A 28-year-old African-American man with sickle cell disease, B.B., will be admitted to your hospital to undergo a hip replacement. B.B. has a significant chronic pain problem and uses a regular schedule of controlled-release oxycodone 60 mg every 12 hours plus oral transmucosal fentanyl 400 mcg (Actiq, Cephalon) for breakthrough pain crises (less than two doses per day). He is controlled at a pain level of 2; he also takes hydroxyurea 2,000 mg/day. The surgeon asks you about dealing with B.B.'s pain medications in preparation for surgery. Should drugs be held, decreased, or continued as usual?
Sickle cell anemia is associated with severe pain episodes known as "pain crises," necessitating the chronic use of pain medications. Perhaps 19% of patients undergoing hip surgery suffer from a sickle cell event such as a pain crisis following surgery. Patients with sickle cell disease are often opioid-experienced and have tolerance to normal opioid doses. They may require higher-than-normal doses to control pain, especially postoperatively or during a crisis. Adequate pain control preoperatively decreases anxiety and may decrease need for postoperative analgesics, leading to increased overall satisfaction with surgery.
Because this patient is controlled at a pain level of 2 on his current regimen and is likely to require more medication to keep pain controlled following surgery, we recommend he continue current therapy throughout the surgical process. The physician and anesthesiologist should be informed of pain medication taken prior to surgery, especially medications for breakthrough pain. We recommend hydroxyurea be continued.
Pain medication for B.B. should be continued through surgery, but the anesthesiologist needs to be informed. Postsurgery, pain can be controlled in several different ways. First, the NSAID ketorolac 60 mg IM/IV can be administered at closing for hip replacement. This should be followed by postsurgical NSAID therapy. Ketorolac is the drug of choice until oral drugs are tolerated.
Second, use patient-controlled analgesia (PCA). Since B.B. is already using fentanyl without notable adverse effects, it would be a good choice. The pump would need to be programmed for regular dosing plus as-needed dosing. Monitor via the pain scale, respiration rate, heart rate, and blood pressure to reduce the risk of overdosage. As B.B. tolerates oral drugs, the oxycodone could be increased until pain returns to baseline.
Third, use a Stryker PainPump. This pump is similar to an intravenous PCA pump except a local anesthetic is subcutaneously administered to the pain site. This pump has leads attached to it that are surgically implanted into the nerve space, impeding nerve transmission. Medications used include clonidine and bupivacaine. The advantages of using such a pump include decreased sedation, decreased opioid dosing, fewer adverse effects, and earlier recovery and hospital discharge.
The last option, a mixture of all of the options, would be my choice.
Paula J. Ceh, Pharm.D., PA-CFayetteville, N.C.