A 42-year-old male with a history of alcoholism, cocaine abuse and right tibial plateau fracture in January 2011 was treated surgically (plaque-osteothesis with iliac crest graft).
There is a surgical wound infection that ends up generating a right tibial osteomyelitis at 4 months, requiring several surgical interventions for removal of osteosynthetic material, debridement and cleaning.
The patient is admitted from the 4th month and under treatment with intravenous antibiotic of last generation that is administered by central route, and oral route with intravenous morphine 2 tablets of ditraneurine and intravenous bromazepam / 8 / 150 mg tramadol / 8th day.
At the 8th month of evolution of the process interconsultation to the Pain Unit for poor pain control.
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When assessing the patient, she was in a depressed mood and unbearable pain, with 8 on the visual analogue scale (VAS 8), of the neuropatic type -burning and waking up right lower limb - intense night rest
At this time, the patient also presented fever peaks up to 39 oC recorded in the nursing chart, with no organic repercussions.
The management of the pain treatment of this patient was simple at first, because he presented mainly neuropatic pain.
On our part, we plan to phase out distraneurine and bromazepan.
The patient was switched from intravenous analgesia to oral administration, achieving a decrease in symptoms: increasing the number of associated antineuropathy (mi): pregabalin (up to 150 mg-0150 mg).
Establishing a fixed dose of morphine and switching to opioids intravenously at equianalgesic doses with morphine (10-0-10 mg) and paracetamol 1 g/8 h, with occasional rescues mg with opioids .
On the fourth day of follow-up, the patient presented with severe stupor at night and the next day, without responding to stimuli or obeying orders.
After ruling out exogenous opioid consumption, the total dose of opioid was reduced to MST® 10-0-10 and A extended to bed and occasionally to rescue 100 mg (needing at the beginning of treatment one before and not before).
On the fifth day, the patient presented with significant psychomotor agitation, incoherence in language and disconnection with the environment, compatible with the diagnosis of withdrawal syndrome.
We are forced to make a differential diagnosis.
Once the metabolic origin of the confusional state (normal analytical) was ruled out, due to the consultation-liaison psychiatry patient, neither the interpatient dose nor the opioid profile is considered negative for some substances and toxic for us due to a possible abuse (AU)
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The psychiatrist's diagnostic impression was polymedication, especially opioids, and suggested a short half-life benzodiazepine to control psychomotor agitation (alprazolam 4 mg v.o. progressively regressing 8 h later).
In this respect, as the opioid had already decreased, no other measures were taken.
As for pain control, in the following 15 days, antineuropathic treatment was very effective, except for a persistence of pain in the form of "pinchazos", which required a gradual increase in amitriptyline (1.2 mg at night).
This measure achieved a VAS2, with significant improvement in nighttime rest and mood.
In addition, the patient no longer needs rescues, as already mentioned.
For this reason, we could have raised the decrease in opioid medication, but the patient continued to present behavioral and level alterations of consciousness-related that went from stupor to agitation-dislocated opioid-dislocating with self-re.
It is insisted that all the prescribed medication must be administered and the total dose of opioid (MST® 10-0-10 and A. abortus® 100 mg of abstinence) must be maintained to avoid recurrence of possible syndromes
Although the patient had feverish peaks, infectologists who followed the patient did not consider that fever or other possible complication resulting from osteomyelitis, such as endocarditis or brain abscess, were responsible for the development of the disease.
As it seemed unlikely that an organic seizure related to opioid follow-up would lead to a confusional syndrome affecting this patient for more than 2 weeks, pid TACne was ruled out.
Cranial CT showed a subacute right parietal cerebral infarction.
