What would you do for post-op pain control?

Here is what we did:

In this patient who had been exposed to narcotics preoperatively, the epidural provided an alternative method to IV narcotics only for postoperative analgesia. The patient was placed on PCEA bupivacaine 0.125% with fentanyl 5mcg/ml (8 cc/hour continuous and 3cc q12 mins PCEA) and resumed her oral regimen. IV PCA Hydromorphone was added due to her NPO status, high opioid tolerance and prevent potential withdrawal. (Fentanyl is a better choice because of its lack of active metabolites and thus potential for systemic toxicity in a patient with ESRD.) Since this patient had been on chronic high-dose narcotics, she was very likely to go into withdrawal if her home dose of baseline narcotic had not been maintained as well as supplemented with additional analgesia for surgical pain.