14. Pain Management

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Defining Pain and Educating the Patient

The International Association for the Study of Pain defines pain as an "unpleasant sensory and emotional experience associated with actual or potential tissue damage." Pain is the most common symptom that brings patients to see a physician, and it is frequently the first alert of an ongoing pathologic process. Whenever possible, inform the patient beforehand about the nature and the degree of pain to be expected during a hospital stay. Make the pain control options clear during and after hospitalization so that the patient will have realistic expectations.

Classification of Pain

Somatic Pain

A well-localized constant, achy area in skin and subcutaneous tissues and less well-localized in bone, connective tissues, blood vessels, and muscles. Examples are incisional pain, bone fractures, bony metastasis, osteoarthritis and rheumatoid arthritis, and peripheral vascular disease.

Visceral Pain

Poorly localized, crampy, diffuse, and deep sensation originating from an internal organ or a cavity lining. Examples are bladder distention and spasms, intestinal distention, inflammatory bowel disease, hiatal hernia, organ metastasis, and pericarditis.

Neuropathic Pain

A poorly localized, electric-shock-like, lancinating, shooting sensation originating from injury to a peripheral nerve, the spinal cord, or the brain. Examples are diabetic neuropathy, radiculopathy, postherpetic neuralgia, phantom limb pain, and tumor-related nerve compression.

Adverse Physiologic Effects of Pain

Table 14 1 shows adverse effects of pain as they relate to specific organ systems.

Table 14 1 Adverse Effects of Pain as They Relate to Specific Organ Systems

Organ System	Adverse Effect
RESPIRATORY
Increased skeletal muscle tension	Hypoxia, hypercapnia
Decreased total lung compliance	Ventilation perfusion abnormality, atelectasis, pneumonitis
ENDOCRINE
Increased adrenocorticotropic hormone	Protein catabolism, lipolysis, hyperglycemia
Decreased insulin, decreased testosterone	Decreased protein anabolism, decreased sex drive
Increased aldosterone, increased antidiuretic hormone	Salt and water retention, congestive heart failure, edema
Increased catecholamines	Vasoconstriction, hypertension
Increased angiotensin II	Increased myocardial contractility
CARDIOVASCULAR
Increased myocardial work	Dysrhythmias, angina, ischemia
IMMUNOLOGIC
Lymphopenia, depression of reticuloendothelial system leukocytosis	Decreased immune function, increased susceptibility to infection
Reduced killer T-cell cytotoxicity
COAGULATION EFFECTS
Increased platelet adhesiveness, diminished fibrinolysis	Increased incidence of thromboembolic phenomena
Activation of coagulation cascade
GASTROINTESTINAL
Increased sphincter tone	Ileus
Decreased smooth muscle tone
GENITOURINARY
Increased sphincter tone	Urinary retention
Decreased smooth muscle tone

Assessing Pain

Pain assessment has physiologic, emotional, and psychological aspects. Ask the patient about discomfort. Conduct a detailed history interview to gather information about the patient's pain.

Information about what relieves the pain and what makes it worse is as important as how long the pain lasts. Is the pain constant or intermittent? Does it have any precipitating factors? Does the pain radiate to a specific extremity, or is it referred from an internal source? An example of a pain radiating to a limb is lower back pain with associated right or left leg radiation. An example of referred pain is a ureteral calculus referring pain to the ipsilateral testicle. Are there any accompanying symptoms, such as nausea, vomiting, or headache?

In addition to a thorough physical exam, consider using a pain assessment instrument or rating scale to further stratify the level of pain.

Visual Analog Scales

Often called the "fifth vital sign." Ask the patient to indicate on a visual scale the intensity of pain. These scales are particularly useful for assessing pain management interventions. Examples of commonly used visual scales are shown in Figure 14 1.

Figure 14 1.

Scales used to determine pain intensity. The patient is asked to indicate where on the scale their pain would fall. (From Clinical Practice Guidelines Number 9: Management of Cancer Pain, Rockville, MD, US Department of Health and Human Services, ACHPR publication 94-0592).

McGill Pain Questionnaire:

The MPQ (Malzack RR: The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1975;1:227 299) is a checklist of words describing symptoms. Analyze scores in various sensory and affective dimensions to identify the quality of pain. Consider using this tool in the detailed management of pain syndromes.

