What made your jaw drop

  1. Pt had moderate sedation and was brought to recovery drowsy but arousable. PCA started but no other drugs administered by nursing. Pt begins snoring and becomes completely unaroausable. Friend at bedside asked how frequently the pt was pressing PCA button. Friend was indeed pressing the button for the patient q6mins.

    Pt received over 7mg Dilaudid and had to be reversed.



    What's something that made your jaw drop?
    Last edit by DextersDisciple on Jul 7
  2. Poll: Have you ever had a family member/friend press PCA button?

    • No.

      34.00% 17
    • Yes but the patient was not harmed.

      44.00% 22
    • Yes and the patient was affected and/or needed reversal.

      22.00% 11
    50 Votes
  3. Visit DextersDisciple profile page

    About DextersDisciple, BSN, RN

    Joined: Feb '17; Posts: 144; Likes: 412

    51 Comments

  4. by   AnnieOaklyRN
    Why in the heck was the PCA even set to administer that much in that short of a time span?! This is a hospital error and should be reported!

    This really has not so much to do with a family member pressing the button, and all to do with the PCA being programmed incorrectly. The point of the PCA is to allow the patient to safely administer narcotics to themselves, which means the healthcare team has to regulate how much the device can give before it locks out. That clearly was not done in this case.


    Annie
  5. by   klone
    Quote from AnnieOaklyRN
    Why in the heck was the PCA even set to administer that much in that short of a time span?! This is a hospital error and should be reported!

    Annie
    They said that the friend was pressing the button every 6 minutes, not that the PCA was set to every 6 minutes.
  6. by   AnnieOaklyRN
    Quote from klone
    They said that the friend was pressing the button every 6 minutes, not that the PCA was set to every 6 minutes.
    I realize that, but the PCA should be set to lock out the button once a safe maximum dose has been reached, and in this case that was clearly set WAY to high!!

    Annie
  7. by   DextersDisciple
    Quote from AnnieOaklyRN
    Why in the heck was the PCA even set to administer that much in that short of a time span?! This is a hospital error and should be reported!

    Annie
    Lol no this was the standard PCA dose used daily throughout the hospital. Lockout is 2mg an hour. Pt usually sleeps off their bed rest (4-6hrs), VSS so team wasn't concerned. Incident report was written but not a "hospital error".
  8. by   macawake
    Quote from klone
    They said that the friend was pressing the button every 6 minutes, not that the PCA was set to every 6 minutes.
    Quote from AnnieOaklyRN
    I realize that, but the PCA should be set to lock out the button once a safe maximum dose has been reached, and in this case that was clearly set WAY to high!!
    Quote from DextersDisciple
    Lol no this was the standard PCA dose used daily throughout the hospital. Lockout is 2mg an hour.
    Hmm.. I don't work in the U.S. and in my country hydromorphone is pretty much only used in palliative care. So I'm not familiar with dosage and also, I have no idea what type of surgery or procedure this patient had done, or how opioid tolerant they are or if they have any other pain issues unrelated to the surgery/procedure.

    Since I'm not familiar with Dilaudid, I looked at an equianalgesic dosing table and it seems that IV Morphine: IV Dilaudid is approximately 7:1. So the 2 mg per hour maximum allowed by the PCA sounds like a pretty hefty dose, and I wouldn't expect that most patients would need that much. That however, doesn't in my opinion necessarily translate to the PCA being incorrectly programmed.

    In order to be certain to have doses that are low enough and lock out time periods that are long enough, that NO patient would ever suffer from respiratory depression when SOMEONE OTHER THAN THE PATIENT keeps pressing the button even long after the patient is asleep/resting comfortably, the result would be that many patients wouldn't have their pain adequately managed.

    It's called PATIENT-controlled analgesia for a reason. It's not a family-controlled analgesia pump and it's not a friend-controlled analgesia pump. No one else than the patient should be "dosing" the patient. (For that reason, PCA's are only a suitable method of analgesia for patients with the physical ability to push the button and the cognitive ability to understand that pushing the button is what they need to do when they need pain relief).

    The patient wouldn't have kept pushing the button for as long as the awake friend did. From what I understand of the situation, it sounds as if the friend who was continuously giving the patient more doses, is the likely cause. I'm hoping it was done out of misdirected kindness, wanting to keep their friend pain-free. But that person really needs to be educated on how dangerous it is to do what s/he did. Well, after the naloxone, I guess they figured it out.


    OP I'm curious, did that friend actually sit their and press the button every six minutes for over three hours to get to a dose of 7 mg? Was the lockout total 2mg/hour or was there a continuous basal rate programmed as well, on top of the patient-controlled doses? (I have no idea if you normally would or not, I'm only trying to figure out if this took three and a half hours or if the 7 mg were administered during a shorter time-frame).

    People never cease to amaze me It's a reminder to always educate and inform, because people can do some very strange things. We can never be too vigilant.

