Pain Management in NUSS/Pectus Repair

[corbinRN]

Hello! I work in pediatrics and our surgeons currently place pt's on a Morphine PCA and then POD#1 transition to PO analgesics with Oxycontin BID and Norco 1-2 tabs Q4H PRN.

However, the surgeons expect the nurses to administer the pain medications ATC regardless if the pt is sleeping. It is against our hospital policy to administer PRN medications without any indication to do so (signs of pain/pt reported pain).

I suggested them to schedule the Norco for POD#1 and re-evaluate the pt's pain after that to determine if it's time to go PRN, but they said that they couldn't do that because some pts will require 1 tab while others will require 2 and some can go 6 hrs without pain medication, etc.

So then I suggested them ordering Norco 1 tab Q4H scheduled with Norco 1 tab Q4H PRN. That way we could adequately control their pain while not administering PRN medications by proxy (against hospital policy).

Question: What do your hospitals do with post-op NUSS procedures or other procedures?

TIA!

[Tzs1981rn]

We recently started to use thoracic epidurals with a basal and patient control dose using fentanyl and ropivicaine for our pectus repairs. In addition, they also have scheduled iv toradol alternating with onfirmev (they get one or the other every 3 hours) for the first 24 hours. This provides awesome pain management and has greatly decreased the need for additional narcotics, and has resulted in increased mobility.

[nicoled787]

PCA first day is a must, with scheduled Toradol and intermittent Oxy until discharge. Even if it is not "policy" to wake a patient for a PRN, it is important to use your judgment. Talk with the patient before they fall asleep and ask them their preference. Additionally, schedule any narcotics around times you would normally enter the room (morning labs, vital sign checks, etc), as these are moments the patient will probably awake anyway. I have had amazing success by making a plan with the patient and parents prior to them falling asleep, and most end up agreeing with waking up to receive their medication, as usually, it does not produce a huge disturbance in sleep if the medication has its effect!