Psychological Evaluation:

A psychological evaluation is indicated if medical evaluation does not reveal an apparent cause of pain. Two tools frequently used for evaluating chronic pain and depression are the Minnesota Multiple Personality Inventory (Hathway SR and McKinley JC: MMPI. University of Minneapolis Press, Minneapolis, 1989) and Beck Depression Inventory (Beck AT, Steer RA: Internal consistencies of the original and revised Beck Depression Inventory. J Clin Psychol 1984;40:1365 1367). Use these questionnaires to determine the patient's psychological status and to his or her behavior and response to pain and its management.

Electromyography and Nerve Conduction Testing:

Used to differentiate neurogenic from myogenic causes of pain and to confirm a diagnosis of nerve entrapment, neural trauma, or polyneuropathy.

Thermography:

Under normally circumstances, heat from body surfaces is emitted in the form of infrared energy; this emission is symmetrical in homologous areas. Neurogenic pathophysiologic changes result in asymmetry. This infrared energy can be measured and displayed: Hyperemission indicates an acute stage and hypoemission a chronic stage.

Diagnostic and Therapeutic Neural Blockade:

Neural blockade with local anesthetics used in the diagnosis and management of both acute and chronic pain.

Pain Management (Acute vs Chronic)

The goal of pain management is to provide the patient adequate relief with minimum side effects (eg, drowsiness). Always begin therapy with the lowest dose of any medicine that provides significant relief.

Pain management can be generally divided into:

• Pharmacologic
• Nonpharmacologic
• Combinations according to patient response and compliance

Pharmacologic

The World Health Organization has made specific recommendations concerning pain management. These principles apply primarily to cancer pain but can be used in any clinical setting. Start at step 1 and advance to the next level on the basis of the patient's response.

Step 1: Nonopioid agents (eg, NSAIDs, acetaminophen, aspirin, COX-2 inhibitors)

Step 2: Weak opioids (codeine, oxycodone) or opioid-like agents

• Use concurrently with step 1 agents (eg, oxycodone, hydrocodone combinations)
• Weak opioids as single agents (immediate-release codeine, propoxyphene)
• Opioid agonists and antagonists (pentazocine, butorphanol)
• Other agents such as ketorolac or tramadol

Step 3: Strong opioids. Controlled-release oxycodone, morphine, or fentanyl

Step 4: Multimodal approach (eg, neurolysis)

Specific pharmacologic agents are reviewed in the following section and in Table 14 2 with additional information in Chapter 22. Supplemental agents can enhance the effects of analgesics and allow dose reduction of some agents.

