vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007; 298(22):2644–53.Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, Whitten P, Margolis BD, Byrne DW, Ely EW, Rocha MG ; SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009; 301(5):489–99.Biesenbach P, Mårtensson J, Lucchetta L, Bangia R, Fairley J, Jansen I, Matalanis G, Bellomo R. Pharmacokinetics of magnesium bolus therapy in cardiothoracic surgery. J Cardiothorac Vasc Anesth. 2018; 32(3):1289–94.Ling X, Zhou H, Ni Y, Wu C, Zhang C, Zhu Z . Does dexmedetomidine have an antiarrhythmic effect on cardiac patients? A meta‐analysis of randomized controlled trials. PLoS One 2018; 13(3):e0193303.6 A 120 kg 82‐year‐old man with a past medical history of colon cancer, diabetes, and renal insufficiency is admitted to the ICU after a colectomy. Postoperatively, he had bilateral transversus abdominis (TAP) blocks placed. His creatinine clearance is estimated to be 52 mL/min. Which of the following factors increase his risk for local anesthetic toxicity?Renal insufficiencyAdvanced ageMale sexObesityDiabetesLocal anesthetic toxicity (LAST) is a life‐threatening event resulting from inadvertent intravascular administration or excessively dosed local anesthetic medications. The underlying mechanisms of LAST are multifactorial, but primarily manifest with cardiovascular and neurologic deterioration. The risk factors for LAST are extremes of age (choice B), pregnancy, low body weight, and pre‐existing cardiovascular disease. The anesthetic medications should be based on ideal body weight. Renal insufficiency (choice A), gender (choice C), and diabetes (choice E) do not affect the likelihood of LAST. Obesity (choice D) could contribute if the dosage was based on actual rather than ideal body weight.Answer: BEl‐Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anes. 2018; 11:35–44.Neal JM, Barrington, MJ, Fettiplace MR, Gitman M, Memtsoudis SG, Mörwald EE, Rubin DS, Weinberg G The third American society of regional anesthesia and pain medicine practice advisory on local anesthetic toxicity: executive summary 2017. Regional Anesth. Pain Med. 2018; 43(2):113–23.
7 A 112 kg patient with a history of anxiety disorder has been admitted to the ICU. He is intubated and he is on multimodal sedation including a hydromorphone drip 3 mg/h for 7 days. To manage his ongoing sedation and acute pain needs, in addition to the current medications, including IV Tylenol, what is your next best action?Start a ketamine drip to provide dissociative analgesia, 5 mcg/kg/min.Start low‐dose ketamine drip at 1–2 mcg/kg/min after a bolus and start to decrease hydromorphone (Dilaudid) by 20%.Increase the hydromorphone (Dilaudid) drip to 4 mg/h to provide both sedation and analgesia.Add lorazepam (Ativan) drip and increase the hydromorphone (Dilaudid) to 4 mg/h.Start a propofol infusion, switch hydromorphone (Dilaudid) to equianalgesic fentanyl.Higher doses of ketamine infusions contribute to the unwanted side effects including agitation, hallucinations, and somnolence. These psycho‐mimetic effects are particularly worrisome in a patient who may be unable to communicate these effects. For this reason, choice A is incorrect. Sub‐anesthetic doses of ketamine when added to a multimodal pain approach are opioid sparing and may attenuate unwanted side effects of ketamine (choice B). It is not appropriate to use narcotics as a single agent to control both pain and sedition (choice C) because tolerance develops, so increasing doses will be needed. Benzodiazepines are associated with ICU delirium and may contribute to delayed weaning from mechanical ventilation, so choice D is not the best choice. There is no indication to change from dilaudid to fentanyl (choice E).Answer: BDevlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC, van den Boogaard M, Bosma KJ, Brummel NE, Chanques G, Denehy L, Drouot X, Fraser GL, Harris JE, Joffe AM, Kho ME, Kress JP, Lanphere JA, McKinley S, Neufeld KJ, Pisani MA, Payen JF, Pun BT, Puntillo KA, Riker RR, Robinson BRH, Shehabi Y, Szumita PM, Winkelman C, Centofanti JE, Price C, Nikayin S, Misak CJ, Flood PD, Kiedrowski K, Alhazzani W. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018; 46(9):e825–73.Schwenk ES, Viscusi ER, Buvanendran A, Hurley RW, Wasan AD, Narouze S, Bhatia A, Davis FN, Hooten WM, Cohen SP. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018; 43(5):456–66.Radvansky BM, Shah K, Parikh A, Sifonios AN, Le V, Eloy JD. Role of ketamine in acute postoperative pain management: a narrative review. Biomed Res Int. 2015; 2015:749837.
