Ketorolac for pain management

[Carlos Danger]

Curious about your remarks on treating hyperalgesia with acetaminophen. References?

Not so much treating, but preventing. Ketamine and lidocaine are the only drugs that I'm aware of that are used clinically for hyperalgesic syndromes.

I've seen lots of references in articles that I've read, and I'll try to dig one up. This article outlines some of what we know about it from the pre-clinical setting:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669887/

I don't use acetaminophen for this purpose, I just thought it was sort of an interesting nerdy bit to mention.

 

[Brandon O]

Not so much treating, but preventing. Ketamine and lidocaine are the only drugs that I'm aware of that are used clinically for hyperalgesic syndromes.

I've seen lots of references in articles that I've read, and I'll try to dig one up. This article outlines some of what we know about it from the pre-clinical setting:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669887/

I don't use acetaminophen for this purpose, I just thought it was sort of an interesting nerdy bit to mention.

Interesting -- but don't opioids also "prevent" wind-up and hyperalgesia to a certain extent? May be more a matter of timing (early/pretreatment) versus agent?

 

[Carlos Danger]

As an aside~ worse than childbirth, per a mother...x 2.

Women have a massive discharge of beta-endorphins, enkephalin, and other endogenous opioids and oxytocin during childbirth that for most women, probably makes it quite a but less painful than it would otherwise be. This is part of the reason why "tests" meant to demonstrate how wimpy men are compared to women by using a TENS unit to induce muscle contractions (meant to simulate labor pain) are not a fair comparison. It also might explain how women can interpret painful stimuli as being similar to or worse than labor pain, when that stimuli doesn't objectively appear as though it would be.

I'm full of nerdy stuff today.

 

[Carlos Danger]

Interesting -- but don't opioids also "prevent" wind-up and hyperalgesia to a certain extent? May be more a matter of timing (early/pretreatment) versus agent?

Yeah, opioids usually do a good job that, but they (especially the newer fentanyl analogues, sufentanil and remifentanil) can also induce hyperalgesia themselves. And while I'm not sure how common or significant of a problem that really is, acute opioid tolerance is a real thing for sure. The more opioid that is used during surgery, the more that is required post-op and the longer people take them. And we still see pretty high rates of chronic pain development after many surgeries. For that and other reasons there's a pretty significant movement in anesthesia towards less reliance on opioids.

Personally, I don't use any opioids intra-operatively and generally very little post-op. We've seen post-op nausea (which traditionally is a pretty big concern) almost eliminated and people wake up feeling better, needing less pain meds, and ready to go home quicker and asking for fewer refills. A couple of months ago we did a huge 5-hour colectomy on a guy in his 50's with zero narcs and he was discharged POD2 not having taken a single dose of an opioid.

I've thought a lot about how to translate this stuff the the prehospital world or heck, even the ICU, but I don't see it happening anytime soon. There's also less need for it, I think.

 

[Brandon O]

Personally, I don't use any opioids intra-operatively and generally very little post-op. We've seen post-op nausea (which traditionally is a pretty big concern) almost eliminated and people wake up feeling better, needing less pain meds, and ready to go home quicker and asking for fewer refills. A couple of months ago we did a 5-hour colectomy on a guy in his 50's with zero narcs and he was discharged POD2 not having taken a single dose of an opioid.

So what are you using intraop for analgesia? Nothing?

 

[Carlos Danger]

So what are you using intraop for analgesia? Nothing?

So, it depends on a few factors, the biggest of which is simply the expected length of the case and how painful it typically is. Also, the patient's experience with opioids (especially with chronic pain syndromes and continued use) and even anxiety levels clue you in - rather unscientifically, admittedly - on how much of an issue pain is likely to be.

Pre-op clonidine and gabapentin has proven useful. Fairly high-dose lidocaine infusions, ketamine boluses and/or infusion, and clonidine boluses are kind of the mainstay of my opioid-free technique. Toradol at the end of almost every case. Ofirmev at the end of the more painful ones, especially if I'm not doing a block for some reason. Esmolol and magnesium are useful at times. We do nerve blocks whenever possible. I've been doing variations of TAP blocks on pretty much every abdominal case, even smaller ones like lap choles, which many would say is overkill but I've gotten to the point where I feel like a failure if they need any dilaudid in PACU. I'm working on learning some more sophisticated truncal blocks that should be helpful in bigger cases by hopefully covering more visceral pain. Epidurals are the easy choice but our med-surg floor won't take them.

It is a lot more work than just giving a bunch of fentanyl. Today I almost did a sux drip for a 15-minute bronchoscopy because I hate the way they cough and buck, but I also hate giving them fentanyl to avoid it. I was too lazy to mess with that, though. Fentanyl it was.

 

[Brandon O]

Interesting stuff.

