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Pain medicine cases


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Pain medicine cases

  1. 1. Pain Medicine Cases Inpatient 1
  2. 2. Case 1 57 year old female with history of HTN and OA is POD#0 s/p THR. CSE placed in OR. Spinal is wearing off on the floor and you are asked to see the patient. Would you bolus the patient? With what? How much? What are the toxic doses? What is the onset time of various LA? What is the MOA? Site of action? What are your concerns regarding administration of epidural medications? What are your concerns regarding administration of meds via the catheter? What are s/sx of LA toxicity? Neural/Cardiac. Which appears first?
  3. 3. Case 2 • 67 year male history of HTN, DM, smoker is POD#2 s/p R-VATS. Patient is on 7W stepdown. • What is the standard starting PCEA (patient controlled epidural analgesia) infusion at this institution? What is the hourly dose of local anesthetic? Of opioid? • Patient has been stable on an infusion of 6/2/20 since his surgery and has excellent pain control and HD stability • The thoracic PA calls you and demands you stop the epidural infusion immediately as patient’s blood pressure is 80/40. What do you do?
  4. 4. Case 3 29 year old 214kg 4’11” female is POD#1 s/p Bowel resection. She is complaining of abdominal pain in the PACU. How much medication should she get? PCA? Dose? What is Pickwickian Syndrome (OHS)? How do opioids cause respiratory depression? She is found obtunded and non-responsive on 8W. Oxygen is flowing via NRB mask at 10L/min and her sat is 98%. Is this really an emergency? What would you do? If patient this patient’s pCO2 is 80. What is her pH (assume starting 7.37)? What is her K+ (starting 5.3)?
  5. 5. Case 4 74 year old female is POD#3 s/p TKR. The ortho PA calls you to remove her epidural catheter. What do you want to know before removing the catheter? Patient received coumadin 5mg po last night. Do you want to check coagulation studies? Patient has been on heparin 5000U SC Q12 hours for 4 days. Do you want to check any labs? Why? Would you wait to remove the catheter if the patient was on heparin 5000U SC Q8h and just received a dose? How long? What about for therapeutic LMWH? Prophylactic LMWH? Aspirin? Ibuprofen? Clopidogrel? Next day you notice patient also has a femoral catheter. Her INR is 1.8. Can you remove it?
  6. 6. Case 5 What are you thinking? 34 year old POD#1 s/p T12-L5 PLIF. Pain was well controlled POD#1, but now you are called as patient has severe pain. What if this was POD#4? What would you do?
  7. 7. Case 6 67 year old male POD#1 s/p TKR under spinal anesthesia/MAC. Femoral catheter in place. Nurse calls you to let you know that patient’s foot is numb, but he still has pain in posterior aspect of his knee. Describe the innervation of the lower extremity. Innervation of the knee?