Intravenous fentanyl patient-controlled analgesia for perioperative treatment of neuropathic/ischaemic pain in haemodialysis patients: a case series

Background and objective: Use of opioids is common in perioperative haemodialysis patients because they often suffer from intractable ischaemic or neuropathic lower extremity pain. Intravenous (IV) fentanyl, patient-controlled analgesia (PCA) does not appear to have been evaluated in this setting; hence this study. Methods and results: This is a prospective, single-centre study. IV fentanyl PCA was used for pain control in 16 patients with lower extremity, neuropathic/ischaemic pain, scheduled for major lower extremity amputation. IV fentanyl PCA was used before and after amputation in eight patients, before but not after amputation in seven patients, and until death in one terminal cancer patient who chose to forgo surgery. Pain intensity was assessed with the Visual Analogue Scale (VAS) and the McGill Pain Questionnaire. Depth of sedation was assessed on a 4-point scale. Ischaemic pain scores were high before fentanyl PCA started, but decreased significantly and remained low with fentanyl PCA use (P < 0 center dot 001). Phantom pain scores were low (VAS < 4). Respiratory depression was not a problem in any patient. Conclusions: Concerns about accumulation of active opioid metabolites make provision of adequate analgesia problematic in haemodialysis patients scheduled for amputation, and emergency surgery. Our data on a small patient population suggest that IV fentanyl PCA is safe and effective for severe pain in haemodialysis patients.