How much juice do you get out of the clonidine? The parallel for us is presumably dexmedetomidine, but while I know they say it's an analgesic, I've never found it to be all that potent for pain. Are hemodynamics limiting? Assume it's just one part of a larger puzzle, of course.

Have heard good things about the IV lidocaine thing but no experience. What is the interplay with its electrical effects? None of concern?

 

[Carlos Danger]

Interesting stuff.

How much juice do you get out of the clonidine? The parallel for us is presumably dexmedetomidine, but while I know they say it's an analgesic, I've never found it to be all that potent for pain. Are hemodynamics limiting? Assume it's just one part of a larger puzzle, of course.

Have heard good things about the IV lidocaine thing but no experience. What is the interplay with its electrical effects? None of concern?

I don't have a lot of experience with demetetomidine because we don't have it where I work, hence the clonidine. People who use it regularly seem to love it. Others won't use it because they hate it. I don't have enough experience with it to have an opinion.

Clonidine seems to work pretty well, and the clonidine/ketamine/lidocaine combo is pure gold. When we give clonidine PO (0.2 or 0.3mg) it is common to hear about mild hypotension on the floor overnight, but it sounds like it typically resolves with a fluid bolus and they are getting more comfortable dealing with it. Have had no problems with being unable to discharge people because of hypotension. When you give an IV bolus you'll definitely see an effect on HR and MAP, but it usually isn't all that long lasting.

Lidocaine is an amazing drug. I've used ~2mg/kg boluses in combination with much-smaller-than normal doses of fentanyl to treat acute pain in large OSA patients who I didn't want to give dilaudid to, with excellent results. It seems to really potentiate the fentanyl, making it more potent and last longer, without the respiratory effects. A couple months ago I used the same dose plus some versed to completely terminate a migraine that had been refractory to everything the ED could think of (I had offered a SPG block but the patient was to anxious for that). During general cases, I typically give about 1-1.5 mg/kg on induction and then run an infusion at 2-3 mg/min, which works out to about 1-2 mg/kg/hr in most patients, and like I said, it works great. Haven't seen any problems with these larger doses of lidocaine at all. People do get a little loopy with much more than 1mg/kg bolus and I always instruct them to report any strange sensations or sounds as I'm giving it. Tinnitus or tongue or circumoral sensations is not uncommon. I think having benzos (and ideally, lipids) available is probably a really good practice, but lidocaine is pretty safe and forgiving. Just recently I read something somewhere about a place that was giving massive doses for chronic pain - I think it said they were working up to 10mg/kg for an hour over a handful of sessions!

Like I said before, I'm not sure how to translate this stuff outside the anesthesia setting. It just doesn't seem practical. Maybe in the ICU you could try a lidocaine infusion + low-dose ketamine infusion in patients whose pain is hard to manage, or in whom you want to minimize opioids for whatever reason? Even if it doesn't eliminate the need for narcs it might drastically reduce it. I've really started to be convinced that while narcs are certainly indispensable in many cases, prolonged dosing and large doses often causes as many problems as it solves. In someone who narcs just don't seem to be working in, you are likely seeing some sort of opioid-induced acute tolerance, if not an actual hyperalgesic state. No need to try to differentiate, really.

 

[Brandon O]

Like I said before, I'm not sure how to translate this stuff outside the anesthesia setting. It just doesn't seem practical. Maybe in the ICU you could try a lidocaine infusion + low-dose ketamine infusion in patients whose pain is hard to manage, or in whom you want to minimize opioids for whatever reason?

It's relevant because opioids don't do us any more favors than they do you. (Plus we have plenty of postsurgical/post-trauma folks who are basically your patients anyway.) They slow vent weaning, decrease mobility, worsen pulmonary toilet, slow gut motility, etc. Less is better, but at least in the acute setting, a lot of the multi-modal maneuvers are contraindicated. I can slap on a lidocaine patch or the like, but a lot of these people are too ill for acetaminophen or NSAIDs. The gabapentin thing never really filled my sails (although I'm open to be proven wrong), and likewise tramadol (less open). Epidurals are great but a logistic challenge to implement. I like ketamine but the comfort level among providers/nursing is poor -- our pumps don't even have a preprogrammed mode for it.

So I'm always interested in other tools. Lidocaine would be a neat trick, but I don't have any experience with it. (Outside the OR the only other place I've heard of it was in one of those opioid-free ED concepts.) Maybe the pain folks here could make it happen.

 

[TransportJockey]

I used to carry it out west. Used it a lot for renal colic and gallbladder issues. From first hand experience as a patient, for gallbladder pain it works amazingly well. Way better than opiates

 

[RocketMedic]

I used to carry it out west. Used it a lot for renal colic and gallbladder issues. From first hand experience as a patient, for gallbladder pain it works amazingly well. Way better than opiates

Lidocaine or to radio?

 

[TransportJockey]

Lidocaine or to radio?

Toradol. Havent had the lido for it. But i saw that on a study and it looks interesting