Table 14 2 List of Commonly Used Analgesic Agents

Generic and (Brand) Names	Dose Range/Interval (Adults)	Dose Range/Interval (Children)	Indications	Contraindications	Comments
Acetaminophen (Tylenol)	650 1000 mg q4 6h and PRN; daily max 4000 mg	10 15 mg/kg q4h	Mild to moderate pain. Use in aspirin-sensitive patients.	Use with caution in liver disease or history of alcohol abuse	No peripheral antiinflammatory effects, unlike NSAIDs
Tramadol	50 100 mg q4 6h; daily max 400 mg	Not recommended under age 16	Moderate to moderately severe pain	Caution if used with hypnotics, centrally acting analgesics, opioids, or psychotropic drugs or acute intoxication with alcohol	Risk of nausea, dizziness, seizure in patients with SSRIs, tricyclics, MAO inhibitors, neuroleptics and history of seizures
SALICYLATES ACETYLATES
Aspirin	650 975 mg q4h; daily max 4000 mg	10 15 mg/kg q4h	Mild to moderate pain	Do not use in children <12 w/viral illness because of risk of Reye syndrome	Risk of GI bleeding, ulcers, perforation, platelet dysfunction. Must be discontinued for 7 10 d if patient is to undergo surgery
SALICYLATES NONACETYLATED
Choline magnesium trisalicylate (Trilisate)	1000 1500 mg bid; daily max 2000 3000 mg	25 mg/kg bid	Long-term management of OA, RA; acute pain of shoulder or knee	Sensitivity to nonacetylated salicylates	Useful in patients with bony metastasis and those who are allergic to ASA. The drug has minimal antiplatelet activity.
Diflunisal (Dolobid)	1000 mg initial, followed by 500 mg q12h; daily 1500 mg	Not recommended < age 12	Acute and long-term mild to moderate pain; OA, RA	Hypersensitivity to aspirin or other NSAIDs	Potential for life-threatening (NSAID) hypersensitivity syndrome; disrupts platelet function with high doses; Reye syndrome
Salsalate (Disalcid)	500 mg q4h; daily max varies	Not indicated	Pain related to OA, RA, other rheumatic disorders	Hypersensitivity or allergy to salsalate	Minimal antiplatelet activity; useful in patients with bony metastasis and those who are allergic to ASA
NONSELECTIVE NSAIDS
Ibuprofen (Advil, Motrin, Nuprin, Mediprin, Rufen)	400 mg q4 6h; 800 mg q8h; daily max 2400 mg	5 10 mg/kg q6 8h; daily max 40 mg/kg	Mild to moderate pain, fever in children, RA, OA, other pain	Hypersensitivity to aspirin or other NSAIDs; severe kidney disease	Increases risk of GI bleeding, ulcers, perforation, platelet dysfunction
Indomethacin (Indocin)	25 mg q8 12h; daily max 100 mg	6 mo, 0.5 mg/kg IM/IV q6h, max 30 mg/dose	Mild to severe acute pain, OA, RA, other rheumatic disorders	Hypersensitivity to aspirin or other NSAIDs	Usually a second-line drug because of high incidence of GI and CNS sensory adverse effects
Ketorolac (Toradol)	30 60 mg IM or 30 mg IV initial, 15 or 30 mg IV or IM q6h, also available PO	Not indicated for pediatric use	Short-term management of moderate to severe acute pain, eg, postoperative	Hypersensitivity to aspirin or other NSAIDs; GI disease; bleeding disorders; renal disorders; labor and delivery; nursing	Increases risk of renal failure in dehydrated patients; may cause fluid retention, CHF. Treatment should be limited to 5 d max.
Nabumetone (Relafen)	1000 2000 mg/d q12 24h; daily max 2000 mg	Not indicated for pediatric use	Signs or symptoms of OA, RA, ankylosing spondylitis	Hypersensitivity to aspirin or other NSAIDs	Has increased risk of GI bleeding, ulcers, and perforation like any other NSAID
Naproxen (Aleve, Anaprox, Naprosyn)	550 mg initial, 250 subsequent q6 8h; daily max 1250 1375 mg (depends on formulation)	5 mg/kg q12h	Acute and chronic pain of OA, RA, other rheumatic disorders	Hypersensitivity to aspirin or other NSAIDs	Risk of GI bleeding, ulcers, perforation
Oxaprozin (Daypro)	600 1200 mg q24h; daily max 1800 mg	For juvenile RA > age 6 10 20 mg/kg q24h; daily max 1200 mg	Acute and long-term management of OA, RA	Hypersensitivity to aspirin or other NSAIDs	Increased NSAID-related, risk of GI bleeding, ulcers, perforation
Piroxicam (Feldene)	20 mg/d, q12 24h; daily max 20 mg	Not indicated for pediatric use	Acute and long-term management of OA, RA	Hypersensitivity to aspirin or other NSAIDs	Increases risk of GI bleeding, ulcers, perforation; steady-state blood levels are reached in 7 12 d
MUSCLE RELAXANTS
Carisoprodol (Soma)	350 mg q8h and at bedtime	Not indicated	Acute, painful musculoskeletal conditions; does not directly relax tense skeletal muscles	Acute intermittent porphyria; sensitivity to related compounds	Use with caution in patients with altered kidney/liver function; it has potential for abuse
Cyclobenzaprine HCI (Flexeril)	20 40 mg/d q6 8h; daily max 60 mg	Not indicated	Muscle spasm associated with acute painful musculoskeletal conditions	Use of MAO inhibitors; acute MI; heart disorders; hyperthyroidism	Enhances the effects of alcohol, barbiturates, and other CNS depressants
OPIOID ANALGESICS
Codeine	15 60 mg q4 6h; daily max varies	> 1 y old; 0.5 1 mg/kg q4 6h	Mild to moderate pain	Hypersensitivity to codeine	Drug effects may be exaggerated in head injury, may obscure its clinical course; caution with liver/kidney disease. May cause significant respiratory depression; patients should be monitored judiciously with pulse oximetry or respiratory checks or both
