use of Cadd pumps in pain management

Specialties Hospice

Published

The hospice I work for almost never approves the use of a CADD pump for the administration of morphine due to the high cost of using a pump. I feel that sometimes we are providing inadequate pain control because of this.What is the experience of other hospice nurses with this situation?

There doesn't seem to be a way to program in the prn doses. This CADD is used generally for chemo--the onco's office loaned it. The wife is giving the prn doses. I thought they said he uses the prn a lot, turns out it is still a little rare.

The wife is very young also, but has learned a lot and the onco has confidence in her. I didn't see any of the usual flags for concern about "loose" morphine in the house (makes me wonder why there's little concern for Roxanol at twice the strength, but worry about other forms :uhoh3: ), and I did also ask.

As for increasing the dosage, he resists that. He does not want to be out of control, doesn't want to feel at all fuzzy. Would rather tolerate the discomfort.

At 27, he seems to be fighting dying while being OK with his impending death. I did talk with him about kicking the crap out of the pain before it gets a good grip, maybe that will help him.

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Specializes in hospice, Med-Surgical, Cardio-Pulmonary.

Has the team considered discontinuing the duragesic and increasing the morphine to cover the patch dosage? Maybe he's not absorbing the duragesic.

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Specializes in Med Surg, Administration, ER, OR, SCU,.

That's been a consideration. Gotta get with his MD on this. Wish we'd never started it though. It's harder to convince a patient that they can get the same relief by taking po meds once they've started on a pump.

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i understand pts forfeiting more aggressive analgesia while opting to maintain their alertness.

but still, this man does not sound like he's attained the desired balance.

i think more can be done for him.

leslie

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The Hospice I work with uses CADD Pumps if the MD orders it, either IV or SQ. We shy away from Duragesic patches if the patient can take po or if there is no body fat to absorb meds this way.

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I'm not sure what a CADD pump is, but our palliative care residence (a nine bed residential site) uses syringe drivers to give 24 hour s/c pain relief. We find them to be very useful, for the most part when used with breakthroughs. If we give what we feel to be too many breakthroughs, the dosage in the syringe driver is adjusted.

Our drug combos can be dilaudid or morphine with medaz and/or maxeran, usually.

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i was always instructed that at EOL have the patient free of as much tubing as possible, manage pain with po, liquid, patches....let the patient be as "normal" as possible...none of us would like to be connected to a pump, picc line,, and carry a little bag with us all day. we use hopice pharmacia and they are great at converting dosages.

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A CADD pump is a very small pump that is made to be portable for people in non hospital settings. For ambulatory patients on the go, they can carry them in back packs or waistpacks. I think that many people use the CADD name (like saying "kleenex' instead of the generic tissue name), but there are several small pumps made by different companies for the same purpose. I think many people refer to all of them as CADD pumps since this seems to be the most popular name..

I'm not sure what a CADD pump is, but our palliative care residence (a nine bed residential site) uses syringe drivers to give 24 hour s/c pain relief. We find them to be very useful, for the most part when used with breakthroughs. If we give what we feel to be too many breakthroughs, the dosage in the syringe driver is adjusted.

Our drug combos can be dilaudid or morphine with medaz and/or maxeran, usually.

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i was always instructed that at EOL have the patient free of as much tubing as possible, manage pain with po, liquid, patches....let the patient be as "normal" as possible...none of us would like to be connected to a pump, picc line,, and carry a little bag with us all day. we use hopice pharmacia and they are great at converting dosages.

See, and in my experience, the little syringe driver makes their lives much more comfortable than trying to make sure that their pain doesn't peak. When patients are still ambulatory, in our residence, they rarely use syringe drivers - it's mostly in patients who have advanced to being fully dependant on care.

BTW, the syringe driver is attached to a butterfly so we don't have any type of PICC line or anything like that.

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icon1.gif Re: use of Cadd pumps in pain management

"There doesn't seem to be a way to program in the prn doses. This CADD is used generally for chemo--the onco's office loaned it. The wife is giving the prn doses. I thought they said he uses the prn a lot, turns out it is still a little rare.

