Question/Concern about pt and Dilaudid IVP

Agree that it was not the best choice to infuse fluid with KCl through such a small vein.

The doses of Dilaudid given are in line with my experience with patients with pancreatitis, Crohn's, and some other chronic conditions.

You didn't say what other medical problems this patient had, but with pancreatitis I'm willing to bet there is a history of alcoholism or drug abuse. There is crossover tolerance when this is present. I worked on a detox and plenty of medical units that had GI patients and this kind of patient is not uncommon. Pancreatitis is also quite painful. I'm wondering why the doc didn't also include a few tranquilizers as well to calm her down. People who are addicted can tolerate huge amounts of drugs. It would be interesting to follow up on this patient to see how she is doing. If she isn't on a detox protocol, her pain meds will be addressed I am sure. She will most likely get a central line as well. This is all assuming she doesn't go AMA. She can probably get better drugs outside the hospital if she is able to tolerate the pancreatitis. Otherwise, feel sorry for the unit nurses who are going to get stuck with her and her threats 24/7.

I had a cancer patient not on hospice getting 240mg of oxycontin BID scheduled 175mcg patch of fent at home and oxy cont + methadone 10mg QID and PRN Dilaudid 36-42mg PO Q3H and 4mg IV Q3H at one point he was on . and he could not have been more than 150-160....

All I know is if I am ever in that kind of pain, put me on a morphine drip and kiss me goodbye. And he was up walking around.

(My two cents) am on meds daily that artificially elevate my tryglicerides (650) and am now having to add tricor to try and help lower before i develop pancreatitis. one thing that i have noticed that after 8 years on this same med (not a narc) i have developed a wicked tolerance to narcs in general (8mg of morphine ivp no issues and no relief) this last time at my own er doc tried demerrol.. no pain control at all 4mg..then we switched to dilaudid i had 4 about every 40 mins because i would chew through it so fast. so maybe her other meds or liver dysfunction are to blame. ps this pain was due to a bad fall during a hypotensive sycopal episode this last sunday because of taking my daily meds off schedule on an empty stomach and trying to work after....wierd things happen i try to treat every repeater's complaints as though they were new because the first time you miss a triple a thinking oh its her again...i would feel awful...again just my two cents (im wierd i know) ps im just a tech in er... (hopeful ns student this spring)

amazing what kind of tolerance you can build up when you have pain... poor patient.

Me too with the drip, but I'd like for PAS to be legal (wherever I may be living) so I can choose what I want to do to, and avoid having my family see all of that heartache.

We have this lady come in to the ED several times a week with 'pancreatitis'-- {which she has}, the story of-- "I have appts with my specialists next week, I'm a nurse, blah blah blah} who is very similiar to the OP's patient- demanding, threatening legal action--"just push it all in quick, it works better that way, etc"

Nurse, RIGHT.

Anyway. It is true that people with chronic pain and frequent flyers who are drug seekers build up tolerance and require higher doses of narcotics to help with exacerbations of pain

If our docs suspect drug seeking behavior, they're very good at denying requests fro pain meds but NOT talking to the pt to explain why they're not getting their meds--leaving the fortunate ED nurse caring for these individuals in the middle, the recipient of the pt's wrath.

If the Dilaudid was not effective and your doc WAS trying to treat their pain, next time ask if you can try some other med-like Fentanyl if you can. (drug seekers typically are allergic to everything but their preferred brand)

I've put IV's in thumbs when I could find nothing else, for KCL though I think I would have requested the doc put in a central line. Could also be that the dilaudid was leaking out into the tissues surrouding the IV site, could also be why she was having so much pain with the KCL. Pt's with central lines get pain relief faster because it dumps into the system right away. I've never had to have a central line, I have really, really crappy veins and have had to have KCL before and thought I would die, feels like someone keeps poking ya with a hot poker from the fire!

Sounds like maybe a little Ativan and Haldol would have helped with her getting some rest.

I thought I had seen it all until I had a pt come in the other day on PO Dilaudid 8mg. for neuropathy I believe.

Rj

Toradol might have worked better for her pain, sounds like there is some pain med tolerance there also. Sometimes that is quite common with chronic pancreatitis sufferers. I have only given up to 8 mg dilaudid before but that was on a person who had dropped a table on her big toe and it was squashed like a grape. NEVER move heavy furniture while wearing flip-flops.
I did have a patient when I worked on the floor who had broken her legs in a car accident while drunk. When I got report on her from the PACU nurses, they told me they had given her a total of 16 mg dilaudid, 10mg valium, so much Demerol (I can't remember it now), and had finally had anesthesia do a nerve block in her right leg and the patient was still hollering in the background. This was all given in the hour she was in PACU. SHe was a real treat of a patient too when she got to the floor. That is the only patient I ever swore if I saw her outside of the hospital and I was drunk I'd kick her rear-end. But I'm just glad I was not responsible for giving her the 16mg dilaudid.

Try Ativan Next Time, If You Had To Put Her Iv In Her Thumb She May Be A Ivdu Or Substance Abuser Of Some Sort. Ativan Has Been Studied At Sfgh To Relieve Pain. Some Of It May Be Supratentorial And Her Husband May Be A Little Co-dependent As She Does Have A Chronic Disease.