UNMC Lung Transplant Postoperative Pain Control Regimen - Revision 5

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UNMC Lung Transplant Postoperative Pain Control Regimen - Revision 5
UNMC Lung Transplant Postoperative Pain
Control Regimen
Regimen Goals:
1. Extubation at 12 hours postop
2. Improved patient pain control, function, and ventilation
3. Improved cardiovascular dynamics
4. Reduction in incidence of chronic pain
APS consult to discuss patient expectations, epidural placement, determine chronic opioid
needs, etc...
Multimodal pain medications with sip of water:
o Pregabalin 150mg po
o Acetaminophen 1gm po
At the discretion of cardiovascular anesthesiology
1st 24 to 48 hrs:
Hydromorphone PCA
o APS to manage PCA dosing
o Initiate when patient arrives to unit
o Initial dosing 0.2mg every 8min (demand) with no basal. 0.4mg every 30 min prn
(clinician bolus)
POD 1 to POD2:
Verify normalization of PTT, PT, INR, Platelets 12 hrs after last dose of heparin and every 12
hours in order to determine safety of epidural placement.
o If abnormal determine blood product need to obtain a platelet count >100,000;
INR<1.4; or PTT<37.
Thoracic epidural
o Most beneficial if placed prior to extubation
o Placed when anticoagulation status permits which should be targeted at 12 hrs since
last heparin dose
o To be placed at level of incision
o 0.1% bupivacaine epidural solution at 8 ml/hr
Continue pregabalin 75mg p.o. BID when taking oral meds
Continue acetaminophen 650mg p.o. every 4 hrs
If contraindication to epidural consider paravertebral catheters
o Bilateral at incisional dermatome
o Bifurcated On-Q pump at 14ml/hr
o 0.1% ropivicaine with bifurcated tubing
o May need q 12 hr repeat bolus 15cc bupivacaine 0.2%
POD 3 to POD 4:
Hydromorphone PCA will be discontinued if patient condition warrants
Transition to oral oxycodone or equivalent
o APS to initiate and manage transition in conjunction with C.V. surgery
o Dosing based upon 25% reduction of total 24hr morphine PCA equivalents
I.V. hydomorphone for breakthrough pain
o Dosing to be determined by APS and dependent on patient narcotic needs
POD 5 to POD 7
Maximum life of epidural is 10 days if no infectious concerns related to epidural.
Determine continued need for epidural
o Replace epidural if C.V. surgery determines continued need
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