Case report: perioperative pain management in a patient on injectable opioid agonist treatment undergoing total knee art
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CORRESPONDENCE
Case report: perioperative pain management in a patient on injectable opioid agonist treatment undergoing total knee arthroplasty Patrycja Vaid, MN, RN . Patty Wilson, MScN, NP . Gregory Abelseth, BEng, MD, FRCSC . S. Monty Ghosh, MD, MSc, MBT, FRCPC . Cristina Zaganelli, MN, NP . Jacqueline Klemann, BN, MSN, ACNP
Received: 15 April 2020 / Revised: 24 June 2020 / Accepted: 30 June 2020 Canadian Anesthesiologists’ Society 2020
To the Editor, Injectable opioid agonist treatment (iOAT) is a form of opioid replacement therapy used to treat severe opioid use disorder (OUD) in patients who inject illicit opioids.1,2 The use of iOAT may improve the health of patients when firstline oral medications have failed by reducing OUDassociated health risks, such as overdose from contaminated street drugs.2 We present a case report of a female iOAT patient in her forties who required an elective total knee arthroplasty for post-traumatic osteoarthritis. The patient provided written informed consent to present this case. After conventional OUD treatments failed, the patient was self-injecting hydromorphone 85 mg iv TID in
P. Vaid, MN, RN (&) Acute Pain Service (APS), Department of Anesthesia, Alberta Health Services (AHS), Calgary, AB, Canada e-mail: [email protected] P. Wilson, MScN, NP Calgary Injectable Opioid Agonist Therapy (iOAT) Program, AHS, Calgary, AB, Canada G. Abelseth, BEng, MD, FRCSC Section of Orthopaedics, Department of Surgery, University of Calgary, Calgary, AB, Canada S. Monty Ghosh, MD, MSc, MBT, FRCPC University of Calgary, AHS, Calgary, AB, Canada University of Alberta, AHS, Edmonton, AB, Canada C. Zaganelli, MN, NP Calgary iOAT Program, AHS, Calgary, AB, Canada J. Klemann, BN, MSN, ACNP Orthopedics, AHS, Calgary, AB, Canada
addition to taking slow release oral morphine 250 mg OD and other analgesics (listed in Table 1) for OUD and chronic pain upon admission and was very anxious because of previous stigma surrounding her OUD. We implemented principles of pain management for opioid tolerant individuals to treat the patient’s postoperative pain,3,4 such as tailored patient-centred care, multimodal analgesia, non-pharmacologic therapies (i.e., ice), intraoperative lidocaine and ketamine, local anesthetic infiltration, adductor canal block, and spinal. The hydromorphone was given intravenous piggy-back instead of self-injection because of institutional barriers, and was reduced as the patient had adequate analgesia and was highly motivated to wean off opioids. She was provided with patient-controlled analgesia to self-titrate her withdrawal symptoms and pain. Postoperative ketamine and lidocaine analgesic infusions were considered but not utilized as the patient experienced superb postoperative analgesia. A full list of relevant medications administered, and her outcomes, are summarized in the Table 1. The above approach resulted in adequate postoperative analgesia, withdrawal management, functional improvement, a 58% opioid reduction one month postoperatively, improved quality of life,
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