The Obese Surgical Patient: A Need for a Strong Multimodal Analgesia Approach

Chris Pasero, MS, RN-BC

Disclosures

March 20, 2014

Case Outcome: Pain Management

Preoperative and intraoperative care

  • The patient received a preoperative dose of IV acetaminophen 1000 mg and a total of 75 μg of IV fentanyl with general anesthesia intraoperatively.

  • The duration of the surgical procedure was 1 hour and 40 minutes.

Postanesthesia care unit

  • The patient's vital signs were within normal limits throughout the PACU stay.

  • She was breathing without difficulty while receiving 3 L/min supplemental oxygen by nasal cannula on admission and was placed on continuous capnography and pulse oximetry.

    • ETCO2 values ranged between 35 mm Hg and 40 mm Hg, and O2 saturation values ranged between 99% and 100% on admission.

    • Supplemental oxygen was discontinued shortly after admission; ETCO2 remained stable between 35 mm Hg and 40 mm Hg, and O2 saturation remained stable between 96% and 98%.

  • Pain rating was 4 on a scale of 0 to 10 (4/10) on admission.

    • The nurse administered ketorolac 30 mg IV, and hydromorphone 0.5 mg IV was ordered.

    • Pain rating was 3/10 on discharge to the clinical unit.

  • POSS score was 2 (Table 3) on discharge to the clinical unit. Duration of PACU stay was 1 hour.

Admission to the clinical unit

  • Vital signs remained stable and within normal limits.

  • Continuous capnography and pulse oximetry were continued. ETCO2 was 38 mm Hg, and O2 saturation was 97%.

  • POSS score: 2 (Table 3).

  • Pain rating 4/10, and patient stated she did not want any additional pain medication.

  • Acetaminophen 1000 mg IV and ketorolac 30 mg IV were continued in scheduled doses every 6 hours for 24 hours.

  • Oral oxycodone 5-10 mg could be given as needed every 4 hours.

Overview of postoperative course. The patient sat in a chair at the bedside for 30 minutes and ambulated 50 yards the night of surgery. Ambulation was gradually increased over the next 2 days. She was able to walk a distance of approximately 175 yards prior to discharge in the afternoon on the second postoperative day. Vital signs, ETCO2, and O2 saturation remained stable with no evidence of respiratory depression throughout the hospital stay. Continuous capnography and pulse oximetry were discontinued on the morning of the second postoperative day. Her POSS scores were consistently between 1 and 2 (Table 3). Her pain ratings ranged from 2/10 to 5/10, and she was transitioned to oral acetaminophen 650 mg and ibuprofen 400 mg in scheduled every 8-hour doses on the second postoperative morning. She took a total of 10 mg oral oxycodone during her hospital stay.

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