discharge 24 December 2011

CT KUB clear of stones Patient anxious ++ when jar of renal stones

temporarily misplaced during admission

Corroborative medical history

GP in USA Mayo Clinic input

confirmed stones in early years Multiple lithotripsies One percutaneous stone removal

Palliative care physician input Infected intrathecal pumps x2 Escalation of opioid & other medication doses

Progress – Jan/Feb 2011

Maintaining boundaries

Dr A Powell + HIPS nursing staff

Multidisciplinary assessment

11 March 2011 – Pols, Daunt, Hayes Pain History

1st kidney stones in early 20’s Increased formation rate since mid 30’s 14 lithotripsies, multiple ureteric basket removals

& 1 percutaneous surgery Initial pain pattern typical of renal colic

Multidisciplinary assessment

Pain History Change 6 years ago with development of more generalised

pain syndrome - fibromyalgia Medically unexplained symptoms Negative investigation for MS Atonic bladder & bowel Numbness & tingling R side of body Shivers & sweats

Multidisciplinary assessment

2 years ago – input from palliative care physician Intrathecal pumps x2 infected Central line infected, removed then reinserted

Current pain Total body pain syndrome with muscle tenderness Intermittent waves of bilateral loin pain – patient

related to passage of stones

Multidisciplinary assessment

Activity Intensive CBT program in 2009 “learned some skills but no significant overall

change” Much of day resting in bed

Multidisciplinary assessment

Life story Married to Daniel for 20 years, clergyman 2 teenage children Work conflict 6 years ago – aggravation of pain Difficult childhood with sustained sexual abuse 5-

18 years. “Mum did not protect me” Jodie unable to confront her mother about this

prior to the mothers death Coping via sporting/outdoor activity Worked in Girl Guides & disability sector – last

work 2 years ago

Overall Assessment

Persistent pain in the context of medical co-morbidities and a traumatic developmental history

Sensitised nervous system rather than structure Possible gravel formation ?? Opioid situation improved Low physical activity Possible factitious disorder

Whole Person Management: reprogramming old patterns

Thoughts

Actions

Lifestyle

Story

Biological

Retrain the brain

Restore the tissues

Choosing

Awareness

Management Strategy

Understanding – mindbody connection Biological

Rotate Oxycontin 10mg bd, Endone 5mg x3/d prn In future alternate between oxycodone and

hydromorphone GP support re opioid boundaries Dr A Gillies review – central line, IV fluids, stones

Nutrition - “Nutrition & Pain” Activity – Moving with Pain offer Story – “My Story”, Dr M Pols review

Time for a break …