We were very excited to welcome new palliative care attending Dr. Jay Vanston to HUP. He gave us an excellent talk on basics of pain management and PCA titration. While I couldn’t possibly capture the scope of the wisdom he imparted in that hour, here are some pearls:
PAIN MANAGEMENT PEARLS
1) If you don’t have IV access, you can give the same dose SQ. Both IV and SQ administration will cause peak effect in ~10-15 min (SQ a little slower)
2) PO doses of most oral opiates peak in ~1h; IV doses peak in 10-15 min
3) Quick tip for fentanyl patch conversion: a 50 mcg fentanyl patch = 50mg PO morphine q12 hours
4) Fentanyl patches have a peak around 12-17 hours after application, so don’t shut off their IV opiates until ~6h after patch placement
5) Methadone potency depends on baseline opiate use. The higher the patient’s baseline opiate use, the more potent methadone will be for that person.
- Basal dose: start with ~1/6 of the IV dose given over the 1st hour of attempted pain control
- Bolus dose: generally 1/2 of hourly basal rate, can give q10-15 min
- Conversion to PO: calculate 24h dose, convert to PO opiate of choice, and divide in half to get long acting (MS Contin/Oxycontin) dosage BID.
- You can give 10% of the 24h dose as PO breakthrough (generally q2-4h)