zorn
Bluelighter
I was reading papers on ketamine/opioid analgesia last night and came across this paper which documents the most extreme case of opioid tolerance I've ever seen [1]. At its height this woman was receiving 7mg/hour of fentanyl (yes, milligrams) and was still pain.
This was a 22-year old woman in the last stages of terminal skin cancer; she had just rejected a white blood cell transfusion. Check it out:
"Five days after hospital admission her medication included hydromorphone 28 mg, fentanyl 350 µg, and lorazepam 6 mg per day."
"On ICU day 15, the patient was receiving 7000 µg/h of fentanyl and 10 mg/h of midazolam in addition to 100 mg methadone per day. Despite this regimen her pain control was inadequate and she complained of severe pain by nodding her head, grimacing, and fighting the ventilator."
"[On day 15] an initial attempt to convert fentanyl to an equipotent dose of hydromorphone (2065 mg) failed." (this was apparently done because she was receiving 3.4 liters/day of fentanyl infusion.)
"In an attempt to reduce opioid tolerance and improve analgesia, a ketamine infusion was started at 0.1 mg · kg-1 · hr-1 (8 mg/hr based on admission weight of 80 kg)... A taper of the fentanyl and midazolam infusions was initiated. Despite a lack of improvement of her overall medical condition, she progressively awoke over the next 5 days and on ketamine infusion day 6 (ICU day 21) she followed commands and indicated that she was comfortable by nodding her head appropriately to questions."
"The patient was transferred to the ward on ICU day 45 receiving only methadone at 300 mg/day"
Now this poor woman was intubated and ventilated, so respiratory depression wasn't an issue.. but the amount of opioids she was on is still truly amazing. Even more shocking is that 8mg/hr of ketamine made such a difference.
Comments anyone?
[1] Eilers H et al. (2001) The Reversal of Fentanyl-Induced Tolerance by Administration of "Small-Dose" Ketamine. Anaesthia and Analgesia 93:213-214.
This was a 22-year old woman in the last stages of terminal skin cancer; she had just rejected a white blood cell transfusion. Check it out:
"Five days after hospital admission her medication included hydromorphone 28 mg, fentanyl 350 µg, and lorazepam 6 mg per day."
"On ICU day 15, the patient was receiving 7000 µg/h of fentanyl and 10 mg/h of midazolam in addition to 100 mg methadone per day. Despite this regimen her pain control was inadequate and she complained of severe pain by nodding her head, grimacing, and fighting the ventilator."
"[On day 15] an initial attempt to convert fentanyl to an equipotent dose of hydromorphone (2065 mg) failed." (this was apparently done because she was receiving 3.4 liters/day of fentanyl infusion.)
"In an attempt to reduce opioid tolerance and improve analgesia, a ketamine infusion was started at 0.1 mg · kg-1 · hr-1 (8 mg/hr based on admission weight of 80 kg)... A taper of the fentanyl and midazolam infusions was initiated. Despite a lack of improvement of her overall medical condition, she progressively awoke over the next 5 days and on ketamine infusion day 6 (ICU day 21) she followed commands and indicated that she was comfortable by nodding her head appropriately to questions."
"The patient was transferred to the ward on ICU day 45 receiving only methadone at 300 mg/day"
Now this poor woman was intubated and ventilated, so respiratory depression wasn't an issue.. but the amount of opioids she was on is still truly amazing. Even more shocking is that 8mg/hr of ketamine made such a difference.
Comments anyone?
[1] Eilers H et al. (2001) The Reversal of Fentanyl-Induced Tolerance by Administration of "Small-Dose" Ketamine. Anaesthia and Analgesia 93:213-214.
