Narcan?

[Antikigirl, ASN, RN]

So I had a pt that was post op came at 1830, heavier pt older... They came to the floor sound asleep, and only had 0.9mg of dilaudid in post op. We had a PCA set up for 0.3mg dilaudid PCA only (basal rate of 0.2 after 2200). Pt was on 3 L/min O2 to keep sats above 94%, and otherwise just sedated.

Pts color started to look bad, and the pt had to be laying flat for 48 hours. I discussed this with my charge nurse and we voted to do a log roll and keep flat with pillows because pt was snoring so badly pts sats were dropping. Also, I removed the lower dentures that were hindering the airway. Color improved immedately, and I kept coming in every few minutes to check vs and 02 sats. During a snore it was 75%, then after 97%. I spoke with a RT who was doing things on our floor and she found that to be normal for pts that snore and the pt should seek advice about sleep apnea, which I told the daughter and spouse who were in the room. (Patients resps remained constant at 18).

Pts VS were stable, pt was just sedate. I took the PCA button away from pt, which I noted was pressed twice for 0.6mg dilaudid when the pt first was to the floor and more alert..but that knocked them out. I called the MD who wasn't too thrilled with me for calling without an emergency happening (I wanted to know what he would like me to do about the sedation level..and he agreed with the button being held, and no basal rate which I had suggested...but other than that just monitor vs!).

Patient remained stable but sedate...and this was post recovery hour 3, and my change of shift. I alerted the next RN of the probelms and what I had done and what the MD had said and that we are to monitor pt closely. And also I had heard from the spouse that pt is overly senstitive to any IV medications, and this was not new for pt to be this sedated, and suggested that we switch to PO pain meds ASAP and DC those IV meds.

SO as soon as I left, I guess the next shift tweeked and narcan was given times two and pt awoke in serious pain. (I forgot to tell the RN about another pts fever that was controlled and needed to be followed up on so I called the moment I got home and found out about this).

Now...do you feel the use of narcan was vital? VS were stable, it was midnight when they gave and woke the pt in pain. AND now what are we going to use for pain meds till the narcan wears off? Was this really necessary or couldn't the pt just be monitored and sleep the meds off (which was my trend...I was watching the pt carefully and ready with narcan if probelms started, and was also alert enough to warn admin that if needed I may have to transfer pt to a tele floor for continous pulse ox).

When I called the MD, we didn't even go there on narcan...I wonder why all the sudden! I asked the RN and she said vs were still stable but the sedation level was too much and she couldn't get an accurate assessment done! Okay so who was the narcan for the RN or the PT?

THoughts???? (I am open to comments, I want to learn from this one...I felt narcan was out of line at midnight and considering there was no set plan for pain management afterwards!).

[nuangel1, BSN, RN]

if he remained with stable vs and sat's but sedate i would not have given the narcan .however if rr was low

[PANurseRN1]

The only times I ever gave Narcan were for true resp. depression or for heroin ODs. This sounds like it was unnecessary if the pt's resp. status was not compromised.

[Antikigirl, ASN, RN]

Thanks! Our protocol is to give narcan if resps fall below 12, but pt never got near that thankfully. Bi pap was considered but the MD didn't order it during my shift (I suggested it and an RT consult).

Due to the fact the pts resps were stable, and vs stable..I didn't see the reason for narcan. Thanks!

[Medic/Nurse, BSN, RN]

I don't know how VITAL the narcan was, but I tend to be very deliberate with reversal agents including narcan. There are risks to narcan, too.

If this patient was having marked desaturation and I am having limited success at arousal and/or the patient becomes so sedate that they cannot protect their airway - I'd tend to consider it.

But, bear in mind that the effects of narcan are short and would require repeated doses in most cases. The fact that this "dosing" brought this patient out of their "sedation" and negated all pain control makes me think more than one dose or high dose (some give 0.4 mg some do 2 mg) may have been given or the patient still had limited narcotic left in their system - so then I would wonder WHAT made reversal necessary to the nurse that followed you. The fact that RR was sufficient and sat's remained > than 96% would make me question the need. The fact that the patient was post-op and it was nighttime would make me reluctant to wake 'em up. Like you I'd have watched close, but...

