What is the best course of action for a 66-year-old female patient, status post (S/P) video-assisted thoracic surgery (VATS) for diaphragmatic eventration plication, who is experiencing severe pain (8-9/10) and tachycardia despite receiving midazolam and oxycodone, in the post-anesthesia care unit (PACU)?

Immediate Management of Severe Post-VATS Pain in PACU

Aggressively escalate to a multimodal approach immediately: add IV paracetamol and ketorolac (if no contraindications), consider IV dexmedetomidine infusion, and urgently consult for rescue regional anesthesia (paravertebral block or erector spinae plane block) as VATS is associated with severe postoperative pain that requires regional techniques as part of multimodal analgesia. 1

Immediate Actions (Next 15-30 Minutes)

Step 1: Optimize Systemic Multimodal Analgesia

• Administer IV paracetamol 1g immediately if not already given, as this is foundational baseline analgesia without respiratory depression risk 1, 2
• Add IV ketorolac 15-30mg (or another NSAID/COX-2 inhibitor) unless contraindicated by renal impairment, heart failure, or active bleeding risk 1, 2
  • The combination of paracetamol and NSAIDs provides superior analgesia compared to either agent alone 1
  • Ketorolac showed equivalent efficacy to paracetamol with minimal clinically relevant bleeding increase in VATS patients 1

Step 2: Initiate IV Dexmedetomidine

• Start dexmedetomidine loading dose 0.5-1 mcg/kg over 10 minutes, followed by continuous infusion at 0.4-0.7 mcg/kg/hr 1, 2
• Dexmedetomidine reduces pain scores and opioid demand while decreasing postoperative agitation, cognitive dysfunction, and nausea/vomiting 1
• Monitor for bradycardia and hypotension, though these are usually not clinically significant in patients without severe cardiac disease or conduction disorders 1
• This patient's tachycardia (HR 110) makes dexmedetomidine particularly appropriate as it provides analgesia while addressing sympathetic activation 1

Step 3: Continue Opioid Rescue Appropriately

• Continue oxycodone as rescue analgesic only, not as primary analgesic 1, 2
• Consider switching to IV morphine 2-4mg boluses every 5-10 minutes, titrated to effect, as IV route provides more predictable pharmacokinetics in acute severe pain 3
• Critical: Allow 3-5 minutes between doses to assess peak CNS effect before additional administration to avoid oversedation and respiratory depression 3

Step 4: Reassess Midazolam Use

• Discontinue or minimize further midazolam administration as it increases respiratory depression risk without providing analgesia 3
• Midazolam is appropriate for anxiolysis but should not be the primary sedative in this pain crisis 3
• The combination of midazolam with opioids significantly increases risk of respiratory depression, airway obstruction, and arrest 3

Urgent Consultation (Within 1 Hour)

Regional Anesthesia Rescue

The addition of regional analgesic technique is strongly recommended as VATS is associated with severe postoperative pain that systemic analgesia alone cannot adequately control. 1

First-line options (equal efficacy):

• Paravertebral block with continuous catheter infusion - superior efficacy with limited side effects compared to thoracic epidural 1, 2
• Erector spinae plane (ESP) block with continuous catheter - non-inferior to paravertebral block, potentially easier placement with fewer complications 1, 2

Key technical points:

• Continuous infusion preferred over intermittent bolus techniques 1, 2
• Surgeon-placed paravertebral catheter under direct visualization is feasible and effective 1
• ESP block may be specifically indicated if pleural integrity is compromised from the surgical procedure 1

Second-line option:

• Serratus anterior plane block - simpler and quicker but less established efficacy; reserve if first-line options unavailable 1

Critical Monitoring Requirements

Respiratory Status

• Continuous pulse oximetry mandatory given combination of opioids, benzodiazepines, and dexmedetomidine 3
• Maintain verbal contact; assess respiratory rate and effort every 5 minutes during titration 3
• Have resuscitation equipment and personnel skilled in airway management immediately available 3

Hemodynamic Monitoring

• Continuous cardiac monitoring for bradycardia (HR <50) from dexmedetomidine 1
• Blood pressure monitoring every 5 minutes during loading, then every 15 minutes 1
• Have atropine/glycopyrrolate readily available for symptomatic bradycardia 1

Pain Assessment

• Reassess pain score every 15 minutes during acute escalation phase 3
• Assess both rest pain and movement/cough pain as these may respond differently 1

Common Pitfalls to Avoid

Don't rely solely on opioid escalation - VATS pain requires multimodal approach including regional techniques; opioid-only strategies lead to inadequate analgesia with excessive side effects 1, 2

Don't delay regional anesthesia consultation - severe pain (8-9/10) despite opioids indicates need for regional technique; early intervention prevents pain escalation and respiratory complications from splinting 1, 2, 4

Don't continue midazolam without clear indication - benzodiazepines increase respiratory depression risk without analgesic benefit in this context 3

Don't forget to assess surgical complications - severe refractory pain may indicate hemothorax, pneumothorax, or other surgical complications requiring intervention beyond analgesia 4

Ongoing Management

Continue Multimodal Regimen

• Paracetamol 1g IV every 6 hours 1, 2
• Ketorolac 15-30mg IV every 6 hours (maximum 5 days) or transition to oral NSAID 1
• Dexmedetomidine infusion continued for 24-48 hours if effective 1
• Regional anesthesia catheter maintained for 48-72 hours 1, 2
• Opioids as rescue only for breakthrough pain 1, 2

Transition Planning

• Inadequate pain control directly impairs pulmonary function, causing splinting, atelectasis, and impaired respiratory physiotherapy 2, 4
• Aggressive multimodal analgesia is essential for preventing respiratory complications and enabling early mobilization 2, 4