LN is 84 YOM who is in hospital for a back surgery. His height is 5 feet and 4 inches, weight 85 kg and
NKDA.
His past medical history includes hypertension, diabetes mellitus, major depression, hypothyroidism and
chronic back pain. Post-op day 1, LN’s medication includes Dexamethasone 8mg iv q6h with taper dosing,
Ondansetron 4mg iv q6h prn for N/V, Levothyroxine 0.075mg po daily, Lisinopril 10mg po daily, Citalopram
20mg po daily, Docusate sodium / Senna 1 tab po twice a day, Bisacodyl 10mg suppository daily prn for
constipation, Famotidine 20 mg iv q12hr, Metoclopramide 10mg iv q6h, Metformin 500mg po bid, D51/2NS
with 20K at 125 mls/hour and Hydromorphone PCA at 0.2 mg/hour of basal rate, demand dose 0.1mg. lockout every 6min, one hour limit 2.2mg/hour. Pertinent morning labs includes serum creatinine 1.4mg/dl, Mg
1.5mg/dl, K 5.0mmol/L, Na 135mmol/L. Day 3 post-operation LN’s pain was much better and only used 3
mg of hydromorphone in the 24hrs.
Physician wants to change to oral morphine. What would be your best recommendation?