ACDF Anesthesia Techniques and PACU Pain Management-

SubSippi · Aug 27, 2015

I don't work in a PACU and have never had a patient with that sort of procedure. I'm in a CVICU, and recover thoracic, vascular, and trauma surgeries, and open hearts.

Do you ever give PO oxycodone when you can't manage the pain with fentanyl? Even though it takes a few minutes to kick in, I've found that 15 of oxy seems to be better at taking the edge off than high doses of fentanyl. I'm sorry if that sounds way too obvious, I just thought I'd mention it because I know in my unit we sometimes tend to forget about PO pain meds immediately post-op.

Also, could you get the surgeon to order a fentanyl patch to be put on before the procedure? Although it takes several hours to reach its full effect, it could help.

My favorite pain med is Toradol. Unfortunately, we can't give it to open hearts (black box warning), but I have found it to be EXTREMELY effective at managing post-op pain. I have seen patients go from writhing in pain to feeling like they could run around the block, which is something I never see with fentanyl. I was given Toradol after I had some ovarian cysts burst (they were extremely painful, when I moved it hurt so badly that it knocked the breath out of me) and the pain completely disappeared within minutes. So I'm a big believer!

What pain meds are you using, other than fentanyl?

Nurse_Ratched · Aug 27, 2015

Thanks SubSippi. Besides Fentanyl, we can give Dilaudid, Morphine, Robaxin, Phenergan as an adjunct, and Toradol (only with the surgeon's okay - Neurosurg usually stays away from it due to bleeding risks occluding the airway, certain OB-GYNs also refuse to give it for several hours post-op). PO Oxycodone can be tricky with these patients because usually they're on it at home and "it doesn't work anyway for me". Sometimes, pre-op will give it, depending on the surgeon's orders (a typical ortho cocktail may be Oxy, Celebrex, and a controlled-release narcotic). The Fentanyl patch is not a bad idea but may be hard to titrate. I, too, love Toradol, but many surgeons do not.

azhiker96, BSN, RN · Aug 28, 2015

When you have a patient who will have a lot of pain, anesthesia needs to medicate well during the case. Otherwise you will be playing catch up for awhile. I work with burn patients, heroin addicts, trauma patients, spinal fusion, and other surgical patients. These patients either have a lot of pain, are resistant to narcotics, or sometimes both.

It is not uncommon for me to get a patient who had 250 mcg fentanyl, 2 mg Dilaudid, and 4 mg morphine during a case. On some patients anesthesia will also add ketamine to help with postop pain.

Occasionally anesthesia will do a great job premedicating and I need to give little to no narcotics. I always complement them when this happens. I like to encourage that kind of behavior.

Sometimes they can't safely give enough narcotics during the case and then I have to give a lot to catch up. What is a lot? One particular pt comes to mind. She received 500 mcg fent and 2 mg dilaudid during the case. I gave another 500 mcg of fent, 25 mg demerol, 6 mg dilaudid, 20 mg morphine, and 12.5 mg phenergan. She still reported 7/10 pain but I had to put O2 2L NC on to maintain sats when she would doze off. Oxygenation comes first.

Nurse_Ratched · Aug 30, 2015

Thanks, azhiker96. Lately I'm finding more and more of these cases coming out with absolutely no Dilaudid or anything else long-acting on board. Our CRNAs tend to run them on a Remifentantil drip and give additional Fentanyl and Ketamine if they see changes in the vital signs. The Neurosurgeon will write for Robaxin 750mg TID and we can give the first dose in PACU if needed, but again, the point is, like you said, we're playing catch up at that point.

I do agree with you though, ABCs come first for sure. But I'm between a rock and a hard place when the patient has had close to 500-600mcg Fentanyl and 2-3mg Dilaudid total (OR and PACU) and is still writhing in pain, to the point where I don't even know if I can get them through the post op CT without getting crappy images.

RainMom · Aug 30, 2015

Interesting. I'll have to pay more attention to how anesthesia medicates our ACDF pts. It is usually the pts with the posterior approach that have more pain & our TLIF pts are the ones with the severest pain, crying & rolling side to side. The ACDFs don't usually have significant pain for us.

Thinking about my last ACDF, he had received 0.6mg dilaudid & 100 mcg fentanyl in OR. His primary complaint for me was the hard collar putting pressure & causing pain to the back of his neck. Readjusted the collar, raised the HOB & 1mg of dilaudid took care of it.

Our total joints often get oxycontin & lyrica preop (which works well) but I don't recall seeing that the spines are premedicated.

TheGooch · Aug 31, 2015

I had a 2 level ACDF and hardly any pain after the procedure. I was on Norco and valium while in the hospital and it continued when I was home. That was the only pain meds that my NS prescribed. I only had one incident in the hospital where I asked for my pain med earlier(which the nurse refused) In PACU I asked for some but I wasn't rolling around in pain like your patients.

All in all the pain BEFORE the surgery was a lot worse. NOTHING helped that and I was in excruciating pain for several months before the surgery.

Nurse_Ratched · Aug 31, 2015

I hope I'm not coming off as calloused when I say "rolling around in pain", while many ACDF patients were previously chronic pain patients, I am not trying to say they are faking their post-op symptoms. Coming out of anesthesia after a procedure that lasts several hours, I honestly don't think they have much energy left to do anything but remember to breathe and try to wake up. I don't doubt that their post-op pain is very real, I just don't understand why more long-acting narcotics are not given during the case.

TheGooch · Sep 3, 2015

I hope I'm not coming off as calloused when I say "rolling around in pain", while many ACDF patients were previously chronic pain patients, I am not trying to say they are faking their post-op symptoms. Coming out of anesthesia after a procedure that lasts several hours, I honestly don't think they have much energy left to do anything but remember to breathe and try to wake up. I don't doubt that their post-op pain is very real, I just don't understand why more long-acting narcotics are not given during the case.

I think it's because of the fact that most ACDF patients have been on pain killers for so long that they have built up a tolerance to the meds. So they might need a higher dosage of pain meds. Most surgeons want ACDF patients to try conservative treatments like PT ans epidural injections before surgery so they've probably built up a tolerance to them.

My procedure was about 4 hours for a 2 level ACDF,

Nurse_Ratched · Sep 3, 2015

I think it's because of the fact that most ACDF patients have been on pain killers for so long that they have built up a tolerance to the meds. So they might need a higher dosage of pain meds. ,

Exactly! All the more reason that long-acting narcotics should be given intra-op, instead of having the PACU nurse playing catch-up.

OC_An Khe · Sep 6, 2015

Long acting narcotics in these patients is very useful. Particularly if they are chronic pain patients and routinely take opiates daily on a routine basis, you need to "catch them up" to their daily opiate level before you can get effective pain relief post op.

offlabel · Dec 23, 2015

What patients bring to the OR in terms of chronic pain determines analgesic strategy for anesthesia. Patient's having an ACDF don't necessarily bring chronic pain. They do hurt though, and good anesthesia plan involves adequate analgesia into the immediate post operative period. A lousy plan doesn't.

Any patient with chronic pain will be a challenge to get/keep comfortable and be dischargeable from pacu. A patient in a coma is comfy, but has to stay in the PACU.