Clinical Pharmacy Note RE: Pain Management

Mar 2/17 (1400hr) Clinical Pharmacy Note RE: Pain

ID: 46 yo male admitted with traumatic brain injury and fractures on face and both legs from falling 12ft off a tree

S/O:

  • v/s: 37.1, HR 90, BP 105/60, RR 21
  • RASS -1 to 0, BPS 5/12, NRS 10/10 (patient regularly banging (not agitated) on side of bed to ask for more pain medication)
  • Ongoing, non-resolving shooting, burning and aching pain to neck and both legs
  • Current pain meds:
    • Dilaudid 0.1-0.5mg IV Q5min PRN (received >20 doses so far today)
    • Dilaudid 1mg OG Q4H regular (started today)
    • Acetaminophen 975mg OG Q6H reg
  • Previous PRN dilaudid IV doses (total daily doses) – Feb 28: 5.8mg, Mar 1: 6.4mg

A:

  • Ongoing pain (likely combination of neuropathic and nociceptive) is not being adequately managed
  • Current regularly scheduled dilaudid OG (total daily dose: 6mg equivalent to 3mg IV) is not adequate in managing pain
  • Pregabalin is effective in managing neuropathic pain and would help decrease requirements for opioids
  • No significant drug interactions with pregabalin

P: Suggest

  • ↑ Dilaudid to 2mg OG Q4H reg (total daily PO dose = 12mg equivalent to 6mg IV)
  • Start pregabalin 75mg OG BID
  • Monitor pain (BPS, NRS) Q4H and use of PRN dilaudid IV daily
  • Monitor for AEs of pregabalin: drowsiness, dizziness, headache, dry mouth, constipation, peripheral edema
  • Monitor for AEs of dilaudid: drowsiness, dry mouth, nausea, vomiting, constipation, urinary retention, pruritus
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