[BRANDY LPN]

My 9y/o son was d/c'd today after having an appy done Sunday night. I don't believe they treated his pain appropriately and was wondering what you guys see for orders after an appendectomy.

The doc ordered Demerol 25-50 Q4 *IM*, or APAP po, and phenergan PR, and refused to give ANY meds IV even though he had an IV. GRRR

Is this normal or does this surgeon REALLY need some pediatric pain managment classes?

[Jolie]

I'm not sure what's done on the peds floors these days, but if he had been an infant in the NICU, he most definitely would have received IV pain medication, probably morphine or fentanyl.

Hope he's feeling much better!

[Jolie]

Was your son's surgery was done by a general surgeon in a local hospital, where peds cases are fairly rare?

I can't imagine an experienced pediatric practitioner expecting a young child to endure multiple IM injections.

Again, hope he's feeling better!

[BRANDY LPN]

Originally Posted by Jolie

Was your son's surgery was done by a general surgeon in a local hospital, where peds cases are fairly rare?

I can't imagine an experienced pediatric practitioner expecting a young child to endure multiple IM injections.

Again, hope he's feeling better!

No it was in a fairly large hospital, with a busy peds floor,but he was a general surgeon, the nurses commented several times that this surgeon and one other are the only ones who do this. As for the injections, he got one while in recovery and one the next am, after that he refused to take them.

He did eventually order some darvocet po *after* I confronted him about the lack of pain management and mentioned "standard of care" a few times in the convo. The bad thing was I was just basically bluffing I have no idea what stand of care is in peds lol, and if he had confronted me I wouldn't have known what to say. He said to me at one point "well what do you give him at home for pain?" me: "uh tylenol and motrin, but I generally dont cut his belly open either"

[ButterflyRN04]

Originally Posted by BRANDY LPN

No it was in a fairly large hospital, with a busy peds floor,but he was a general surgeon, the nurses commented several times that this surgeon and one other are the only ones who do this. As for the injections, he got one while in recovery and one the next am, after that he refused to take them.

He did eventually order some darvocet po *after* I confronted him about the lack of pain management and mentioned "standard of care" a few times in the convo. The bad thing was I was just basically bluffing I have no idea what stand of care is in peds lol, and if he had confronted me I wouldn't have known what to say. He said to me at one point "well what do you give him at home for pain?" me: "uh tylenol and motrin, but I generally dont cut his belly open either"

Absolutely Not! What kind of pediatric floor is this. There is absolutely no IM's in pediatrics unless it cannot be avoided ESPECIALLY id the patient has IV access. I have been working pediatrics for one year and when I see orders for IM pain meds I call the doctor and explain that this is a pediatric floor and we do not give IM pain meds, it defeats the purpose. I had one doctor tell me that he wasn't going to order anything IV because IM worked much better and I told he was going to have to come and administer it because I refused. He eventually gave in. Those nurses are not patient advocates and should not be working with children. Typically what I see ordered is Morphine every 2 to 3 hours IV when needed, Zofran IV and sometimes either tylenol with codeine if they dont want the morphine or regular tylenol every 4 hours around the clock for thar first post-op day. I'm sorry your child had to go through that, if he was my patient he would have never even had that first phnergan IM. We don't even draw blood or start IV's on our florr without first using a topical anesthetic on the skin.

[z's playa]

I've often wondered why some doctors give IM when access to an IV is available. The answer I always get is "Well it lasts longer this way." I seriously never experienced better pain relief this way. I don't know why but I never did. Maybe because they kept the dose the same ...50 IV...50 IM. Dunno.

I hope your son is doing better. Pain management is a touchy/contraversial subject and isn't dressed at our schol as much as I'd like it to be.

Z

[capgirl]

We are a large teaching hospital. We usually have orders for Morphine IV, Tylenol 3 or regular Tylenol for pain post-op. I can't even remember the last time I gave an IM to a peds patient. Also, I haven't seen any orders for Demerol in years. If Morphine isn't ordered, then fentanyl is instead.

The issue I sometimes see is that the Morphine is ordered at too long an interval, such as q 4 hours. The effectiveness decreases after 2 hours.

"Standard of Care" - glad those words worked for you!!

[*PICURN*]

wow i can't believe he was ordering for IM injections.....ESPECIALLY if your child had IV access!!!!!!

[traumaRUs]

I would definitely write a letter to patient relations expressing your dissatisfaction with this situation. This is horrible.

[mydesygn]

I've been a pediatric nurse for 14 years working in a dedicated pediatric facility. In those 14 years, I have probably given less than 5 IM injections and 3 of those were in ER for children going home. It is absolutely unacceptable to give a child IM pain medication after surgery when there is a IV available (typically Morphine IV is given with a range dosing based on weight, ex: Morphine 2-4 mg for severe pain prn, Morphine 1 mg for pain prn) and often the next day depending on level of pain, an oral pain med will be added such as Tylenol with Codeine q 4-6 in and the IV morphine would be d/c. Even if you lost the IV, we would have started oral pain med. IM pain med would be an absolute last resort. Even as an adult, I would not accept IM pain med for post-surgical pain. Also, I have seen Demerol used only if the patient is allergic to Morphine, Demerol is not a good first choice for pediatric patients due to some of it's side effects.