We face some unsatisfied patients, refractory to standard analgesics even with max doses. It often occurs following major surgeries in both genders but particularly substantial among the middle-aged females. OIH may be one of the causes! Counseling and psych-support do contribute a lot but for a while, which proves that they need some pharmacological adjuvants. What are the significantly effective agents without much side-effects? Again, which will not prolong the hospital stay as well. May the learned and practicing clinicians share your valuable experiences, please?
In these cases, intravascular hallopuridol, or intramuscular Promethazine 50 mg can be helpful.
I'm assuming poorly controlled pain is the PRIMARY problem
If Opiod Induced Hyperalgesia (OIH) is contributing then low dose ketamine may be useful. Dosage range 1->5 ugm (microgm)/kg (ideal bw)/minute intravenously.
1ugm/kg/min is opiate analgesia enhancing, 3ugm/kg/min has some inherent analgesic action and opiod sparing, 5ugm/kg/min max analgesic effect. Above 5 psychomimetic effects likely (hallucinations etc).
Other suggestions
Add non steroidal ( first 24-48 hrs) eg ibuprofen 400 Q6h (adult) if no contraindication can be expected to reduce opiod requirement about 30%
+/- paracetamol 1gm Q6h can be expected to reduce opiod requirement about 25%
Consider
Local anaesthetic regional blocks depending on type of surgery and facilities at your institution
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