What is the appropriate management for a patient with severe postoperative pain, currently rating 9/10 with movement and 6/10 at rest, radiating to the legs, after receiving 0.2mg of Dilaudid (hydromorphone) for L5-S1 posterior lumbar interbody fusion (PLIF)?

From the Guidelines

I strongly recommend increasing the pain management for this patient who recently underwent L5-S1 posterior lumbar interbody fusion (PLIF) surgery, as the current pain level is unacceptable and may lead to further complications, such as increased morbidity, mortality, and decreased quality of life. The patient is experiencing severe pain (10/10) in the neck radiating down to the surgical site and legs, which persists at 9/10 with movement and 6/10 at rest despite receiving 0.2mg of Dilaudid at 0141.

Current Pain Management

The current pain management strategy is not effective, and the patient requires a more aggressive approach to manage their pain. According to the guidelines, opioids are strong and fast-acting analgesics that are very effective and convenient in use for severe acute postoperative pain (APP) 1. However, the use of opioids should be reduced as much as possible in postoperative pain management strategies, and multimodal pain management should always be considered to improve analgesia while reducing individual class-related side effects 1.

Recommended Pain Management Strategy

I suggest administering an additional dose of 0.4mg Dilaudid IV now, followed by reassessment in 30 minutes. If pain remains poorly controlled, consider adding a muscle relaxant such as 5-10mg Flexeril orally or increasing to scheduled Dilaudid 0.5-1mg IV every 4 hours as needed. The patient should also be positioned with slight elevation of the head of bed and proper pillow support.

Notification of Surgical Team

These new pain complaints, particularly the neck pain radiating downward, warrant notification of the surgical team for evaluation as they may indicate post-surgical complications such as nerve impingement or hematoma formation. The inadequate pain control with the initial low dose of Dilaudid is not surprising given the extensive nature of PLIF surgery, which involves significant tissue manipulation and nerve root decompression, often resulting in severe postoperative pain requiring multimodal analgesia.

Multimodal Analgesia

Multimodal analgesia involves the use of different classes of analgesic medications with different mechanisms of action on the peripheral and/or central nervous system. The different combinations of these drugs lead to additive or synergistic effects on pain relief and can potentially reduce the side effects of mono-modal interventions. Consideration should be given to the use of non-opioid drugs, such as acetaminophen, NSAIDs, and gabapentinoids, in combination with opioids to achieve optimal pain control 1.

Regular Assessment and Reassessment

Regular assessment and reassessment of the patient's pain level are crucial to ensure that the pain management strategy is effective and to make any necessary adjustments. According to the guidelines, postoperative pain assessment, at rest and—if possible—on movement, is strongly recommended, to improve patient management after emergency surgery 1.

Key Considerations

Some key considerations in the management of this patient's pain include:

• The use of opioids should be reduced as much as possible in postoperative pain management strategies 1.
• Multimodal pain management should always be considered to improve analgesia while reducing individual class-related side effects 1.
• Regular assessment and reassessment of the patient's pain level are crucial to ensure that the pain management strategy is effective and to make any necessary adjustments 1.
• The patient's pain complaints, particularly the neck pain radiating downward, warrant notification of the surgical team for evaluation as they may indicate post-surgical complications such as nerve impingement or hematoma formation.

From the FDA Drug Label

14 CLINICAL STUDIES Analgesic effects of single doses of hydromorphone hydrochloride oral solution administered to patients with post-surgical pain have been studied in double-blind controlled trials. In one study, both 5 mg and 10 mg of hydromorphone hydrochloride oral solution provided significantly more analgesia than placebo. In another trial, 5 mg and 10 mg of hydromorphone hydrochloride oral solution were compared to 30 mg and 60 mg of morphine sulfate oral liquid. The pain relief provided by 5 mg and 10 mg hydromorphone hydrochloride oral solution was comparable to 30 mg and 60 mg oral morphine sulfate, respectively.

The patient received 0.2mg of dilaudid, which is a different formulation and dose than what is described in the study. The study discusses hydromorphone hydrochloride oral solution in doses of 5 mg and 10 mg.

• The patient's pain is 9/10 with movement and 6/10 with no movement, and is radiating down to the legs.
• The study does not provide information on the use of 0.2mg of dilaudid for this patient's specific condition. The FDA drug label does not answer the question.

From the Research

Patient Complaints and Medication

• The patient is complaining of 10/10 pain in the neck that traveled down her back to the surgical site, and still complaining of 9/10 with movement and 6/10 with no movement pain radiating down to the legs.
• The patient received 0.2mg of dilaudid at 0141.

Relevant Studies

• A study comparing hydromorphone and fentanyl for epidural analgesia and anesthesia found that fentanyl caused less excessive sedation and unresponsiveness 2.
• A study comparing morphine and hydromorphone epidural analgesia found that the two treatments provided equivalent analgesia, but the occurrence of moderate to severe pruritus on the first postoperative day was reduced by the use of hydromorphone 3.
• A study comparing epidural morphine, hydromorphone, and fentanyl for postoperative pain control in children found that epidural hydromorphone demonstrated less side-effects and was preferable to morphine and fentanyl for epidural analgesia in children 4.
• A study on the CSF and blood pharmacokinetics of hydromorphone and morphine following lumbar epidural administration found that the blood and CSF pharmacokinetic profiles for morphine and hydromorphone are similar after lumbar epidural administration 5.
• A historical cohort study to evaluate the quality of postoperative analgesia found no significant difference in postoperative pain score ratings between adult patients receiving intravenous hydromorphone vs intravenous morphine on discharge from the post-anesthesia care unit (PACU) 6.

Medication Comparison

• The studies suggest that hydromorphone and morphine have similar analgesic effects, but hydromorphone may have a lower incidence of side effects such as pruritus and respiratory depression 3, 4, 6.
• The choice of medication may depend on the individual patient's needs and medical history, as well as the specific surgical procedure and postoperative care plan.