Hydromorphone (Dilaudid)	Start tabs 2 4 mg q3 4h; liquid 2.5 10 mL q3 6h; daily max varies	> 6 mo: 0.03 0.08 q4 6h	Moderate to severe pain	Impaired respiration	Caution in head injury, abdominal conditions; decrease dose for older patients. Significant respiratory depression may occur; monitor respiration carefully.
Meperidine (Demerol, Mepergan)	Tabs/syrup: 50 150 mg q3 4h; daily max 600 mg	Tabs/syrup: 0.5 1 mg/lb q3 4h or 1 1.75 mg/kg q3 4h	Moderate to severe pain	Do not use concomitantly with MAO inhibitors. Avoid its use in elderly patients and in renal disease.	Caution in head injury, abdominal conditions, sickle cell disease, impaired respiration; may cause seizures, psychosis, anxiety, delirium; toxic metabolites; normeperidine can accumulate, especially in patients with renal insufficiency and the elderly
Methadone (Dolophine)	Tabs/soln 2.5 10 mg q4h	Not indicated	Severe acute and chronic pain; heroin withdrawal	Hypersensitivity to methadone	Use with caution in head injury, abdominal conditions, or concomitant use of other CNS depressants
Morphine immediate release (MSIR, Roxanol)	Oral form given q4h to establish daily opioid requirement	Some forms may be used in children; most are not indicated	Moderate to severe pain; used most often in terminal illness	Respiratory depression, severe asthma, paralytic ileus	Use with caution in head injury, abdominal conditions, renal disease, use of other CNS depressants, and older patients. Respiratory depression precautions.
Morphine sustained release (Kadian, MS Contin, Oramorph SR, Avinza)	Given only after establishing daily opioid requirement; daily requirement given q12h	Some forms may be used in children; most are not indicated	Moderate to severe pain; used most often in terminal illness	Respiratory depression severe asthma, paralytic ileus	Use with caution in head injury, abdominal conditions, renal disease, use of other CNS depressants, and older patients. Respiratory depression precautions.
Oxycodone immediate release (OxyIR, Roxicodone)	Regimen can be individualized according to opioid/nonopioid requirements	Dosage forms should be adjusted for weight	Moderate to severe pain	Respiratory depression, severe asthma, paralytic ileus	Use with caution in head injury, abdominal conditions, renal disease, use of other CNS depressants
Oxycodone sustained release (OxyContin)	Regimen can be individualized according to opioid/nonopioid requirements	Not indicated < age 18	Moderate to severe pain	Respiratory depression, severe asthma, paralytic ileus	Use with caution in head injury, abdominal conditions, renal disease, use of other CNS depressants
Propoxyphene (Darvon, Darvon-N)	Darvon: 65 mg q4h; Darvon-N: 100 mg q4h	Not indicated	Mild to moderate pain w/wo fever	Suicidal or addiction-prone patients; do not use with alcohol; hypersensitivity to propoxyphene	Propoxyphene metabolites may accumulate. Overdose may cause seizures. Drug carries risk of renal toxicity.
COMBINATION ANALGESICS
Codeine/acetaminophen (Tylenol w/codeine)	15 60 mg/300 100 mg on varying schedule; daily max 360/4000 mg; elixir form is available	> age 3 y 0.5 1 mg/kg q4h based on codeine	Tabs for mild to moderately severe pain; elixir for mild to moderate pain	Hypersensitivity to any component	Use with caution in head injury, abdominal conditions and in older patients
Hydrocodone/acetaminophen (Hydrocet, Lorcet, Lortab, Vicodin)	1 2 (2.5 10 mg/500 mg) caps q4 6h; daily max 8 caps	Not indicated	Moderate to moderately severe pain	Hypersensitivity to hydrocodone or acetaminophen	Use with caution in head injury, abdominal conditions; respiratory depression may ensue; monitor respiratory function closely
Oxycodone/acetaminophen (Percocet, Roxicet, Tylox)	1 2 (2.5 10 mg/325 mg) tab q4 6h; daily max varies	Not indicated	Moderate to moderately severe pain	Hypersensitivity to oxycodone or acetaminophen	Use with caution in head injury, abdominal conditions, and elderly population
Propoxyphene/acetaminophen (Darvocet)	100 mg/650 mg q4h; propoxyphene daily max 600 mg	Not indicated	Mild to moderate pain w/wo fever	Hypersensitivity to propoxyphene or acetaminophen	Caution in head injury, abdominal conditions and impaired hepatic or renal functions
Pentazocine/aspirin (Talwin)	2 (12.5 mg/325 mg) caplets q6 8h; daily max varies	Not recommended < age 12	Moderate pain	Hypersensitivity to pentazocine or acetaminophen	High potential for abuse. Caution in head injury, abdominal conditions; may cause respiratory depression, renal/hepatic disorders, and risk or Reye syndrome. Subcutaneous injections may cause severe tissue damage.
		30 mg IM/IV q3 4h; IM max 60 mg; IV max 30 mg
Hydrocodone/ibuprofen (Vicoprofen)	1 (7.5 mg/200 mg) tablet q4 6h; max 5 tabs daily	Not recommended < age 16	Best for short-term (< 10 d) of moderate to severe acute pain treatment	Hypersensitivity to hydrocodone, ibuprofen, aspirin, or other NSAIDs	Increases risk of anaphylactic reaction; possible GI ulceration, bleeding, perforation. Use with caution in head injury, abdominal conditions. Can cause respiratory depression.

