What alternative analgesic can be given to a 65-year-old female patient with hypovolemic shock, dehydration, acute kidney injury (AKI), and lactic acidosis, who is experiencing a severe headache, unrelieved by Tylenol (acetaminophen)?

From the Guidelines

For a 65-year-old female with hypovolemic shock, dehydration, AKI, and lactic acidosis who is experiencing an 8/10 headache unresponsive to Tylenol, I recommend administering Dilaudid as it is preferred over morphine or fentanyl in the non-intubated patient 1. Given her acute kidney injury (AKI), it's crucial to avoid non-steroidal anti-inflammatory drugs (NSAID) as they can exacerbate renal injury 1. Considering her critical condition, a multimodal approach to pain management, including patient-controlled analgesia (PCA), should be integrated into her treatment plan 1. Before administering any pain medication, ensure her blood pressure is stable, as hypotension is a concern in hypovolemic shock. It's also essential to simultaneously address the underlying causes of her headache by continuing treatment of her hypovolemic shock with appropriate fluid resuscitation, which may itself help alleviate her headache. Some key points to consider in her management include:

• Monitoring her renal function closely
• Avoiding medications that can worsen her AKI
• Using a multimodal approach to pain management
• Ensuring stable blood pressure before administering pain medications
• Continuously reassessing her pain level and adjusting her treatment plan as necessary. Reassess her pain level 30 minutes after medication administration and monitor her vital signs and urine output closely.

From the FDA Drug Label

OVERDOSAGE Clinical Presentation The manifestations of fentanyl overdosage are an extension of its pharmacologic actions with the most serious significant effect being hypoventilation. Treatment For the management of hypoventilation, immediate countermeasures include removing the fentanyl transdermal system and physically or verbally stimulating the patient These actions can be followed by administration of a specific narcotic antagonist such as naloxone.

The patient is complaining of a headache and requesting something stronger than Tylenol. Fentanyl is a potent opioid analgesic that can be used for severe pain. However, given the patient's condition of hypovolemic shock, dehydration, AKI, and lactic acidosis, caution should be exercised when administering any medication, especially opioids.

• The patient's respiratory status should be closely monitored due to the risk of hypoventilation associated with fentanyl use.
• Naloxone should be available in case of an overdose. The decision to administer fentanyl should be made by the attending physician, Dr. Miller, considering the patient's overall clinical condition and the potential risks and benefits of the medication 2.

From the Research

Patient's Condition

The patient is a 65-year-old female experiencing hypovolemic shock, dehydration, acute kidney injury (AKI), and lactic acidosis, with a complaint of a headache rated 8/10. She has already been given Tylenol, which has not provided relief, and is requesting something stronger.

Treatment Considerations

• The patient's condition and the fact that she is experiencing AKI are crucial factors in determining the appropriate treatment for her headache.
• According to 3, opioids should always be avoided in the treatment of headaches.
• Additionally, 4 and 5 discuss the association between opioid use and acute kidney injury, highlighting the need for caution when considering opioids, especially in patients with AKI.
• 6 suggests that for severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors, but with careful consideration of the risks, especially in patients with conditions like AKI.

Alternative Treatment Options

• Considering the patient's AKI and the need to avoid opioids, alternative treatment options for her headache should be explored.
• 3 emphasizes the importance of early initiation of therapy and adequate dosing at the first dose, as well as avoiding too frequent administration of acute therapy to prevent medication overuse headaches.
• 6 recommends acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatment options for most patients with acute mild to moderate pain, but notes that nonselective NSAIDs should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease.
• Given the patient's condition, it may be necessary to consider other non-opioid pain management strategies or to consult with a specialist for further guidance.