Is this common practice?

[Sugarcoma, RN]

I work in an SICU. It is common that I will receive a pt. who is intubated and on propofol or versed and has either nothing at all ordered for analgesia or what is in my opinion very skimpy pain med orders i.e. tylenol or 1 5/500 hydrocodone. Every once in a while I might luck out and find an old order for morphine 2mg Q 6 hours or if I am really lucky the PACU orders that have not been d/ced yet.

Very few of the other nurses give these meds at all. They question why I feel the need to give them, but I have found that when I do give pain meds consistently I can often turn the sedation down a little bit and the patient does not buck the vent as much. Also their foreheads relax and they look more peaceful to me. I take this as evidence that they are in pain.

I work nights and the night coverage is VERY hesitant to add any type of medication orders because our intensivists freak out when they do. Is this normal? To have a restrained, intubated patient on sedation only?

I personally think this is barbaric and it haunts me. This is my first and only ICU job so I am not sure how things are done elsewhere. I would love to hear from others!

[ChaseZ]

I am just a student but I will offer my input. I have always been trained (In EMS, so probably different priorities) that analgesia should be the main priority followed by sedation. A patient properly medicated with analgesics should require less sedation. Sedatives only (Propofol/versed) does nothing for pain. Some people like to argue that the patient will not remember the pain so it is not a priority but I still think pain has a significant physiological effect and should be controlled. Some will even be as bold as to purposely not use analgesia as a way to maintain BP (Pain = catecholamine). Almost every intubated patient I have transported has been on a Fent/Morph drip (Usually Fentanyl). But, as I said I am just a student and do not have ICU experience so my comments may not really mean much. Here is a good link to an Emcrit post about post-intubation analgesia/sedation. http://emcrit.org/podcasts/post-intubation-sedation/

[Sun0408, ASN, RN]

Sounds like your unit could use some education.. S stands for surgical correct, so obviously these pts will be in pain.. Where is the surgeon ?? The ones I have worked with are pretty good at ordering generous pain meds.. For a surgical pt, I would call the surgeon. The hospitalist or intenstivist are the ones more conservative. Many because they are new themselves in practice or scared the pt will be over sedated or just not very familiar with the pt..

If you are not getting anywhere with the primary or the intensivist, I would bring this up to your NM. Pain control is so beneficial in soo many areas of recovery.

[focker14]

Most places do not practice like that espeically in a SICU....If you need some backup there are numerous articles about post-op pain and length of stay in ICU on both intubated and non-intubated patients....I'd much rather have the pain meds vs the sedation...Wow..however it seems as if that is the norm for you place and most likley won't get changed soon....I am a SRNA and have been to over 10 different clinical sites and can tell you that every one of them allowed more than adequate pain meds for their intubated patients, not just surgical....Sorry you even have to deal with that!

[hodgieRN]

Agreed. Any vented pt coming out of surgery should have pain meds ordered (usually morphine or fentanyl). If it's not on there, ask the doc. If it's at night, call them or catch the surgeon before he/she leaves. Fentanyl gtts are common in our unit too. Do a sedation hold and tell the doc they are in pain when woken up.

[CrufflerJJ, BSN, RN, EMT-P]

At least you get the pt with sedation in place. In my ICU, I often get pts with no sedation or pain meds ordered (other than a PCA ordered with no basal rate for an intubated pt).

The CRNA dropping off the pt sometimes does a "dump & run" after pushing a bit of Neo & Propofol. A few minutes later, the pt starts to rouse, quite unhappy (along with a lousy pressure).

To counter this, I try to get with the Intensivist ahead of time (after PACU calls report) to see if they prefer Propofol or Fent/Versed for sedation, and whether they prefer fluids or pressors for BP management.

Pain management is important. Preferable IV pain meds, either continuous or PRN. Your thoughts of a sedated post-surgical pt lacking pain meds being barbaric is perfectly correct. It suggests laziness or a lack of intellectual rigor on the part of the surgeon. The surgeon's job isn't done when the pt leaves the OR. IMHO.

[Sugarcoma, RN]

Yeah I figured this was NOT the norm. I have taken this up the chain to management to no avail. The problem is the physicians at this place are kinda like the bullies in the sandbox. They do not want any one else touching their toys and if some one does they throw temper tantrums that would rival that of any two year old. So what happens is that the interns and residents learn very quickly not to order anything for these patients. Our surgical patient's are not even managed by surgeons here, they are on consult, any orders they may write post-op must be approved by the intensivist and most of the time they are d/ced. We have a surgical resident at night but again unless it is something extremely urgent we are out of luck and god help the poor nurse who actually calls the intensivist at home. A crappy situation all around.

[hodgieRN]

Our surgical patient's are not even managed by surgeons here, they are on consult, any orders they may write post-op must be approved by the intensivist and most of the time they are d/ced. We have a surgical resident at night but again unless it is something extremely urgent we are out of luck and god help the poor nurse who actually calls the intensivist at home. A crappy situation all around.

That sucks!

[CrufflerJJ, BSN, RN, EMT-P]

That sucks!

For the patient, and the nursing staff. Not good at all.

That being said, it would be truly unfortunate if the state Inspector General or CMS were anonymously notified of concerns re: poor pt care of sedated pts with inadequate pain control. Truly, I say....

[MunoRN, RN]

That's messed up. Our orderset for has analgesia defaults to help make sure it doesn't get forgotten. You could try and educate your MD's. There's a wealth of information out there, but usually your best chance to be successful is to use an argument written by a peer. Here's a paper written jointly by the American College of Critical Care Medicine and the Society for Critical Care Medicine. (Specifically, see the Analgesia section on page 1)

[jcmelhorn]

I work at a SICU at a Level 1 trauma center. Our patients that are intubated post-op more often than not come straight from the OR without being reversed. We start all of our patients on propofol and fentanyl gtts unless the doctor specifically indicates otherwise. Once they are extubated a lot of ours (especially our thoracic its) get PCA orders. If they remain intubated and or end up trached and still on the vent we obtain PO access and switch to PO meds after awhile. But yes, we start a fentanyl gtt for pain management. Both our propofol and fentanyl gtts are ordered to titrate to a riker of 4 (unless they want the patient more sedated).