Pain Management Using an Epidural Catheter
A 59-ycar-old man was admitted to the surgical ICU following a thoracotomy with wedge resection of the left lung for small-cell lung cancer. He was extubated on the morning of the first postopentive day. He had two left pleural chest tubes in place with moderate amounts of drainage and a continuing air leak. He was alert, responsive, and able to communicate his needs by writing notes and gesturing. He had a thoracic epidural cathe«:r in place ('Ii-T8) with a bupiwcaine (0.625 mg/mL) and fcntanyl (4 mcg/mL) combination infusing at 6 mL/h. He also had an elasmmerk infusion device that was providing a localiud block at the incision site using LA only. When asked about his pain level, he wrote that it was 5 on a scale ofO (no pain) to 10 (worst pain imaginable).
After he was extubated, his nurse noticed he was reluctant to cough and seemed to have some difficulty taking a deep breath. She also noticed his oxygen saturation was slowly drifting downward from 97% to 95%. His respiratory n.te was increasing, as was his heart rate. When she listened to his breath sounds, they were bilateral and equal, but diminished throughout with scattered rhonchi. When she asked him about his pain, he said his pain was still a 5 as long as he did not move or cough. He also indicated that he tried to avoid taking a deep breath because it would make him cough and increase the pain level to an 8 or 10.
The rwrsc knew the patient needed to breathe deeply and cough to clear his lungs. but his pain and discomfort were limiting his ability to perform those maneuvcr8. He also refused to move :liom the bed to a chair. The nurse disCUBscd strategies to help minimize the pain associated with this activity. Fll'St, she found an extra pillow fur him to UBe as a splint to support his incision and chest wall, and to stabilize his chest tubes.
Then she called the anesthcsiologist to confer about increasing the rate of the bupivacaine/fentanyl infuaion to increase the pain relic£ She also inquired about adding ketorolac or IV acetmn.inophen to his analgesic regimen to help with chest tube-as110ciated pain.
Because the patient also had an elastomeric infusion pump with LA along the surgical incision, she cbeclad to make sure the clamp was open and the medication Wll8 infusing. The addition of the pillows for splinting helped the patient to take deep breaths. The anesthesiologist prescribed a bolus of 3 mL of the epidural solution via the pump and increased the continuous rate to 8 mUh and added ketorolac, 15 mg, IV every 6 hours and a dose of IV acetaminophen. Over the course of the next 2 hours, the patient was able to cough more effectively, with less pain. His oxygen saturation returned to 97% and he was also able to sit in his chair for lunch.
What are the .advantages of wing cpidural -1gaia?
(A) Local anesth.cti.c blocks the entire surgical area
(B) Combining an opioid with LA improves pain relief, decreases opioid needs, and can increase respiratory efforts
(C) An epidural provides the patient with a metlwd of continuous pain relief
(D) Patients like epidural& because they provide superior pain relief
What u the value of adding ketorolac or acetaminophen to the pain regimen?
(A) IV medications work very quickly
(B) The two medications do not make the patient sedated
(C) Adding non-opioid medications can reduce opioid needs and decrease opioid-related side effects
(D) Patients have fewer allergies to non-opioid medications