Case #2 Discussion Questions:

  1. What are the total 24 hour po morphine equivalents of her pain medications?

Since she is not tolerating po, we need to switch her to IV PCA Morphine. Start with a basal infusion to equal patient's 24 hour morphine equivalents.

  1. How do you do this?
  2. What demand dose would you order, with what duration lockout?

After 48 hours, her use of IV Morphine helped to keep her pain score decreased from 10 to 5 /10. The 24 hour IV morphine use equaled 750 mg. Radiation Oncology service was consulted and radiation therapy was started to her thoracic and lumbar spine. After 4 days of radiation her IV morphine use had decreased to 300 mg in 24 hours. Ibuprofen 600 mg every 6 hours was also started on day 2 of her admission. At this point it was decided to switch her back to oral analgesics in prep for discharge.

  1. What new dose of sustained release morphine (MSContin) should we start?

The patient's appetite also started to increase once the pain became controlled, but was now complaining of constipation and nausea.

  1. What should your next step be?

The patient continued to make progress and was ready for discharge home. Her social situation involved 3 children (age 3,5, and 6) and her husband, who worked full-time. They had some family, friends and neighbors available to help, but not consistently. Prior to the discharge home, social services gave resources to the patient and her husband for homemaking services. The patient was continued on oral sustained release morphine and an immediate short acting morphine for breakthrough pain, ibuprofen, and a bowel program. The patient develops severe nausea and vomiting.

  1. How would you treat this?

The patient requests a change to a different medication.

  1. What do you do?