post CABG pain mgmt

nimbex, RN · Mar 20, 2003

we "fast track" all patients, assuming they fast track themselves. we even have off pump cases comming out of OR extubated.

To fast track, we never give any pain meds IV, we give morphine SC, nothing OG, due to pending extubation (belly is usually off still anyway). If they have mid to moderate pain with no contraindications we have standing protocol for toradol.

One surgeon does a mid-cab appoach where the sternum is not severed, only with certain vessles, the lateral left rib 4 or 5 is removed for accessed and replaced and a SQ buivicaine injection is used.

Once extubated we use toradol and Darvocet.

If the patient is bleeding, unstable like epi drips, IABP or LVAD, we use morphine IV, because we won't be extubating.

No literature on no Darvocet..... my surgeons (5 of them) prefer it.

FYI, we stay away from the IV narcs due to ansethesia still being on board and we try to wake them to determine extubation status.

Our patients pain never seems to be GONE, we make it tolerable to extubate........tough choices when you're saying, can you hold on for a little longer so we can pull that breathing tube.....

So to answer we never seem to acheive a pain free status but comfort IS a big priority, balanced with a quick extubation and OOB six hours post that.

nimbex, RN · Mar 20, 2003

forgot to mention, those comming out of the OR extubated are the most challenging to controll pain. Your fresh post op requires hemodynamic stabalization and they're talking to you!!!!!!!! complaining of pain, maybe hypotensive, and you can't give IV morphine, stuck with SQ, which does work and toradol.

More ideal for nursing is having that 2 hours to stabalize and set up the patient, before they are conversing with you..... huge challenge!!!

JohnnyGage · Mar 20, 2003

We also fast track out patients... while we don't have them come back extubated, they are usually extubated within three hours. We use IV fentanyl before and after extubation for the first night. After that we use Vicodin or Percocet. Toradol is used as well if they are less than 65 years old.

We have been using Precedex on all of our hearts which not only allows for great sedation (sleep -- not knocked out). We are able to extubate while they are still on Precedex and it has the advantage of analgesia so we only need about half the normal narcotic dose.

J. Tigana · Mar 22, 2003

what parameters do you use to determine if your patients are ready to to be extubated. Here is London we want the base defecit to be -2 to =2, po2 of apporoximately 10 kpa ( i think that 75 of your units) The co2 4.5-6.0 ( you can multiply that by 7.5, if you wish) temperature of 36.0 degrees centigrade, the patient to be able to obey commands and no obvious problems such as bleeding e.t.c. We want our fast track patients to be extubated within four hours but all of our patients have i.v. morphine. Which we may decrease, or stop. We then give p.r. parcetamol (Tylenol) if we want to extubate and we believe that the morphine is depressing the respiratory drive. The paracetamol usually works, but if it doesn't we use i.v. tramadol. In our itu we have high risk patients therefore we don't rush extubation. They all continue on I.V. morphine and proprofol for pain control and sedation.

mattsmom81 · Mar 22, 2003

I guess I'm lucky our docs give a wide variety of pain meds to us including IV if needed for appropriate pain management post CABG. We have standing orders with nurses' choice and can adjust our drugs and dosages within them. On night shift I also always have the option of letting my patient get rested, stabilized and extubated first thing in the am if I choose.

I agree the too early extubated patient is often most challenging immediately post CABG as we're trying to stabilize and pain response can compound the problem. Guess I'm spoiled and like to proceed at my own speed and what's best for the patient. :)

zambezi, BSN, RN · Mar 23, 2003

thanks for all of the responses...we also try to early extubate...usually between four and six hours...if the patient needs to rest, we let them sleep...patients usually come back from or with a fentanyl/propofol gtts...we have a weaning checklist that has lots of criteria, both rt and nursing...some examples:

temp between 36-39

ct output

no dysrhthmias

urine output > 30 cc/hr

pawp

fent off 30 minutes before weaning trial

propofol off 15 minutes before weaning trial

hob 30 degees

there are some others too...vent is decreased, simv 5, then cpap...parameters obtained, abgs drawn and must fit within the acceptable parameters...if all goes well, then we can pull the tube...

about the pain control issue, it sounds like we are doing about what other people are doing...an other suggestions...thanks for all your help...

Furball · Mar 23, 2003

We use toradol (only if renal function is normal) along with MSO4 IV/sc then percocets.

J. Tigana · Mar 23, 2003

Zambezi, I might be being stupid but what's Simv 5? Here we wean the patient untill they are on simv mode, pressure support of 10, peep of 5 and fio2 of 30%. Then put then on cpap with the same peep, p.s. and fio2 and if they still meet the parameters we extubate. Is it the same for you? I'm just interested in any potential differences in nursing in the U.S. and England. Also if there are differences I wonder which system is supported by the research.

zambezi, BSN, RN · Mar 24, 2003

H J. Tigana...simv rate of 5 is what i meant...straight out of or for the "normal" post open heart vent settings usually start at usually pressure support of simv rate of 10, psv 12, peep of 5 , fio2 at 40% to start....just the average that i see, there are variations for pt condition of course :). When weaning put pt. to Simv rate of 5, psv 10 or 12 for five minutes, if tolerated put on cpap and psv of 5...if all looks good and pt. meets a few other parameters, we extubate...

Pete495 · May 7, 2003

We have to call the surgeons and ask for toradol when the patient is not pain controlled. A majority of our patients are over 65, so they don't often prescribe it. That and toradol carries with it the risk of renal failure which we all know is a common complication after cabg surgery, esp. on pump. Basically though, our unit uses morphine on post op patients, and then we taper them to darvocet when they are walky talky. If they're able, and in a lot of pain, we give toradol, but the surgeons are real stingy with handing out anything else for pain medicine which upsets a lot of nurses.

When a patient is out of control, what does everyone else use for sedation? We have a standing order for versed if patient is not early extubation candidate, though the surgeons hate it, and often d/c it when the orders reach us. We use diprivan as a very very last resort. mostly they will use fentanyl, but patients always build a tolerance to fentanyl, and we end up going up on it if they are still out of control. but surgeons don't often realize that sometimes we can't do anything more when the patient is climbing out of his restraints.