Scenario : You are shifting your patient & the epidural catheter got broken at the filter end. You troubleshoot but to no avail it is working. The surgery and patient characteristics are : ASA 1, obese male & he underwent open radical nephrectomy with a loin incision with only one functioning kidney.
What would be your alternatives to manage pain in a resource limited setting? Will IV tramadol, with IV PCM (mulitmodal) produce similar pain scores in a patient receiviing epidural morphine alone?
Epidural is superior to all the suggested modalitirs of pain relief.
But, considering the given situation, enteral or intravenous paracetamol and enteral or intravenous tramadol could be supplemented. We use intravenous lignocaine infusions in similar patients in our set up ( a District General Hospital) under close monitoring usually for 48 to 72 hours in the intensive care. Dose reduction is required in this patient with asingle functioning kidney for lignocaine. We provide a 1mg/kg /hr infusions with very good pain scores.
With all due respect, Having intravenous paracetamol or tramadol I would not call this as a LOW RESOURCE CENTER though.....
I would use continue ketamine as pain adjunct post op with morphine in a trully limited setting. I would prefer an esp block if possible
Support Gezy's answer. Don't forget oral / parental paracetamol adjunct.
Consider Paravertebral block / catheter or replace epidural if skill set available. Wound dressing may prevent access.
Single dose SHORT acting NSAID to assist initial pain stabilization, should not compromise other kidney.
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