what would you have done?

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This situation just kind of sits in my caw. I floated to a same day surgery orthopedic unit. My patient a 30ish year old otherwise healthy man, came out with ACL repair. He had had a femoral block but soon upon arrival was complaining of a lot of pain, but he was acting weird, saying he needed to straighten his leg, he needed to stand up, even kind of trying to get out of bed, then saying he has claustrophobia, that he gets panic attacks when he flies. I asked if he had seen a doctor for his panic attacks, he said no, I asked what he did when he got panic attacks, he said he drank (I'm pretty sure he was referring to when he flew??? I don't think? he was an alcoholic?) I was giving the IV pain meds as ordered but was thinking this guy could use some versed?

I mention to the charge nurse his weird behavior, that I had maxed out his pain meds (not a whole lot had been ordered) and that I thought he needed versed (I would have called anesthesia for an order). She said NO if he got versed he would be here too long. I gave more IV pain meds, (he never got a LOT, I have given more than he got to different patients)

I was trying to push his PO intake so he could get PO pain meds, I had alreayd given him IV Zofran, and as I was getting the PO pain meds he threw up!!!! By then it was my turn for lunch, he was passed onto another nurse and it was mentioned to me "she will get him out of here!" He was gone when I got back but still I feel annoyed. How did the charge nurse get the idea some versed would lengthen his stay???? I have no idea if it would have helped, or made any difference, but to say, no then he will be here longer seems crazy?

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Specializes in ER, Trauma.

Comes down to priorities, giving the patient the care he needs, or the staff's convenience by getting a patient out faster. I know what I would have preferred. Are you available next time I need surgery?

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thanks, I get annoyed at same day surgery centers that watch the clock (time is money?) more than what the patient is doing!!!!!

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Specializes in multispecialty ICU, SICU including CV.

Patient had outpatient surgery. Patient needed to be deemed stable, recovered from anesthesia and sent home. Getting versed means putting the patient back down. It is counterproductive to the patient goal, which is leaving to go home safely. I can understand the IV pain medication and IV antiemetics, and I am sure that you realize that after every IV dose of medication you give you need to keep the patient for another XXX amount of time, so knowing that and the sedative effects of versed, this is likely why she questioned you.

Patients wake up in all different kinds of ways. Just because this guy was acting a little off didn't mean he needed to be put back down and it actually may have compromised his hemodynamic stability and his safety after he got home.

Here is some perspective -- I had nearly the same surgery (ACL reconstruction) and I was in PACU for 5 HOURS. I couldn't wake up. I don't know what happened or who overmedicated me, but I was really not happy about that happening after the fact. I remember being in pain (obviously) but I don't remember asking for a ton of pain meds. I still don't know what really went on that day.

Here's some more -- a good friend of mine went to the ER for a severe spinal headache after she had her baby (complications from the epidural, etc.) She got a blood patch and IV dilaudid. She was still in pain, so they dosed her with dilaudid again and sent her home after the 1/2 hour wait period. She had a respiratory arrest at home and her husband had to call 911.

Just some things to think about. If OP surgery isn't your specialty, I wouldn't question the experienced nurse's judgment on this one.

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Specializes in ER, Trauma.

NO! Thank you!! Lately there have been a lot of posts on this and other sites where nurses have put themselves (time, money, emotions) ahead of the patients. I'm so relieved to know someone else out there isn't a "nursebot." That someone else remembers that nursing is ABOUT the patient. The shame of it all is that you even had to ask the question.

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Maybe the pt was a bit hypoxic? needed some O2?

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Great to think of hypoxia. Sometimes we forget the basics! His vitals were fine the whole time.

CNL2B I do moderate sedation for GI's, I give patients from 3 up to 8 mgs of versed. In our eye clinic cataract patients (often elderly) get fentanyl and versed from anesthesiologists. Both these patients are safely out the door 1/2 hour post procedure! I wouldn't call it "putting them down." I'm not giving versed to a sedated patient, he was WIDE awake and anxious!

But I do appreciate your perspective, we all learn from each other, our mistakes, and the mistakes of others, i.e, your friend's husband having to call 911!!!

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Specializes in ICU-CCRN, CVICU, SRNA.

For some reason I have noticed Dilaudid causing more resp. arrests than any other. Is it just my observation?

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Specializes in Peds, PACU, ICU, ER, OB, MED-Surg,.

I think you right on the mark with the versed. I worked couple years in PACU/DSU. You would have had to keep him a little longer but it would have been worth it to make sure he was going to be able to keep down his pain meds and it would be under control.

I do not believe in the get'em in get'em out mentality some DSU's and ER's adopt. It is after all about the patient. Do they feel comfortable going home, if not I call the MD and discuss with them. Everyone tolerates pain and meds differently.

Dilaudid, I've seen many resp codes due to this medication. I believe it builds up and then hits them all at once. It should not be used for someone going home and not being monitored, period.

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Specializes in PeriOperative.

CNL2B I do moderate sedation for GI's, I give patients from 3 up to 8 mgs of versed. In our eye clinic cataract patients (often elderly) get fentanyl and versed from anesthesiologists. Both these patients are safely out the door 1/2 hour post procedure! I wouldn't call it "putting them down." I'm not giving versed to a sedated patient, he was WIDE awake and anxious!

Conscious sedation is very different from general anesthesia. Many people (typically teenage boys) wake up and hit the ceiling. We have the entire OR team restrain them for 5-10 minutes until they come down enough to be transported to PACU. If the safest thing to do was to give a benzo for transport, I'm sure that would be the standard practice, but it isn't.

To answer your original question, when I have patients react like this (in the OR and and PACU, not the floor or unit), I try and reorient them to where place and situation, and take whatever non-pharm measures I can to keep them from hurting themselves. If the patient is actively at risk of hurting himself (like trying to jump out of the bed, or has jumped out of bed and is running nekkid through the hallway), I get help from other nursing staff and anesthesia to restrain the patient appropriately.

He was uncomfortable, but not a danger to himself. No, I don't think versed would have been to his benefit.

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"Dilaudid, I've seen many resp codes due to this medication. I believe it builds up and then hits them all at once. It should not be used for someone going home and not being monitored, period."

I know this is off topic but omg this happened to me. I had dosed my pt every 2 hours with IV dilaudid our standard amount. She was complaining of pain all night. Doc came in the am and talked with her changed her pain meds since the dilaudid wasn't doing it.

I gave report and day shift took her had to narcan her like 4 times. I swear all night she was fine then it was like bam!

To the OP I'm not sure about versed but I like your mentality, I'd take a nurse like you over someone who is unresponsive to pain/anxiety.

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Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.

I would have called the anesthesiologist and asked to have him/her evaluate the patient. After all, isn't it the anesthesiologist who has ultimate accountability when giving the OK for discharge?

P.S. I gave Versed to many patients in ambulatory surgery; helped to alleviate some of the anxiety; didn't have to use as much narcotic, and it wasn't because of sedation. Some patients wake up in a panic from anesthesia, and a "touch" of versed helps!

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