Chronic Back Pain Patient Has Surgery

[Tweety, BSN, RN]

I floated to neuro the other night, a field and floor I'm very familiar with having worked there for three years.

Anyway, I took care of a lady in "intolerable pain" who had back surgery. It wasn't a minor laminectomy, she had some instrumentation, but it was a posterior approach, so it wasn't the worst kind of surgery either.

Long story short MD took her off her pca because it wasn't working and was giving Morphine 10 IM with Phenergan 25 mg q4h, with percocets for btp. She was in pain, "give me everything I can possibly have". Which was her routine prozac, wellbruitrin, xanax, a restoril 15 mg for sleep, soma, and two percocets. An hour later it's still 10/10 and I give her the MS with Phenergan. She finally falls asleep, but everytime I went in the room it was intertolerable 10/10 pain.

With all this stuff on board what more could I or the MD have done? She seemed groggy and would readily fall asleep, so we got through the night, but every waking moment was sheer misery. The MD rounded right after I got there, so he ordered Xrays to check things out, so he was aware and did change from PCA to IM.

[RNKPCE]

She probably has built up a tolerance to opiates due to having long term back pain. What about a fentanyl patch? Toradol?

[kids]

She probably has built up a tolerance to opiates due to having long term back pain. What about a fentanyl patch? Toradol?

If she had instrumentation placed she had a fusion...NSAIDS are now contraindicated in spinal fusion, research has shown a direct connection between NSAIDS and failure (I just had a major revision and extension of a fusion in April).

Duragesic (fentanyl) patches are not indicated for acute pain.

I am pretty opiate tolerant after 11+ years of back pain and multiple surgeries. From my *personal* experience the best thing that could have been done for her is a continuation of her pre-op pain meds (assuming they were sustained release) with additional short acting meds for break thru. If she was on short acting pain meds on a PRN basis it may have been of benefit if the doctor had ensured she was getting the same amount of them daily plus the PCA.