Another pain thread

I agree amnesia is not enough. My son had a severely broken leg and they tried to do a closed reduction using versed but we were in the room and he was in absolute agony. I am glad he does not remember it but I still dont think he should have had to feel it in the first place.

I am all for pain control but I was wondering how safe it would be to give narcs when you have a pt you are doing conscious sedation on? I know when I worked ER we did alot of bone setting under c sedation and the pts were in pain a lot of the time but there resp were sometimes pretty low already. We were always ready to reverse but if we put narcs in on top of that, mights make it harder?? Erin

In my experience, we usually give a cocktail of Versed and Fentanyl. Works pretty well. Then as the anesthesia resolves, you can treat pain with narcs, ideally in a controlled, monitored environment such as PACU.

Originally posted by DelightNP

In my experience, we usually give a cocktail of Versed and Fentanyl. Works pretty well. Then as the anesthesia resolves, you can treat pain with narcs, ideally in a controlled, monitored environment such as PACU.

Delight

That is what we used also. Sometimes the pt would scream out when we pulled the joint or bone into place so I know it was painful. They never had any recollection once the sedation wore off and we did have several who dumped their vitals pretty low..I am not sure narcs would have been a safe way to go, what do you think? Erin

Erin,

I don't think so. I agree that pain control is important, and pain is often undertreated, but I wouldn't want to go so far as to make the patient hypotensive and bradypneic.

I've seen more than one patient treated a bit too agressively with narcs and need Narcan. Now that's a rude awakening.

Its a balance between comfort and safety.

Delight

That is how I feel also. I hate to see people in agony even if they don't remember it..we used to set wrists using a bucket filled with cement and an IV pole to pull the joint into place and it reminded me of toture!! I was right there when they started to come out of it with pain meds if they needed them and their vitals supported giving them to the pt. C sedation always made me a little nervous since usually when the pt crashed it was quick. I would not have to battle MS or the like on top of the Fent and Versed...:) Erin

Precisely, Erin. I'd rather have a patient express a bit of pain than have a RR of 4.

Wow your poor son! I have had broken arm and a broken wrist, separate incidents, in that last two years. For my arm they offered me nothing and I toughed it out. For the wrist it was very different and extremely painful.

Poor guy,

renerian:eek:

I personally have not done a lot of conscious sedation. However, when I have seen it done or have known someone else to have done it a narc (usually fentenal)was always given with the versed.

I have see a lot of people AFTER conscious sedation and the amnesia effect is often not very good.

For instance as a student the first time I saw conscious sedation the pt was given a narc with the versed. The next day I talked to the patient. He did no remember who was in the room but he kept talking about how bad the pain was all though the procedure. The pain was the one thing that stood out in his memory the best.

Versed's effect is far from complete and often the very thing we want to block using it is the thing that is not blocked. I would not bet on it doing its job, as I would wish.

As far as pain vs memory of pain. Failing to treat pain because it presumably will not be recalled is like saying if a tree fell in the forest and no one saw it happen then it never happend. Rediculous. It happened. If no one witnessed Chernoble it still happed and still has a lasting effect.

I truly believe weather it is versed or another agent used in sugrery we underestimate the awareness of patients. Generally we do not get feedback or much feedback about what a patient knew or remembers. We are assuming they don't remember. The fact is I and patients who have talked to me on the subject were assumed to be "out of it" or unaware when we were not. These were facts not revealed nor relayed to the persons present during the procedure.

My only problem with conscious sedation is with the docs. They want you to push the medication so quickly. I like to titrate it a little at a time so I don't overdo it and don't underdo it either. I have had doctors stop me from treating pain when a patient has had versed saying that they wouldnt remember it anyway. There is a thin line in conscious sedation, you don't usually realize youve crossed the line until after the procedure (usually reducing a fracture, thereby relieving the pain) is over and your patient's respirations drop to 8 and BP is in the gutter. I've had to give narcan, never given romazicon to reverse. Never had to intubate anyone either. I really wish that more local anesthesia could be used, but it would cause local swelling and make it harder to reduce the fracture. One hospital here in town uses nitrous for procedures like suturing children, I have never tried that, no hospital Ive ever worked in used it in the ED.

In my ER we have a Ketamine protocol for peds so the doc can set bones and suture as needed. Ketamine seems to maintain resp and gag reflex, etc better than other conscious sedation meds. The patient still needs a bit of analgesia, but the ketamine works fantastic for about 15 minutes. I had never heard of it until last year. I wish I had a link for it, but I guess you will just have to take my word for it. ;-)