Question of the Week

For March 20, 2018

A 69-year-old woman with pancreatic cancer that has metastasized to the liver is admitted for abdominal pain, vomiting, and volume depletion. Her pain is located mainly in the midepigastric region and radiates to the back. At home, she has been taking morphine 15 mg every 4 hours by mouth, but she still rates her pain at 7 on a scale of 0 to 10. The current hospitalization is her third in the past month.

On examination, she is tender to palpation in the midepigastric region. Her abdomen is otherwise soft with normal bowel sounds.

Laboratory testing reveals a total bilirubin level of 1.2 mg/dL (reference range, 0.3–1.0) and a serum creatinine level of 2.8 mg/dL (0.6–1.1).

What is the most appropriate next step for managing this patient’s pain?

Initiate patient-controlled analgesia with intravenous hydromorphone
Increase the dosing and frequency of immediate-release oral morphine
Start intravenous morphine boluses as needed
Add a fentanyl transdermal patch and continue immediate-release oral morphine
Consult pain medicine service for a celiac-plexus block