ASA = aspirin; CHF = congestive heart failure; CNS = central nervous system; GI = gastrointestinal; MAO = monoamine oxidase; MI = myocardial infarction; NSAID = nonsteroidal antiinflammatories; OA = osteoarthritis; RA = rheumatoid arthritis; SSRI = selective serotonin reuptake inhibitors.

Nonopioid Analgesics:

A multimodal approach may involve pharmacologic and nonpharmacologic methods. Aspirin, acetaminophen, and NSAIDs are the principal nonopioid analgesics used to manage mild and moderate pain. NSAIDs are primarily cyclooxygenase inhibitors that prevent prostaglandin-mediated amplification of chemical and mechanical irritants of the sensory pathways. Short-term (maximum 5 d of use) perioperative use of ketorolac (Toradol) can reduce pain medication requirements. Side effects: Possible hepatotoxicity (large dose of acetaminophen); stomach upset, nausea, dyspepsia, ulceration of gastric mucosa; dizziness; platelet dysfunction; exacerbation of bronchospasm; acute renal insufficiency (aspirin and NSAIDs).

Opioids:

Attach to opioid receptors, which are responsible for their analgesic effect. Side effects: In acute pain, nausea and vomiting are the most common side effects and usually resolve with time or antiemetics. In chronic pain, constipation is the most common side effect and persists until treatment cessation. Other side effects include sedation, miosis, and dizziness with smaller doses. Larger doses can precipitate respiratory depression, apnea, circulatory arrest, comma, and death. These more serious side effects may necessitate supplemental oxygen therapy, pulse oximetry monitoring, and close patient supervision. Opioids can be taken orally or parenterally or by the neuroaxillary route (intrathecal/epidural). Opioids are available in short- (q4h) and long-duration forms (eg, q12h, q24h). Opioids can also be given IV as a patient-controlled analgesia (PCA). Comparison of opioids can be found in Table 14 2.

Antidepressants:

Work well as adjuncts and are an appropriate consideration mostly for chronic pain associated with diabetic neuropathy, postherpetic neuralgia, and chemotherapy. Side effects: Antimuscarinic effects (dry mouth, impaired visual accommodation, urinary retention), antihistaminic (sedation), and alpha-adrenergic blockage (orthostatic hypotension).

Neuroleptics:

Used to treat patients with agitation and psychological symptoms. Side effects: Extrapyramidal and neuroleptic drug symptoms; mask-like facies, festinating gait, cogwheel rigidity (bradykinesia) managed with benztropine or diphenhydramine.

Anticonvulsants:

Suppress spontaneous neural discharge. Side effects: Bone marrow depression, hepatotoxicity, possible ataxia, dizziness, confusion, and sedation (at higher doses).

Corticosteroids:

Antiinflammatory agents. Side effects: Hyperglycemia, increased risk of infections, peptic ulcer, osteoporosis, HTN, myopathy, Cushing syndrome.

Local Anesthetics:

Bind to sodium channels, exerting effect on the cellular level. Effect usually localized to the area where the drug is injected. Side effects: Relatively few side effects. Allergic reactions usually due to PABA-like preservatives in the solution and not the agents themselves. Toxicity (usually due to overdose) includes tonic clonic seizures, respiratory arrest, and subsequent cardiovascular collapse.

Benzodiazepines:

Used to manage anxiety and muscle spasms associated with acute pain. Side effects: No analgesic effects and must be used with caution because of abuse potential.

