ICU Patient Discussion

Clinician Specialty: Pain Management Specialist Patient: Mrs. Eleanor Vance, 78-year-old female, admitted with severe acute on chronic lower back pain, presenting from a nursing home. Relevant demographic information includes a history of osteoarthritis and osteoporosis. Referring Team: Geriatric Medicine Service Reason for Discussion: To discuss escalation of pain management strategies for Mrs. Vance, who is experiencing intractable lower back pain unresponsive to current oral analgesics, impacting her ability to participate in physical therapy and causing significant distress. Concerns include potential for opioid-induced adverse effects given her age and comorbidities, and the need for a comprehensive pain management plan to facilitate rehabilitation. Current Clinical Status: Vital Signs: BP 130/80 mmHg, HR 72 bpm, RR 16 bpm, SpO2 96% on room air, Temp 37.0°C. Pain score reported as 9/10 on visual analogue scale. Neurological status: Alert and oriented x3, no focal deficits. Respiratory status: Clear on auscultation. Cardiovascular status: Regular heart sounds, no oedema. Renal status: Stable, UO 0.8 ml/kg/hr. Gastrointestinal status: Soft, non-tender abdomen, last bowel movement yesterday. Patient is distressed, grimacing with movement, and reluctant to mobilise due to pain. Background Medical History: Osteoarthritis (knees, hips, lumbar spine), Osteoporosis, Hypertension, Type 2 Diabetes Mellitus (well-controlled on metformin). Previous surgeries: Left total knee replacement (5 years ago). Social history: Lives in a nursing home, uses a walking frame for mobility, requires assistance with ADLs. Recent Investigations: Lumbar spine X-ray (dated 1 November 2024): degenerative changes, disc space narrowing at L4/5 and L5/S1, no acute fractures. Bloods (dated 1 November 2024): WCC 7.2, Hb 12.8, Platelets 250, Creatinine 80, eGFR 65, Glucose 6.1, CRP 5. Urine dipstick: negative. Discussion with ICU Team: Discussed patient's current pain crisis and the limitations of current oral analgesic regimen (paracetamol, codeine). ICU team acknowledges the complexity due to age and comorbidities. Recommendations include a trial of a continuous intravenous opioid infusion (e.g., fentanyl) with close monitoring for respiratory depression and sedation. Agreed on a protocol for vigilant observation and naloxone availability. Also suggested a regional nerve block if the IV opioid infusion proves insufficient or has intolerable side effects, to be performed by anaesthetics. Plan: 1. Initiate continuous intravenous fentanyl infusion at a low dose, titrated according to pain response and side effects, with continuous pulse oximetry and capnography monitoring. 2. Regular pain assessment using a validated scale (e.g., VAS or Numeric Rating Scale). 3. Re-evaluate pain and sedation levels hourly for the first 6 hours, then every 4 hours. 4. Commence bowel regimen with a stimulant laxative and stool softener due to opioid use. 5. Physiotherapy and occupational therapy to continue gentle mobilisation and exercises as tolerated, with regular communication regarding pain levels. 6. Consult Anaesthetics for consideration of a lumbar nerve block if IV opioid infusion is ineffective or poorly tolerated. 7. Continue current anti-hypertensives and diabetes medications. 8. Review by Pain Management team within 24 hours.