Dilaudid IV "peaks" 20-45 minuted following dose, so I'd wonder how long it had been since the last dose AND what is the patient presentation? These would be key in any decision to use a reversal agent.

I have seen very rare cases where dilaudid causes immediate severe respiratory depression and then reversal is more urgent.

ANY time reversal is necessary (especially with a prolonged time between narcotic administration and need for reversal agent) the patient should be very closely monitored for the next 2-6 hours.

Hope this helps. I don't think you were wrong - but, like everything else in nursing...practices differ. So...

Good LUCK and Practice SAFE!

[Antikigirl, ASN, RN]

Awesome! Thanks! I said the same thing to my hubby (Paramedic) once I found out what the other RN had done...that it was my clinical opinion not to...and hers to for some reason...so nursing differed there.

I don't necessarily find fault in what she did because I wasnt there...however, the noc shift has been very angry lately and has been writing me up for any little happening they find in the wrong...so I am sure I will have to defend myself against this one. I want my ducks in a row, and feel that I was in my rights to not use it at that time. And I documented like crazy too! LOL! (I am good at CYA).

I dont' know what is up with noc shift lately...they seem to have a huge chip on their shoulders and angry. I wish I could help them be more positive in their work place, but instead I guess I am seen as a meddler in their clique if I try, and are certainly telling me my nursing skills and sugestions are not wanted...that is so disappointing! We don't have these probelms in day or swing, and we communicate together wonderfully!

Oh well...I felt my clincial judgement was just fine, and will defend it...just helps to hear others agree (or even disagree and say why so I can learn more...I learn daily!) so I can face things logically!

[meownsmile, BSN, RN]

I think a decrease in the PCA would have been prudent, along with strict instructions to the patients family NOT to use the PCA button FOR the patient. I dont know that narcan was necissary if the vitals were ok and it was only sats that were questionable. If the patient truely was not arousable even through a turn it could be that they were boardering on overdose, but thats a call only the RN standing at the bedside can make.

I remember when i had my open chole, they put me on a PCA and i lost the whole next day. Stable but out in lala land someplace.

[Rio, ASN, RN]

triage34 ! how are you dear ? have not chatted with you for awhile...

how old was patient and what was patient weight ? I don't think, IMO, that narcan was indicated.

I believe that 1 mg Dilaudid is about equivalant to 10 mg morphine.. give or take.. I haven't dealt with a PCA in about 12 years , so I can't give an op on the PCA gig... but it's the PATIENT and ONLY the PATIENT that is triggering the dose..

there fore I would expect the patient to become alert enough to self administer or hit the call button to find out where's the 'relief' ?

Just curious but were there orders for breakthrough pain ? not that they were nessecary...

take care ..

[GatorRN]

If the pts RR was >12, and his sats and BP were holding steady, I see no reason why your relief nurse felt the need to give Narcan. Particularly if the pt was just 3-4 hrs post op. They were probably still feeling the effects from the anesthesia at that point as well. It's not unusual for pts to be sedated for many hrs post op, as I'm sure you know. From what you've described, the pt sounds to me like they were stable. Under those conditions, I wouldn't have given the Narcan, and continued to monitor closely, especially with it being midnight. Of course, I wasn't at the bedside, there may have been other factors that influenced the nurses decision to do so.

[P_RN, ADN, RN]

I wonder if the night shift nurse perhaps felt a bit "guilty" maybe for getting to the patient later than she had planned.

Given you probably reported at 11p, maybe after she got her whole report it was say 12 or 1215? Do you think maybe that was so?

What if she gave the naloxone because her patient was still "out" an hour or so after you saw him.......just supposition here.

[morte, LPN, LVN]

triage.....have you read any of the threads on "mobbing".......................

if the nurse who gave the narcan didnt document a worsening in vs (a marked worsening!) there would seem to be no need for narcan.....and especially to repeat it........ i would wonder if it were done in an attempt to make me look bad, if i were you..................

[P_RN, ADN, RN]

Good suggestion morte. It's been known to happen to the best of us.

Also I was wondering why was the patient lying flat for 48h?