Post-op pain!

  1. Right after we wheel a mother from the OR - c/s with BTL - into recovery, the anesthesiologist deemed it necessary to immediately take out her epidural catheter "because of some sterility breakdown". 15 minutes later the mother was in agony. My preceptor mumbled something about the "stupid doctors", but it was left to me to let the MDs know that her pain scale was 8. Why nobody anticipated this I don't know. I mean, hell, you just cut open a woman, you should expect her to be suffering if you inadvertently had to remove her only source of relief. Finally, they ordered morphine PCA. Meanwhile, no one knew where to get a pump, or even how to work one. Another 15 minutes go by and the mother is now burning up with pain, and I am frantic. I asked if something could be done while we are getting the PCA set up, and finally, one MD tells me I can give her 10 mg morphine SC stat.

    My question is, in your experiences, was this 10 mg SC the right thing for this woman? Bear in mind she has DM and is totally insulin dependent, morbidly obese, and has asthma and cholestasis. I am so torn because I really don't know what the right pain medication for her should have been. I know this was ordered only because I insisted on something being done, but being a stupid newbie, I didn't really know what exactly she should be getting. And because I found the doctors so apathetic, I don't know for sure if they did the right thing.

    Is there anything else one could do for a post c/s pain when the epidural fails?
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  2. 19 Comments

  3. by   NewEastCoastRN
    Didn't she have an IV? She must have if she just a c/s and was ordered for a PCA. Why wasn't IV morphine given?
  4. by   Altalorraine
    Our anesthesiologists always remove the epidural catheter in the OR. The patients either have Duramorph or are ordered for a PCA by the OB (it's the nurse's job to actually call the pain service to get one). Since it takes about an hour for the CSE to wear off, the pain service usually has the PCA set up by the time the patient feels anything. On rare occasions I've had to give IV morphine to tide the patient over.

    Altalorraine
  5. by   JAHJF
    Our CRNA's always remove the epidural catheters before leaving the OR and have "post epidural/spinal anesthesia orders" that they can check off, usually allowing for IV morphine, something for nausea, something for itching and toradol if the morphine doesn't work (these orders are to be followed for 24hrs post op then the OB's PO med orders kick in). We normally only use a morphine PCA when a mom has had a c/s w/general anesthesia.
  6. by   SFCardiacRN
    You are the patient advocate. You are the one to assess the situation. You are the one to inform the MD when standard protocol is not working. It is the MD who decides the treatment to be given. It is your responsibility to re-assess the patient after treatment. Everyone is different and no one treatment works for everyone. As you gain experience, you will learn to anticipate needs better.
  7. by   epiphany
    Thank for you responses. I was not scheduled to circulate to OR yet - I'm still in the labor & delivery training, so it was my first recovery experience. I was just supposed to observe because my actual preceptor did not show up. Anyway, as I understood it, the epidural was not scheduled to be removed - even the MD indicated that. She wasn't even my patient, but I was just panicking because she was in such pain and no one seemed concerned. If I hadn't made a fuss, she would have gotten nothing for a while. I really don't know why they wouldn't give a bolus IV.

    In a way, I have learnt from this because I don't want this to happen to my patient when I start to do recovery. It was not a good thing.
  8. by   SmilingBluEyes
    She should have been receiving IV pain meds to catch up----what about Toradol? Our MDA gives Toradol, 30mg IVP in OR before we leave the OR for the PACU/PT room. Our MDA removes the epidural cath (if there is one----these ladies who have planned c/s have spinals mostly) IN the OR before we transfer the patient to her bed. Usually with duramorh spinals, we see the patient is comfy for hours or even a day or so after surgery. But if there is "breakthrough" pain, we are allowed to use MS PCA PRN to help them.

    So yes, with folks like this, we set them up w/Morphine PCA right away, if any inkling they will have pain is shown----and we give them a bolus of pain med from that as well as another 30 mg Toradol IM immediately on return from OR. This usually does the trick. NEVER heard of using Morphine SC for post op pain control. New to me.

    I feel for this lady--it must have been horrible to be in such pain. I am glad you are so caring. Our patients depend on us to be. Keep fighting that good fight.
  9. by   jwk
    Quote from epiphany
    Thank for you responses. I was not scheduled to circulate to OR yet - I'm still in the labor & delivery training, so it was my first recovery experience. I was just supposed to observe because my actual preceptor did not show up. Anyway, as I understood it, the epidural was not scheduled to be removed - even the MD indicated that. She wasn't even my patient, but I was just panicking because she was in such pain and no one seemed concerned. If I hadn't made a fuss, she would have gotten nothing for a while. I really don't know why they wouldn't give a bolus IV.

    In a way, I have learnt from this because I don't want this to happen to my patient when I start to do recovery. It was not a good thing.
    99% of our CS patients keep their epidurals and get PCEA postop for 24-48 hours. We have standing orders for breakthrough pain.

    Your docs actions don't make sense. If there was a question of "sterility", why did they complete the epidural in the first place? And MS SC? Never heard of it. Since they knew the epidural was coming out, they should have dosed it prior to removing it, given some IV narcs even WITH the epidural, and since I assume they know it takes a while to get a PCA pump, they should have seen to the initial postop pain management by ordering something in the meantime.
  10. by   epiphany
    Quote from SmilingBluEyes
    She should have been receiving IV pain meds to catch up----what about Toradol? Our MDA gives Toradol, 30mg IVP in OR before we leave the OR for the PACU/PT room. Our MDA removes the epidural cath (if there is one----these ladies who have planned c/s have spinals mostly) IN the OR before we transfer the patient to her bed. Usually with duramorh spinals, we see the patient is comfy for hours or even a day or so after surgery. But if there is "breakthrough" pain, we are allowed to use MS PCA PRN to help them.