The wife is very young also, but has learned a lot and the onco has confidence in her. I didn't see any of the usual flags for concern about "loose" morphine in the house (makes me wonder why there's little concern for Roxanol at twice the strength, but worry about other forms :uhoh3: ), and I did also ask.

As for increasing the dosage, he resists that. He does not want to be out of control, doesn't want to feel at all fuzzy. Would rather tolerate the discomfort.

At 27, he seems to be fighting dying while being OK with his impending death. I did talk with him about kicking the crap out of the pain before it gets a good grip, maybe that will help him."

OK

At the risk of being too picky, what else is he on and what type of pain is he having? IV meds are still helped by adjuncts like neurontin and NSAIDS and dexamethasone for inflammation. These things would not make him groggy, but could give hime huge help. It's one of the things I love about methadone, it also helps nerve pain.

Thanks for listening and caring.

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Specializes in Community nursing/hospice/case mgmt.
Well, I admitted my patient with his CADD pump.

He is on MS 1 mg IV q 1 hr cont infusion plus 2 mg IV push q 20 minutes for breakthrough.

He also has duragesic 150 on.

And still he winces.

My CADD (the Legacy) does not have a PCA attachment--no pushing buttons for this guy, his scheduled dose is programed.

But he really does seem to need it, and I don't see him surviving long enough to change out the cassette (which is supposed to last a week).

We use the CADD legacy pumps. Ours has a screen that says "demand" where you can set the prn dosing, then after that screen it lets you set the lockout. This is in addition to the scheduled dosing. I think the CADD pumps are great, especially in home settings where you have other family members "stealing" pt pain meds. We use the Grasby also, and while I find that easier to work with since i've used it more, it does not have a lockout as far as the prn doses go since its just a syringe driver. Also, i'm surprised your pt still has his duragesic. Our doc transfers all the doses of pain meds into whatever is going to be in the pump and d/cs the other pain meds. Of course most of the time we don't put our pts on pumps until they are unable to swallow. Plus if he's wincing its obvious he needs somewhat of an increase....which leads me to another reason I like the CADD pumps...the fact it tells you how many prn doses they've recieved and how many were attempted. Anyhow good luck with that.

Nicola

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As the CHPN curriculum suggests, we tend to use the gut if it's working, either PO or PR. I've actually had good results in a pinch filling gel caps with Roxanol and giving it rectally, as much as 60mg (3ml) Q2.

With that said, we use our own CADD type pumps where injectable analgesia is indicated. We use SQ sets, they are like a tiny Huber, 25g 1/2". We will use an existing PICC line if there is one, and sometimes place one if there is absolutely no SQ tissue and we have tried a SQ with poor results. I've never known us to use a peripheral line other than a PICC, which as we all know is considered a central line. Hospice patients often have poor venous access and even if it's viable, it's a stick every three days. I'm also not a big fan of Durgesic in situations where rapid titration is likely to be necessary, say someone who has widely fluctuating pain levels.

And just an FYI, don't think that if you have a home situation where you think diversion is an issue that it's not possible to divert out of a CADD pump. My professional experience has shown me otherwise.

We believe that it's our ethical and legal obligation to make whatever changes are necessary until the patient indicates that the pain is at a level acceptable to the patient. Although we own our pumps, the meds are expensive and maintaining a sub Q site has a labor cost associated with it. Plus it's invasive, you are sticking someone every three days or more often. For all those reasons, we don't exactly jump at the chance to put someone on a pump.

For those nurses whose management don't want to use pumps because they are too expensive, maybe bring up the fact that if a chart gets audited and the person's pain was not well controlled the fines can be HUGE. Also, given that symptom control is supposed to be what we do, suing a hospice for pain and suffering over ineffective pain management is one of the few suits likely to be successful against a hospice and its staff.

But bottom line (no pun intended) I believe it's unethical and immoral to not use a CADD pump if one is indicated simply because they are expensive.

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