[my2sons]

What are y'all using for post-op pain control? All I've got are MS 2mg IV Q 1h PRN while on ventilator, Demerol 75mg/Phenergan IM Q 3h PRN, Vicodin when taking PO. This makes it tough to medicate for pain when they are newly extubated (hesitant to give the vicodin on an empty belly with no bowel sounds.) Not liking the Demerol, I've had 2 patients in the last 3 weeks go crazy on me! One tried to choke me with his chest tubes. What does everybody else use?

[ZASHAGALKA]

Toradol IV takes the edge off and allows a touch of morphine or demerol IM to work.

At first, the docs were afraid to use it due to it being an NSAID and bleeding risks in fresh post op pts - but more and more it is being realized that risk is small compared to the benefit.

Diprivan while on the vent is almost a mainstay where I work.

And then there is Precedex for the first several hours off the vent, but my hospital rarely uses it. Shame, though. Precedex works like diprivan but stimulates natural sleep and can be used from before extubation through to several hours after extubation.

(Edit: I'm sorry, my CVICU is a mixed unit, we don't use diprivan or precedex on routine CV pts - only if they don't extubate the first day. I was thinking post op pts more globally than just CV.)

Sometimes the paradoxical reaction can be to the phenergan. An alternative in pts that show those symptoms would be to give demerol IM and then zofran IV instead of the phenergan. Of course, you don't get the synergistic affect from zofran that you would w/ phenergan, but combined w/ toradol, might not be needed.

Just a few ideas, maybe someone else has more input.

~faith,
Timothy.

[bj76302]

We use Morphine liberally up to usually 5-8 mg IV q 1 until pt is extubated. And also use Toradol initial dose of 60 and then 30 mg q 6 x 6 doses only. And toradol of course is contraindicated in diabetics and creatinine greater than 2.

[pricklypear]

We use Fentanyl drips before extubation, sometimes leaving the drip on at lower doses after extubation. We use MS usually after extubation, then percocet or darvon for po meds - don't think we routinely use hydrocodone anymore. Our surgeon is encouraging the nurses to use less IV MS after extubation - he thinks we are over sedating. We also use Toradol on patients who have well functioning kidneys - it works really well.

[chaosRN]

We use morphine 2-4mg Q2 hrs, Percocet when off vent & tolerating po, if morphine doesn't work, dilaudid 1-2mg Q4-6 hrs.

[hrtprncss]

We use MS 1-2 mg q 1-2/h prn(while intubated). Then Toradol. Then when patient is taking po, we switch to Vicodin 1-2 tab q 4-6/h prn or T3 1-2 tab q 6h prn. These are for post op CV patients.

[dorimar]

We are much more liberal wlith the morphine... 2-10 mg Q1-2 H prn.Some of our docs use fentanyl IV. Also, we use propofol while tubed. I've seen poor results with precedex causing hypotension & poor analgesic/anti-anxiety results. Toradol can cause bleeding and, if prolonged use, psychosis, and of coarse it is nephrtoxic. The main thing is not to oversedate for early extubation.

[my2sons]

Why is toradol contraindicated for diabetics? First time I heard of this.

[zambezi]

for our post op hearts we use:

fentanyl drip and propofol while on the vent.

After extubation:
MS 2-4 mg IV Q1 hour (we can give more if necessary, after other options)
MS 2-12 mg IM Q3 hours
Toradol 30mg IV Q6 x3 doses
Percocet 1-2 Q4
Vicodan 1-2 Q4
Darvocet 1-2 Q4
Demerol if they are allergic to MS
Oxycontin 10 or 20 mg BID (doc has to selectively check this- the rest are standing orders)

Usually, I crush 2 percs just before extubation and put it down the NG before I pull it...even with minimal BS...I haven't had any problems with N/V lately...If the patient meets the parameters for toradol (<70, no allergy to NSAIDS, peptic ulcer disease, creatinine <1.2) I give toradol while weaning. I use the IV MS to cover patient until they can take PO pills without difficulty. If they are really painful, I give the IM MS and cover with IV MS until the percs and IM MS kick in or until pain is toleable and patient comfortable.

We can choose between percs, vicodin, darvocet, tylenol as needed per patient presentation...I find that we have pretty good flexibility with these options and if we need something else we can just call for it...

For N/V we can use inapsine or zofran (and phenergan might be on there too, but I can't seem to remember right now.

[AlexCCRN]

What do we use? All drug doses are determined by patient weight. Unless you're caring for gerbils, the doses you mention are insufficient. Compensating by allowing more frequent dosing is a cop out. Furthermore, Demerol is bad pharmacy except for post op rigors. Advocating for appropriate pain management can be frustrating but, it's our role. Sounds like your prescribers are following a rule that's designed to minimize their risk exposure and insurance expense.