    (OP, I couldn't answer the poll. My answer would be; no, not that I'm aware of).
    Last edit by macawake on Jul 9
  9. by   DextersDisciple
    Quote from macawake
    Hmm.. I don't work in the U.S. and in my country hydromorphone is pretty much only used in palliative care. So I'm not familiar with dosage and also, I have no idea what type of surgery or procedure this patient had done, or how opioid tolerant they are or if they have any other pain issues unrelated to the surgery/procedure.

    Since I'm not familiar with Dilaudid, I looked at an equianalgesic dosing table and it seems that IV Morphine: IV Dilaudid is approximately 7:1. So the 2 mg per hour maximum allowed by the PCA sounds like a pretty hefty dose, and I wouldn't expect that most patients would need that much. That however, doesn't in my opinion necessarily translate to the PCA being incorrectly programmed.

    In order to be certain to have doses that are low enough and lock out time periods that are long enough, that NO patient would ever suffer from respiratory depression when SOMEONE OTHER THAN THE PATIENT keeps pressing the button even long after the patient is asleep/resting comfortably, the result would be that many patients wouldn't have their pain adequately managed.

    It's called PATIENT-controlled analgesia for a reason. It's not a family-controlled analgesia pump and it's not a friend-controlled analgesia pump. No one else than the patient should be "dosing" the patient. (For that reason, PCA's are only a suitable method of analgesia for patients with the physical ability to push the button and the cognitive ability to understand that pushing the button is what they need to do when they need pain relief).

    The patient wouldn't have kept pushing the button for as long as the awake friend did. From what I understand of the situation, it sounds as if the friend who was continuously giving the patient more doses, is the likely cause. I'm hoping it was done out of misdirected kindness, wanting to keep their friend pain-free. But that person really needs to be educated on how dangerous it is to do what s/he did. Well, after the naloxone, I guess they figured it out.


    OP I'm curious, did that friend actually sit their and press the button every six minutes for over three hours to get to a dose of 7 mg? Was the lockout total 2mg/hour or was there a continuous basal rate programmed as well, on top of the patient-controlled doses? (I have no idea if you normally would or not, I'm only trying to figure out if this took three and a half hours or if the 7 mg were administered during a shorter time-frame).

    People never cease to amaze me It's a reminder to always educate and inform, because people can do some very strange things. We can never be too vigilant.

    (OP, I couldn't answer the poll. My answer would be; no, not that I'm aware of).
    Hey macawake, your post really makes me think- I had no idea dilaudid wasn't common in the UK. Anyway, patients typically receive 250mcgnof fentanyl during along with a sedative- is it a pretty painful procedure so this is a part of the post op order set.

    Dilaudid is given during procedure many times as well. I'd say the typical single dose of the drug is 0.5mg and goes in increments of 0.5mg (0.25 mg is lowest dose I have seen). The friend admitted to doing this every 6 mins for the pt bc she "thought" she needed it. Friend was educated on the severity of their actions and the purpose of the PCA. I won't go into specifics but the results of her actions extenses the pts recovery time significantly as a result of the reversal.

    The dosing was given over the 3 hrs so the pump functioned correctly. I'm not
  10. by   DextersDisciple
    Quote from macawake
    Hmm.. I don't work in the U.S. and in my country hydromorphone is pretty much only used in palliative care. So I'm not familiar with dosage and also, I have no idea what type of surgery or procedure this patient had done, or how opioid tolerant they are or if they have any other pain issues unrelated to the surgery/procedure.

    Since I'm not familiar with Dilaudid, I looked at an equianalgesic dosing table and it seems that IV Morphine: IV Dilaudid is approximately 7:1. So the 2 mg per hour maximum allowed by the PCA sounds like a pretty hefty dose, and I wouldn't expect that most patients would need that much. That however, doesn't in my opinion necessarily translate to the PCA being incorrectly programmed.

    In order to be certain to have doses that are low enough and lock out time periods that are long enough, that NO patient would ever suffer from respiratory depression when SOMEONE OTHER THAN THE PATIENT keeps pressing the button even long after the patient is asleep/resting comfortably, the result would be that many patients wouldn't have their pain adequately managed.

    It's called PATIENT-controlled analgesia for a reason. It's not a family-controlled analgesia pump and it's not a friend-controlled analgesia pump. No one else than the patient should be "dosing" the patient. (For that reason, PCA's are only a suitable method of analgesia for patients with the physical ability to push the button and the cognitive ability to understand that pushing the button is what they need to do when they need pain relief).

    The patient wouldn't have kept pushing the button for as long as the awake friend did. From what I understand of the situation, it sounds as if the friend who was continuously giving the patient more doses, is the likely cause. I'm hoping it was done out of misdirected kindness, wanting to keep their friend pain-free. But that person really needs to be educated on how dangerous it is to do what s/he did. Well, after the naloxone, I guess they figured it out.


    OP I'm curious, did that friend actually sit their and press the button every six minutes for over three hours to get to a dose of 7 mg? Was the lockout total 2mg/hour or was there a continuous basal rate programmed as well, on top of the patient-controlled doses? (I have no idea if you normally would or not, I'm only trying to figure out if this took three and a half hours or if the 7 mg were administered during a shorter time-frame).

    People never cease to amaze me It's a reminder to always educate and inform, because people can do some very strange things. We can never be too vigilant.

