both pain and sedition (choice C) because tolerance develops, so increasing doses will be needed. Benzodiazepines are associated with ICU delirium and may contribute to delayed weaning from mechanical ventilation, so choice D is not the best choice. There is no indication to change from dilaudid to fentanyl (choice E).Answer: BDevlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC, van den Boogaard M, Bosma KJ, Brummel NE, Chanques G, Denehy L, Drouot X, Fraser GL, Harris JE, Joffe AM, Kho ME, Kress JP, Lanphere JA, McKinley S, Neufeld KJ, Pisani MA, Payen JF, Pun BT, Puntillo KA, Riker RR, Robinson BRH, Shehabi Y, Szumita PM, Winkelman C, Centofanti JE, Price C, Nikayin S, Misak CJ, Flood PD, Kiedrowski K, Alhazzani W. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018; 46(9):e825–73.Schwenk ES, Viscusi ER, Buvanendran A, Hurley RW, Wasan AD, Narouze S, Bhatia A, Davis FN, Hooten WM, Cohen SP. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018; 43(5):456–66.Radvansky BM, Shah K, Parikh A, Sifonios AN, Le V, Eloy JD. Role of ketamine in acute postoperative pain management: a narrative review. Biomed Res Int. 2015; 2015:749837.
8 A 30 year old patient with a history of substance abuse is admitted after a motor vehicle accident with left 3 rd , 4 th and 5 th rib fractures and proximal tibia fracture. He takes buprenorphine 8 mg daily. What is the appropriate management of acute pain for a patient taking 8 mg buprenorphine daily?Always stop buprenorphine because it competes with opioid receptors.Continue buprenorphine in the same dose and order patient‐controlled analgesia with dilaudid without basal rate.Request a femoral nerve block, avoid narcotics, and stop buprenorphine.Start dilaudid PCA with a basal rate and a demand dose of 0.5 mg every 10 minutes.Increase the dose of buprenorphine by 50% and start dilaudid 0.5 mg q4h prn.Buprenorphine is a lipophilic, semisynthetic opioid with partial agonist activity and high affinity for the mu receptor. Patients on buprenorphine maintenance therapy are frequently encountered in the ICU. In certain doses (more than 12 mg daily), buprenorphine can block the ability to use other opioids for breakthrough pain which does not occur at lower doses of buprenorphine (less than 8–12 mg daily sublingual dose). At low doses, there may be synergistic analgesia between buprenorphine and other opioids. Current opinion favors continuation of low‐dose buprenorphine (either at full or reduced dose), so choice B is the correct answer. Patients on buprenorphine maintenance may have severe postoperative pain and experience buprenorphine‐induced hyperalgesia. It may not be appropriate to stop buprenorphine at this dose (choices A and C). While regional anesthesia is ideal for this patient, given his type of injury, a femoral nerve block will mask symptoms of compartment syndrome that may result from tibial plateau fractures (choice C), so he may not be a candidate for regional anesthetic. Patient controlled analgesia (PCA) is another good choice but basal rates are not recommended due to risk of apnea, even in patients with tolerance (choice D). Basal rates increase both the overall amount of drug delivered and adverse effects without improving analgesia. There is no indication to increase the dose of buprenorphine (choice E).Answer: BBuresh M, Ratner J, Zgierska A, Gordin V, Alvanzo A. Treating perioperative and acute pain in patients on buprenorphine: narrative literature review and practice recommendations. J Gen Intern Med. 2020; 35(12):3635–43. doi: 10.1007/s11606‐020‐06115‐3. Epub 2020 Aug 21.Goel A, Azargive S, Weissman JS, Shanthanna H, Hanlon JG, Samman B, Dominicis M, Ladha KS, Lamba W, Duggan S, Di Renna T, Peng P, Wong C, Sinha A, Eipe N, Martell D, Intrater H, MacDougall P, Kwofie K, St‐Jean M, Rashiq S, Van Camp K, Flamer D, Satok‐Wolman M, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth. 2019; 123(2):e333–e342. doi: 10.1016/j.bja.2019.03.044. Epub 2019 May 29. PMID: 31153631; PMCID: PMC6676043.Leighton BL, Crock LW. Case series of successful postoperative pain management in buprenorphine maintenance therapy patients. Anesth Analg. 2017; 125(5):1779–83.Chen KY, Chen L, Mao J. Buprenorphine‐naloxone therapy in pain management. Anesthesiology. 2014; 120(5):1262–74.
