Complex Pain Review

521 MD documents in 12 months

ID: 30 F

• dx in 2019 with distal rectal ca
• Neoadjuvant chemorads completed 2019 Nov
• Liver mets resection 2020 Nov
• + PET LN 2021 Jan
• R pelvic side wall resection, partial vaginectomy, TAH-BSO with muscolocutaneous flap 2022 Nov

Further Hx

• Bilateral pudendal N block 2023
• Recurrent SBO
• Other PMHX PCOS, GAD
• Mother sought out Palliative Consult June 2023, after being home for one day.

Meds June 23

• Methadone
• Hydromorphone SC, sufenta SL
• Hypogastric and impar blocks recommended per MIPPC

requesting to be on PCU at VGH but remained FC

PSYCH corrected diagnosis of GAD>situational anxiety

TPN
myoclonus w morphine

July 23

• Laparotomy & adhensionolysis
• Epidural for pain (noted not to be great for sacral)

Ganglion Impar Block

Discharged Jul 21 (@ June 24)

Jul 27 @ VGH

• Recurrence of evolving SBO
• Ascites noted
• Ketamine introduced Aug 22, SC route

Aug 30

• Ex lap, adhesions, lysis, peritoneal biopsies

Sept 28 dc (2/12 admission); ketamine oral added

Sept 23

• Caudal epidural
• R superficial inferior pudendal nerve block
• Ambulatory
• Not driving due to ketamine
• Clonazepam taper through PSMC

Oct 23
Night time pain crises vaginal/perineal HS methadone PRN added

MIPPC Nov 23

• Ket 20 PO q6
• Meth 12 PO q8
• Gaba 600 q8
• Morphine 25 sc q1PRN
• Sufenta 25 SL PT
• Oasis Pevic Health Centre referral?
• Repeat blocks discussed

Nov 23

• VGH ED pain crisis
• "cacophany" of pain medications
• Likely mets seen on CT
• Repeated nerve blocks (Caudal epidural, pudendal)
• Ketamine IV, HM IV added
• Stellate ganglion block

GOC Nov 23

• Good insight into recurrent metastatic disease
• Hopeful for treatment options, recognizing non curative nature
• Wished for LST (CPR, intubation)

Dec 23

• T/F to SPH, consideration of ITP
• Lidocaine infusion
• PCU full code patient
• 2 types of pain: perineal, sacral, R buttock; pain crises down r buttock and leg (nocturnal)
• "twitching" noted

Transfer meds

• gaba 600 TID
• HM LA 66 q8
• ketamine 60 PO QID
• methadone 22 q8
• basal

Crisis meds

• Ket 50 SC q2
• HM 12 IV/SC
• Sufenta 50 mcg

GOC

• revisited GOC
• reviewed benefits of LST in the context of metastatic disease
• Changed to DNR 3
• Identified Spiritual Needs

Onc Board Dec 23

No surgical options
Systemic therapies available, not to provide benefit
Repeat XRT considered

Lidocaine 5 mg/kg x 3 days

Night time crises

• Myoclonus>rotated to fentanyl IVI, DC HM (200 mcg start)
• Concerns about Gravol parenteral raised

Dec 8 23

• CT Lumbar block, targeting R pudendal internal branch

Dec 12 23 IT trial
BUPI/HM combo
Dec 18 23 Implanted

Christmas holidays

• Rotated to fent TD
• ++ night pain crises
• night fent infusion
• IT boluses
• Ongoing aggressive titration of patch and infusions

Discharged Jan 19 24

• 7 week admission
• BACK to full code*
• Methadone/Ketamine
• Ketamine/Sufenta
• Mirabegron
• Did well at home until @ March 6 24

Mar 6 24
Pain Crisis

Pain meds at home

• Ketamine 60 IN q 2
• Ketamine SC 65 q 1h
• Ketamine oral 60 QID
• Sufenta 75 q 30

CCOT Mar 6 24
Fever, hypotension

Mar 6 24
ITP
Bupivacaine 6 mg/d
HM 6 mg/d

Mar 7 Med Summary

• Ketamine CIVI 40 mg/h
• TD Fent 325/h
• Gabapentin 600 TID
• Dexamethasone 4 mg/d
• Methadone 30-30-33
• Fentanyl PCA 250 mcg (17 doses overnight)
• Sufentanil 100 mcg

Mar 7 24
Saddle block offered, but had no pain

IR consult Mar 7/24

• Described pain due to invasion of R sided sacral nerve root branches, in addition to pelvic sidewall nerves
• Offered saddle block with hyperbaric bupivacaine
• BUT pain 2/10 on Ket infusion

Total Pain Conversation

Mar 14 24 Trial of Precedex overnight

Mar 15 24
Lidocaine
Re-trial

Theme of Non Pharm Emphasized
e.g. Therapeutic touch
Box beathing

Mar 22 24
Trial of saddle neurolysis
Transient urinary incontinence

Mar 29 24
Debate around disease progression

Ketamine wean

Other options considered

• Hypogastric plexus block
• Sciatic nerve block

Regional Blocks

• Pudendal x 2
• Ganglion impar x 2
• Saddle block x 3
• Sciatic block

April 11 24
CT guided sciatic nerve ablation

Apr 16 24 MIPCC

• Cordotomy (T Con Honey)
• Repeat saddle and or inferior hypogastric block

Apr 19 24 dc meds

• Celecoxib 200 BID
• Gabapentin 600 TID
• Ketamine 60 PO QID
• Methadone 42 mg TID
• Fent TDP 325 mcg
• Mirabegron 50 mg
• 3 antinauseants

Going forward

• Palliative chemo May>improve pain control?
• Callanish retreat
• Wishes to pursue cordotomy
• Repeat saddle blocks can be performed q 2 months PRN
• Complete block of sciatic nerve on R would result in loss of use of limb

Currently...

• Not perfect
• Using a walker but feels more mobile being home
• Allodynia in R LE
• Methadone PRN for neuropathic pain
• IT pump titration

Some ongoing questions

Untitled Slide

How do you think "we" performed as a team?

Problem list

• Why the night crises?
• Ketamine bladder SE
• Ziconitide in ITP
• Lidocaine IV with BUPI in ITP>risk?
• Gravol drug dependency

Other questions

• Full code pitfalls with complex polypharmacy, procedures.
• How did she not get meningitis?
• Receptor conflict in antinauseants
• TLDR...copy pasting
• Questions about diagnostic reports, discrepancies, and truth telling

WHO Ladder

• Essentially living in step 4
• Other options: cannabinoids, PAT, Ibogaine
• Should we have pushed Psych co-involvement more?
• Callanish (or equivalent) inpatient work?

Gratitude