    So yes, with folks like this, we set them up w/Morphine PCA right away, if any inkling they will have pain is shown----and we give them a bolus of pain med from that as well as another 30 mg Toradol IM immediately on return from OR. This usually does the trick. NEVER heard of using Morphine SC for post op pain control. New to me.

    I feel for this lady--it must have been horrible to be in such pain. I am glad you are so caring. Our patients depend on us to be. Keep fighting that good fight.
    I wonder myself if the Toradol was not used because of pt's hx of asthma.
  11. by   epiphany
    Quote from jwk

    Your docs actions don't make sense. If there was a question of "sterility", why did they complete the epidural in the first place? And MS SC? Never heard of it. Since they knew the epidural was coming out, they should have dosed it prior to removing it, given some IV narcs even WITH the epidural, and since I assume they know it takes a while to get a PCA pump, they should have seen to the initial postop pain management by ordering something in the meantime.
    This is all mystery to me and I intend to get to the bottom of this. As for the PCA pump, it appear to me, no-one's used it frequently to even have one around. It had to be fetched from another floor - and then nurses couldn't even figure out how to use it! oy vey.
  12. by   suzanneuthscsa
    I must confess that I really know nothing professional since I don't start nursing school until next week, but I have a personal experience that is related. When my first baby was born, I had emergency c/s and was put under general. Mind you; liver enzymes through the roof and platelets down to 20,000 (I bled alot) due to severe HELLP syndrome. It was because of the platelets that I was unable to receive an epidural. I can tell you that when I woke up I was in the most HORRIBLE pain anyone can imagine. My liver, my incision, my back (from kidney problems). They prescribed Nubain through a PCA pump. What happened next is truly a sin in my opinion. Several hours after I left recovery, they decided to let me rest. My entire family left to be with the baby (he was 1 lb and not expected to survive). Everyone thought that the nubain and anesthesia would make me sleep. WRONG! Apparently the Nubain has some type of container that has to be opened and mixed (or something like that) and the seal was no good when they put it into the PCA pump. As a result, my pain control was going onto the floor instead of into my arm. I could not reach my call button, and my room was kind of separated from the rest. I cried out for 2 hours until my doctor finally came in on rounds and discovered the problem. I believe by that point I had gone 5 hours from the time that the nubain was put in, and I was white, sweaty, and was bleeding profusely from biting my lips. OUCH! My doctor was FURIOUS :angryfire and I heard her yelling for a good 15 minutes. I know that the nurses were busy and that they were trying to let me rest, but seriously....I had nearly died the night before and they should have monitored me more closely especially since my entire family was at a different hospital with my critically ill baby. It sure is nice to hear when a nurse like you advocates for a patient and recognizes that pain is something that everyone has a right to be as pain-free as medically possible. So watch out for Nubain since nobody seemed at all surprised at this occurence, like it is completely normal for the floor to be anesthetized instead of the patient.
  13. by   jwk
    Quote from suzanneuthscsa
    I must confess that I really know nothing professional since I don't start nursing school until next week, but I have a personal experience that is related. When my first baby was born, I had emergency c/s and was put under general. Mind you; liver enzymes through the roof and platelets down to 20,000 (I bled alot) due to severe HELLP syndrome. It was because of the platelets that I was unable to receive an epidural. I can tell you that when I woke up I was in the most HORRIBLE pain anyone can imagine. My liver, my incision, my back (from kidney problems). They prescribed Nubain through a PCA pump. What happened next is truly a sin in my opinion. Several hours after I left recovery, they decided to let me rest. My entire family left to be with the baby (he was 1 lb and not expected to survive). Everyone thought that the nubain and anesthesia would make me sleep. WRONG! Apparently the Nubain has some type of container that has to be opened and mixed (or something like that) and the seal was no good when they put it into the PCA pump. As a result, my pain control was going onto the floor instead of into my arm. I could not reach my call button, and my room was kind of separated from the rest. I cried out for 2 hours until my doctor finally came in on rounds and discovered the problem. I believe by that point I had gone 5 hours from the time that the nubain was put in, and I was white, sweaty, and was bleeding profusely from biting my lips. OUCH! My doctor was FURIOUS :angryfire and I heard her yelling for a good 15 minutes. I know that the nurses were busy and that they were trying to let me rest, but seriously....I had nearly died the night before and they should have monitored me more closely especially since my entire family was at a different hospital with my critically ill baby. It sure is nice to hear when a nurse like you advocates for a patient and recognizes that pain is something that everyone has a right to be as pain-free as medically possible. So watch out for Nubain since nobody seemed at all surprised at this occurence, like it is completely normal for the floor to be anesthetized instead of the patient.
    1) Why were you not in the ICU?

    2) Never heard of a Nubain PCA.

    3) For the previous post, if they have that much trouble finding a PCA, perhaps they shouldn't be using them.

    4) I'm guessing these are pretty small hospitals/OB units. There's a reason why EVERY hospital in the country should NOT be doing OB.
    Last edit by jwk on Jan 3, '06
  14. by   Spidey's mom
    Last year we talked to the surgery committee and now the CRNA leaves the epidural in so we can have him redose. It is crazy to me to remove the epidural - such a great route for pain relief.

    We also use Toradol and morphine IV.

    Never heard of Nubain except here on allnurses. I have given subq morphine in elderly patients and our hospice patients get morphine or dilaudid subq via a pump.

    steph

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