9 A 62‐year‐old patient with chronic pain is admitted after Hartmann's procedure for diverticulitis. His chronic pain was controlled with 40 mg Oxycodone every 8 hours. He is intubated and you want to start a fentanyl drip post op in equianalgesic dose. What is the closest basal fentanyl dose?50 mcg/hr100 mcg/hr150 mcg/hr200 mcg/hr250 mcg/hrThe first step in this calculation is to estimate the total daily narcotic dose and then convert this dose to an equivalent dose of oral morphine. Morphine is the reference point to convert between different narcotics to obtain the starting point for conversion. Each 20 mg of PO Oxycodone is equivalent to 30 mg PO Morphine. And IV to PO conversion rate of Morphine is 1 to 3. IV equianalgesic parenteral dose of Fentanyl to Morphine is 0.1–0.2 mg fentanyl per 10 mg morphine. This patient is taking 120 mg of oxycodone which converts to 180 mg of PO Morphine. 180 mg of PO morphine would be equal to 60 mg of IV morphine, and equianalgesic parenteral fentanyl dose would be 0.6–1.2 mg of Fentanyl daily (600–1200 mcg). Therefore, the hourly drip dose would be closest to 25–50 mcg/hr. Additionally, using higher than necessary continuous infusion rates (choices B through E) can cause opioid‐induced hyperalgesia. Continuous opioid infusions at inappropriately high doses contribute to oversedation and delayed extubation. In context, a simple rule is that fentanyl is 100 x more potent than morphine. An infusion of 100 μg/h fentanyl is equivalent to 10 mg of morphine per hour.Answer: AHurley RW, Hurley NM, Elkassabany and Wu CL. Acute Postoperative Pain. In: Miller RD, ed. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier Saunders.MedicationEquianalgesic dose IV/IMEquianalgesic dose POTypical adult starting dose IVTypical adult starting dose POMorphine10 mg30 mg5–10 mg q3‐4h15–30 mg q3‐4hOxycodone20 mg5–10 mg q4‐6hFentanyl100 mcg (not patch)25 mcg/h transdermal (patch) equivalent PO morphine dose 45–75 mg50 mcg/h patch approx equal 1 mg/h morphine infusionMethadone10 mg20 mg5–10 mg q12hCodeine200 mg30–60 mg q3‐4hHydromorphone (Dilaudid)1.5 mg7.5 mg1–2 mg q3‐4h4–8 mg q3‐4h
10 An 18‐year‐old boy is emergently intubated and exhibits masseter muscle spasm after induction with succinylcholine. He is in the OR for emergency surgery for a ruptured appendix. Which of the following additional symptoms would give you a heightened suspicion for malignant hyperthermia (MH)?BradycardiaEnd‐tidal CO2 of 35 mmHGRigidity of skeletal muscles of the limbsErythemaDiaphoresisThe onset of malignant hyperthermia can be heralded by tachycardia, trismus or masseter muscle spasm, and arrhythmias. Although concerning, as few as 20% of patients with masseter spasm progress to malignant hyperthermia. Triggers for MH include succinylcholine and inhalation anesthetic gases such as desflurane. This susceptibility to these triggers is due to genetic mutations with the most common one being the RYR1 gene or dihydropyridine (DHP) receptors located within the t‐tubule membrane. Monitoring for signs of MH such as increasing temperature, end‐tidal CO2, and rigidity of skeletal muscles is key to prompt recognition. MH can be rapidly fatal and treatment with Dantrolene must be started immediately. Dantrolene is a direct skeletal muscle relaxant that blocks calcium release by antagonistic effect at the ryanodine receptor (RYR1). Metabolism is increased in malignant hyperthermia resulting in hypercarbia (choice B), hyperthermia, and tachycardia (choice A). In this scenario, masseter muscle spasm in combination with rigidity of other muscle groups makes the diagnosis of malignant hyperthermia likely (choice C). Erythema (choice D) or diaphoresis (choice E) is not specific for malignant hyperthermia.Answer: CBandschapp O, Girard T. Malignant hyperthermia. Swiss Med Wkly. 2012; 142:w13652.Denborough M. Malignant hyperthermia. Lancet. 1998; 352(9134):1131–6.Sessler DI. Temperature Regulation and Monitoring. In: Miller RD, ed. Miller’s Anesthesia. 8th ed. Philadelphia, PA: Elsevier Saunders.
11 Which of the following medications is best reversed with Sugammadex (Bridon)?Succinylcholine (Anectine)Cisatracurium (Nimbex)Midazolam (Versed)Ropivacaine (Naropin)Rocuronium (Zemuron)Sugammadex (Bridon) is a dextran compound that surrounds and encapsulates the nondepolarizing aminosteroid muscle relaxant rocuronium, allowing for reversal of its effects. It cannot reverse succinylcholine (Anectine), a depolarizing muscle relaxant which makes choice A incorrect. While sugammadex can reverse some other nondepolarizing medications, it