Nerve Blocks or Neurolysis:

Destruction of nerves. Side effects: Permanent nerve damage

Nonpharmacologic

Physical Therapy:

Heat and cold can provide pain relief by alleviating muscle spasm. Heat decreases joint stiffness and increases blood flow; cold vasoconstricts and reduces tissue edema.

Osteopathic or Chiropractic Treatment:

Physical manipulation can relax soft tissues, increase range of motion, and alleviate pain. Biweekly or monthly treatments are recommended and are best for chronic pain. Acute treatment minimizes musculoskeletal pain.

Radiation:

Beneficial in management of cancer pain (eg, bony metastasis).

Psychological Intervention:

Cognitive therapy, behavioral therapy, or biofeedback relaxation technique and hypnosis. Pain is often associated with depression, especially when it becomes chronic.

Acupuncture:

Needles are inserted into discrete anatomically defined points or meridians and stimulated by mild electric current. This method is believed to release endogenous opioids.

Electrical Stimulation of Nervous System:

Analgesia is achieved using various methods of treatment. The three methods are:

1. Transcutaneous electrical stimulation (TENS) with electrodes applied to skin.

2. Spinal cord stimulators: Electrodes connected to an external generator into the epidural space. Patient is under general anesthesia and is awakened half-way through the procedure in the lateral recumbent position. The patient is asked specific questions, and the programming is adjusted accordingly. The patient is put back under anesthesia, and the surgeon can close the skin.

3. Intracerebral stimulation with electrodes implanted in the periaqueductal or periventricular area.

Patient-Controlled Analgesia (PCA)

Most commonly used after surgery. Allows the patient to self-administer doses of narcotics with an IV pump. The patient manages the pain as soon as he or she feels it coming on, thus avoiding the peak and trough of a narcotic dosing regimen that can lead to extremes of pain or risk of oversedation. The pain management team can titrate the dose of the drug as required with a computerized system that controls the total dose and the interval between doses with or without a continuous basal infusion. PCA duration varies according to procedure and patient response (eg, gynecologic procedures, 1 2 d; bowel operations, 2 5 d; thoracotomy, 4 6 d). Reduce dose in elderly (1/3 2/3), and consider discontinuation of PCA when patients are able to take analgesics PO.

PCA Ordering Parameters

Table 14 3 shows examples of PCA orders.

Table 14 3 Illustrative PCA Orders

Typical Procedure	Dose (mL)	Lockout (min)	Hourly Max (mL)	Basal
Somewhat painful (lower abdominal, incisions, minor orthopedic, gynecologic, or plastic surgical procedures)	1	6	10	None
Fairly painful (upper abdominal incisions)	1 1.5	6	10 15	None
				Nursing PRN bolus 2 3 mL q1 2h PRN
Very painful (thoracotomy, total knee replacement, shoulder joint repairs)	1 2.0	6	10 20	None
				Nursing PRN bolus 2 4 mL q1 2h PRN

• Dose: Number of milliliters (typically morphine concentration or its equivalent) given on activation of button by patient
• Lockout: Minimum interval of time in minutes between PCA doses
• Hourly Max: Maximum volume (milliliters) that machine will administer in an hour
• Basal Rate: Continuous infusion rate may be programmed in addition to the bolus dosing; not recommended unless a qualified member of the anesthesiology department pain team has evaluated the patient. Basal infusions increase risk of significant respiratory depression and should be monitored more closely with hourly respiratory checks.
• Nursing PRN Bolus: Number of milliliters nurses can administer at their discretion in addition to PCA dose for breakthrough pain.

PCA Opioid Concentration at Equipotent Levels

Drug	Dose
Morphine	1.0 mg/mL
Meperidinea	10 mg/mL
Hydromorphone	0.2 mg/mL
Fentanyl	10 15 mcg/mL

^aUse only if a patient has allergies to other medications greater side effects profile, ie, seizure from metabolites.

PCA in Renal Failure (Nonencephalopathic Patient):

Use fentanyl or hydromorphone only, avoiding morphine and meperidine because of their renal excretion.

Load with fentanyl 25 mcg or hydromorphone 0.5 mcg IV in postanesthetic care unit and repeat every 5 10 min until patient is comfortable.

Maintenance: PCA dose 1 mL; lockout 6 min; hourly max 3 5 mL

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