8 A 30 year old patient with a history of substance abuse is admitted after a motor vehicle accident with left 3 rd , 4 th and 5 th rib fractures and proximal tibia fracture. He takes buprenorphine 8 mg daily. What is the appropriate management of acute pain for a patient taking 8 mg buprenorphine daily?Always stop buprenorphine because it competes with opioid receptors.Continue buprenorphine in the same dose and order patient‐controlled analgesia with dilaudid without basal rate.Request a femoral nerve block, avoid narcotics, and stop buprenorphine.Start dilaudid PCA with a basal rate and a demand dose of 0.5 mg every 10 minutes.Increase the dose of buprenorphine by 50% and start dilaudid 0.5 mg q4h prn.Buprenorphine is a lipophilic, semisynthetic opioid with partial agonist activity and high affinity for the mu receptor. Patients on buprenorphine maintenance therapy are frequently encountered in the ICU. In certain doses (more than 12 mg daily), buprenorphine can block the ability to use other opioids for breakthrough pain which does not occur at lower doses of buprenorphine (less than 8–12 mg daily sublingual dose). At low doses, there may be synergistic analgesia between buprenorphine and other opioids. Current opinion favors continuation of low‐dose buprenorphine (either at full or reduced dose), so choice B is the correct answer. Patients on buprenorphine maintenance may have severe postoperative pain and experience buprenorphine‐induced hyperalgesia. It may not be appropriate to stop buprenorphine at this dose (choices A and C). While regional anesthesia is ideal for this patient, given his type of injury, a femoral nerve block will mask symptoms of compartment syndrome that may result from tibial plateau fractures (choice C), so he may not be a candidate for regional anesthetic. Patient controlled analgesia (PCA) is another good choice but basal rates are not recommended due to risk of apnea, even in patients with tolerance (choice D). Basal rates increase both the overall amount of drug delivered and adverse effects without improving analgesia. There is no indication to increase the dose of buprenorphine (choice E).Answer: BBuresh M, Ratner J, Zgierska A, Gordin V, Alvanzo A. Treating perioperative and acute pain in patients on buprenorphine: narrative literature review and practice recommendations. J Gen Intern Med. 2020; 35(12):3635–43. doi: 10.1007/s11606‐020‐06115‐3. Epub 2020 Aug 21.Goel A, Azargive S, Weissman JS, Shanthanna H, Hanlon JG, Samman B, Dominicis M, Ladha KS, Lamba W, Duggan S, Di Renna T, Peng P, Wong C, Sinha A, Eipe N, Martell D, Intrater H, MacDougall P, Kwofie K, St‐Jean M, Rashiq S, Van Camp K, Flamer D, Satok‐Wolman M, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth. 2019; 123(2):e333–e342. doi: 10.1016/j.bja.2019.03.044. Epub 2019 May 29. PMID: 31153631; PMCID: PMC6676043.Leighton BL, Crock LW. Case series of successful postoperative pain management in buprenorphine maintenance therapy patients. Anesth Analg. 2017; 125(5):1779–83.Chen KY, Chen L, Mao J. Buprenorphine‐naloxone therapy in pain management. Anesthesiology. 2014; 120(5):1262–74.
9 A 62‐year‐old patient with chronic pain is admitted after Hartmann's procedure for diverticulitis. His chronic pain was controlled with 40 mg Oxycodone every 8 hours. He is intubated and you want to start a fentanyl drip post op in equianalgesic dose. What is the closest basal fentanyl dose?50 mcg/hr100 mcg/hr150 mcg/hr200 mcg/hr250 mcg/hrThe first step in this calculation is to estimate the total daily narcotic dose and then convert this dose to an equivalent dose of oral morphine. Morphine is the reference point to convert between different narcotics to obtain the starting point for conversion. Each 20 mg of PO Oxycodone is equivalent to 30 mg PO Morphine. And IV to PO conversion rate of Morphine is 1 to 3. IV equianalgesic parenteral dose of Fentanyl to Morphine is 0.1–0.2 mg fentanyl per 10 mg morphine. This patient is taking 120
