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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
Preoperative:


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
Intraoperative:

At the discretion of cardiovascular anesthesiology
Postoperative:

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)
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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
recommendations
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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