[nurse96]

At our facility we used to have a pt come from O.R. to the unit with and epidural already infusing. After a few mishaps (pt not being able to feel legs for a day) we are now starting them only when the pt begins to feel pain and can move the extremity. 99% of the pts I've cared for have out of control pain for the first couple hours until several other drugs (toradol, benadryl, zofran, phenergan...) are given and only then is the pca or the epidural effective. What do you do at your facility? Do you most of your immediate post operative pts have out of control pain?

[meownsmile]

Ours dont, they get medicated in PACU and then after they get to the unit depending on the Doc, we will start a PCA when they start having pain. Surprisingly we dont have a lot of out of control pain with our arthroplasties. I routinely wean off the PCA on day 1,day 2 at most, and try to move the patient to PO pain pills with maybe a Toradol if it is ordered in between. We dont use epidurals at all on our unit. They use them in OR then maybe give a block right before they come back up from PACU,, but no continuous epidurals.
When do they start getting up if you have continuous epidurals? If they arent feeling their legs,, dont you have to wait till at least late on day 1 post-op to get them up?
We routinely get ours up the night of surgery for 30 min,, and they start with PT in the AM and they all seem to do well.

[alichael]

They are usually started in PACU and continue on the ward. We do block heights with our epidural patients. If they have full motor block we reduce the epidural to run at a slower rate. Our patients usually mobilize with the epidural, as long as they can feel their feet/legs etc!! We also have the Acute pain team, who if we strike any problems we can contact, they have a RN and an anethestist. All our patients are on paracetamol 4 hourly (except for those with an allergy or CRF). We also use M-Eslon (a slow release morphine tablet) day 1 to assesst with pain management. cheers

[hollyster]

Have they tried the ON Q? Works great for ortho cases delivers continous local pain meds without reducing mobility, can cause bradycardia in gastric bypasses.

[alichael]

Originally Posted by hollyster

Have they tried the ON Q? Works great for ortho cases delivers continous local pain meds without reducing mobility, can cause bradycardia in gastric bypasses.

What is ON Q????

[hollyster]

Originally Posted by alichael

What is ON Q????

Sorry. The ON Q is a ball that is filled with Marcaine or sensorcaine,lidocaine etc. A very narrow catheter(about the size of a 20 gauge)that is placed into the wound and releases a continous drip of pain medication directly to the site. The pt cannot change or tamper with the On Q ball. Once it is filled by the nurse or MD thats it. The pt's I have taken care of have rarely neede any oral or IV pain meds. They become mobile much quicker. But I have had a thoracotomy pt and a gastric bypass become bradycardic. I stopped the drip and they recovered quickly. So I think it is a great pain management tool.

[mcmike55]

I remember On Q. We used them a lot for a while. The doc used them on shoulders a lot. Seemed to work fine. It was a bit of a pain filling up the ball with Sensorcaine.
We have been using a pain pump from Stryker, I think.
Works the same basic way. On these the anes doc does like a femoral nerve block, but puts in an epidural type cath.
That is hooked to a continuous drip unit filled with a local. The doc sets the flow rate, lock out and bolus amounts. Kind of like a PCA.
The nice thing is the pt goes home with it, in a day or two, the med runs out the pt/family was taught how, and pulls the cath out at home, and the entire she-bang is thrown in the trash.
Mike

[mwbeah]

For the lower extremities, we performed LP/Sciatic blocks which allows the patient to have great pain control and the ability to use the non-affected limb. It is an easy block to perform and the patient only requires sedation for a total knee.

Mike

[PeachyOrthoRN]

For our total knees and hips we use mainly pca's and intrathecals, most are not out of control pain. We do get a lot of people who are on a lot of narcs at home that need a lot of pain meds when in the hospital. For our upper extremties we do use the Stryker pain pump although I think that it is useless as about 95% our patients have no less pain control with it versus without it. At least that is my opinion.

[alyca]

We are a trauma/ortho unit, so no total joints or little ligament repairs, etc. Our planned foot surgery pts lately have come in with peripheral nerve caths of bupivicaine for 1-2 days post-op, especially for calc fractures. They also may or may not get a fem/sci block. In addition, they have a PCA of either MSO4 or dilaudid hooked up, which most don't need until the PNC is turned off. With the PCA, we give a long acting med, usually MSContin. Works great.

For our trauma patients, when they are post-op, they generally get a PCA of dilaudid 0.2mg/8 min/ 6 mg 4 hour limit or MSO4 1mg/8mins with a 30mg 4 hour limit once their pain is stable in PACU, along with MS Contin or methadone as a long acting pain med. Used to give a ton of oxycontin, but insurances have changed and no one covers it, so now we see a lot of MSContin instead. We have a specific pain relief team that is consulted as needed, which is great. They can get pretty creative with their med orders.