Exam (elaborations)
ADVANCED PHARMACOLOGY (NSG 533) OPIOID GROUP DISCUSSION 2024/2025
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- Wilkes University
ADVANCED PHARMACOLOGY (NSG 533) OPIOID GROUP DISCUSSION 2024/2025
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1ADVANCED PHARMACOLOGY (NSG 533) OPIOID GROUP DISCUSSION
2024/2025
Part 1
Based on the type of injury, what type of pain is this patient likely to experience?
It is likely that the patient will experience both nociceptive and neuropathic pain
postoperatively. Subacute postoperative pain related to wound healing always follows a limb
amputation (Larbig et al., 2019). Additionally, patients can experience phantom limb pain (PLP),
residual limb pain (RLP), and chronic pains “such as ‘mirror image’ pain in the contralateral
limb and back pain” concurrently after a limb has been amputated (Larbig et al., 2019, p. 44).
What type of pain management regimen would you suggest in the postoperative period?
Explain your answer.
Post-amputation pain (PAP) is challenging to manage, as there are multifactorial
underlying mechanisms at play. Such complexity requires a multidisciplinary care approach that
involves medical, rehabilitative, and psychiatric services (Kent et al., 2017). Ideally these
services would work congruently during the perioperative phase and a postoperative pain
treatment plan would be developed during this time. Ghai et al. (2018) offer the following
templet for the multidisciplinary care that is required during the peri and postoperative phases of
a limb amputation in efforts of reducing PLP:
• Identify patients for the prevention of PLP with detailed history taking, assessment of
pain, special attention to neuropathic pain, pain questionnaire, anxiety and depression
pain questionnaire, and neurological examination;
• Consider a team approach including the surgeon, anesthesiologist, pain physician,
physiotherapist, rehabilitation staff, and patient's caregivers;
, 2
• Perioperative epidural analgesia with adjuvants (ketamine or calcitonin or opioids) (Level
II) or IV opioid PCA (Level II) for optimized postoperative pain relief, starting 48 hours
prior to surgery to minimum up to 72 hours postoperatively;
• Include NSAIDs and paracetamol as part of multimodal analgesia;
• Psychological support and rehabilitation;
• Individualization approach regarding use of gabapentanoids as preventive strategy (p.
447).
Additional pain prevention and management options include: i) alternative surgical
techniques, ii) combining spinal epidural anesthesia with general anesthesia during surgery, iii)
perineural catheters, iv) intravenous (IV) opioid patient-controlled anesthesia (PCA), and v) IV
ketamine (Ghai et al., 2018). Despite numerous studies attempting to understand, prevent, and
manage the multifactorial pains associated with limb amputations, no one method has been
identified as superior (Ghai et al., 2018). Ghai et al. (2018) report that aggressive epidural
anesthesia and opioid PCA have been deemed as acceptable measures to prevent PLP.
Part 2
What dosing regimen would you suggest?
According to Chisholm-Burns et al. (2019), 30 mg of hydrocodone is equivalent to 10 mg
of parenteral morphine. The patient is taking 55 mg of morphine per day which would equate to
165 mg of hydrocodone per day without any adjustments for cross-tolerance and 82.5 mg of
hydrocodone per day when adjusted by 50%. I would suggest hydrocodone/APAP 10/325 mg
every four hours as needed for pain.
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