Q. Patient is 89 years old with COPD. Is Hydromorphone a recommended analgesic?
Hello doctor,
The patient is 89 years old and unable to take medications orally. The patient has COPD (with a pacemaker), CCF (congestive cardiac failure), had two TIA's a few years ago and is type 2 diabetic, has delirium, and is in pain. The patient is on iv antibiotics and diuretics.
1) Is it typical not to use Hydromorphone (or alternative analgesia) for pain if a patient is on antibiotics for suspected sepsis and probable pneumonia, on the ground that the Hydromorphone could mask the symptoms of the patient's recovery or decline?
2) Is some other analgesia less likely to disguise such symptoms?
Hello,
Welcome to icliniq.com.
It is not advisable to withhold pain medication while the patient is on multiple antibiotics for the treatment of sepsis. As the patient is suffering from COPD (chronic obstructive pulmonary disease), the use of Hydrocodone is not advisable as it causes respiratory depression in an already compromised patient, but the patient should be prescribed alternative analgesia due to the following reasons.
First, it is inhuman to allow suffering due to pain. Secondly, pain itself a cause to maintain the delirium and prevents recovery from it. Thirdly, the recovery from sepsis can be determined by clinical examination and routine blood count. I agree that Hydrocodone can mask the symptoms but there are other pain medications which are safe and can be used in patients.
Even a simple iv infusion of Paracetamol can be used for pain relief, and it also works as an anti-inflammatory agent. I hope this helps.
Thank you, doctor,
As a matter of interest, what sort of clinical examination or blood test results would determine whether the patient is recovering or declining? Despite suspected sepsis and pneumonia, two blood cultures were negative.
Hello,
Welcome back to icliniq.com.
There is no specific diagnostic test for sepsis. Diagnostically sensitive findings in a patient with suspected or proven infection include fever or hypothermia (temperature below 96.8 degrees fahrenheit generally more common at extremes of age), tachypnea (respiratory rate >24), tachycardia, and leukocytosis (total white blood cell count >12000) or leukopenia, acutely altered mental status, thrombocytopenia, an elevated blood lactate level, or hypotension also suggest the diagnosis.
It does not mean that all should be present in a single patient. The presentation of sepsis is very much variable but on careful observation of all mentioned clinical and biochemical parameters one can reach the diagnosis.
Serial monitoring of the above parameters will tell you the condition of the patient. If the patient improves one or another parameter it indicates the improving status of the patient. If there is deterioration you can suspect that the patient is not responding to current treatment and needs a different set of treatments including antibiotics. These things are easy to monitor clinically or with the help of a simple laboratory which will determine the number of leukocytes, thrombocytes, and lactate levels.
The presence of sterile culture does not mean that there is no sepsis. It may be present due to prior antibiotic administration, the presence of slow-growing organisms, or the absence of microbial invasion of the bloodstream. Statistically, only 30-50% of patients with sepsis have a positive blood culture. In these cases, Gram's staining and culture of material from the primary site of infection or infected cutaneous lesions may help establish the microbial etiology.
I hope this helps.
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