    (OP, I couldn't answer the poll. My answer would be; no, not that I'm aware of).
    Hey macawake, your post really makes me think- I had no idea dilaudid wasn't common in the UK. Anyway, patients typically receive 250mcg of fentanyl during along with a sedative- is it a pretty painful procedure so this is a part of the post op order set.

    Dilaudid is given during procedure many times as well. I'd say the typical single dose of the drug is 0.5mg (during THIS procedure) and goes in increments of 0.5mg (0.25 mg is lowest dose). The friend admitted to doing this every 6 mins for the pt bc she "thought" she needed it. Friend was educated on the severity of their actions and the purpose of the PCA. I won't go into specifics but the results of her actions extended the pts recovery time significantly as a result of the reversal.

    The dose was given over the 3 hrs so the pump functioned correctly. All of this made my jaw drop!
    Last edit by DextersDisciple on Jul 9 : Reason: Typos
  11. by   DextersDisciple
    Quote from DextersDisciple
    Hey macawake, your post really makes me think- I had no idea dilaudid wasn't common in the UK. Anyway, patients typically receive 250mcgnof fentanyl during along with a sedative- is it a pretty painful procedure so this is a part of the post op order set.

    Dilaudid is given during procedure many times as well. I'd say the typical single dose of the drug is 0.5mg and goes in increments of 0.5mg (0.25 mg is lowest dose I have seen). The friend admitted to doing this every 6 mins for the pt bc she "thought" she needed it. Friend was educated on the severity of their actions and the purpose of the PCA. I won't go into specifics but the results of her actions extenses the pts recovery time significantly as a result of the reversal.

    The dosing was given over the 3 hrs so the pump functioned correctly. All of this made my jaw drop!
    Are you from the UK? I thought I read that in one of your posts before.
  12. by   DextersDisciple
    Duplicate
  13. by   smf0903
    Any friend/family member/Joe Shmoe from off the street who got caught pressing PCA button on my patient would be kicked out of the hospital. We have a ginormous obscenely-colored sign on our PCAs that state no one is to press button for patient.

    2 mg/hr seems like a pretty high dose.
  14. by   Mavrick
    Quote from AnnieOaklyRN
    Why in the heck was the PCA even set to administer that much in that short of a time span?! This is a hospital error and should be reported!

    This really has not so much to do with a family member pressing the button, and all to do with the PCA being programmed incorrectly. The point of the PCA is to allow the patient to safely administer narcotics to themselves, which means the healthcare team has to regulate how much the device can give before it locks out. That clearly was not done in this case.

    Annie
    What time span are you talking about? Unless OP has edited the original post no time span was mentioned.

    We use Dilaudid PCAs all the time for post op pain. The typical settings are 0.2 mg per dose with 8 min lockout and 1.6 mg hourly limit. It would take about 4 1/2 hours to get 7 mg of Dilaudid even if the patient fell asleep pressing the button.

    In OP example 7 mg over 3-4 hours (per later post) is not excessive in the general scheme of things but apparently too much for this patient. The settings did prevent a hideous overdose as is the intent even when a well-intentioned but ill-informed friend took control of the button.
  15. by   macawake
    Quote from DextersDisciple
    Are you from the UK? I thought I read that in one of your posts before.
    I'm Swedish Eleven years of nursing and despite having administered analgesics by the gallon, I haven't administered a single dose of hydromorphone.


    Quote from DextersDisciple
    Dilaudid is given during procedure many times as well. I'd say the typical single dose of the drug is 0.5mg (during THIS procedure) and goes in increments of 0.5mg (0.25 mg is lowest dose). The friend admitted to doing this every 6 mins for the pt bc she "thought" she needed it. Friend was educated on the severity of their actions and the purpose of the PCA. I won't go into specifics but the results of her actions extended the pts recovery time significantly as a result of the reversal.

    The dose was given over the 3 hrs so the pump functioned correctly. All of this made my jaw drop!
    No need to get into the specifics, it's probably best not to. I can imagine what the consequences of having to administer an opioid antagonist might have been for the patient. I was only thinking out loud when I mentioned not knowing the specifics of this patient's case. I don't need to know them, I was just trying to make sense of why many posters seem to agree that the PCA pump had been programmed incorrectly.

    It's my opinion that PCA's are a very good way of managing post-operative pain. When patients have control over their own pain relief, it alleviates a lot of stress/anxiety and they usually end up using less opioids than when they have to ring a call bell and hope that the nurse will get there "in time".

    As I said, I don't have experience with this particular medication but I don't think the allowed hourly dose of 2 mg (= 0.2 mg every 6 minutes) seems wildly excessive. Towards the high end perhaps, but there could be a number of patient-specific circumstances that would affect what would be considered a suitable dose. It's not my place to second-guess.

    I guess my main point is that PCA's have a built-in safety apart from the maximum allowed doses and frequency (the lock-out function), and that's the patients themselves. When they get really sleepy/drowsy they won't keep pushing the button. But that "built-in" safety feature doesn't work if a family member/friend/visitor overrides it.
    Last edit by macawake on Jul 9

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