Acute Pain

Editors: Mercede Erikson, MD and Camille Adajar, MD
Faculty Editor: Brandon Pruett, MD

Multimodal Pain Regimen Suggestions

  • * Always check patient’s home meds/CSMD. Restart home regimen as able
    Tylenol
    • Dose: 1,000mg PO Q8H (can reduce to 650mg based on age, weight <70kg, or comorbidities)
    • Indications: Analgesic and antipyretic
    • Contraindications: Cirrhosis – limit to 2000mg daily
  • Gabapentin
    • Dose: 300mg PO Q8H (reduce to 100mg, Q12H dosing, or hold based on renal function, age, or sedation level)
    • Indications: Neuropathic pain
    • Contraindications:  ESRD
    • Side effects: sedation, respiratory depression
  • Robaxin
    • Dose: 500mg PO Q8H
    • Indication: muscle relaxant
    • Contraindication: IV formulation has preservative that is nephrotoxic
  • NSAIDs (check for adequate renal function and GI contraindications)
    • Toradol 15-30mg IV Q6H x 3-5 days
    • Ibuprofen 600mg Q6H
    • Indications: analgesic, anti-inflammatory, antipyretic
    • Contraindications: CKD/AKI, ulcers, GI bleed
  • Opioids
    • Oxycodone 5mg PO Q4H PRN for moderate pain, 10mg PO Q4H for severe pain
    • Hydromorphone 0.5mg IV Q4H for breakthrough pain

Thoracic epidural catheter (TEC)

  • These are done and managed by the Acute Pain Service. With any issues or concerns, APS must be contacted.
  • Indications: pain relief in thoracic dermatome distributions (rib fractures, BOLTs, etc.)
  • Contraindications
    • PLT <80-100, INR >1.5, coagulopathy
    • Hypotension'
    • Positive blood cultures, fever, white count, etc.
  • TECs remain for 5-7 days, risk of infection increases beyond that point.
  • TECs run an infusion of Ropivacaine and Hydromorphone in the epidural space
  • Do NOT need to d/c anticoagulation to pull TEC
    • Pt can only be on 5000 units of Subq heparin
    • Pain service can pull TEC 4hrs after last SQH dose
    • They can NOT be on the weight adjusted 7500 units
    • No Lovenox/Enoxaparin while TEC in place
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