Opioid/anxiolytic combo?

leslie :-D · Mar 29, 2009

so you're not looking to switch pt to another opioid...just reduce the dosage and still manage pain?

leslie

nopainNurse · Mar 29, 2009

I am not sure about adding an anxiolytic, but could the patient take acetaminophen and an NSAID? Using acetaminophen and NSAIDs with opioids has been shown to reduce the opioid needed.

netglow, ASN, RN · Mar 29, 2009

Thanks Leslie...

GI bleed... So... concerns are of pain, but of the damage of the retching/vomiting r/t overwhelming nausea... continued risk of hemorrhage... while dx/tx of underlying cause is continuing revisited...

I read somewhere that a combo of opiod/anxiolytic can help in some situations. I can't find it. Wondering what it is.

RedCell · Mar 29, 2009

Anybody know of an opioid/anxiolytic combo they have seen used as a means of reducing dose of the opioid (Dilaudid) to reduce respiratory side effects (depression) and to synergistically help with pain/nausea/vomiting... that is effective? Give me some ideas? Reglan and Zofran not effective...
Any insight would be great from the all knowing all nurses folks.

If you are looking for anxiolysis with your antiemetic you can always try 1) 6.25-12.5mg promethazine 2) 12.5-25mg diphenhydramine 3)0.625mg droperidol. I am usually hesitant to write for droperidol not due to the black box warning (this is way to low of a dose to worry about QT prolongation), but because it is a dopamine antagonist and like metoclopramide can cause some extrapyramidal side effects as well as that undesired feeling of impending DOOM!

I don't know what kind of patients you are dealing with and of course, each situation is different, but a variation of the above mentioned combo has always made the PACU guys happy.

flightnurse2b, LPN · Mar 29, 2009

i remember reading somewhere that dilaudid given with an anxiolytic and increase the risk of CNS/respiratory depression.

we give reglan with lorazepam for pts with cyclic vomiting or uncontrolled N/V and have good results...

leslie :-D · Mar 29, 2009

yes, anxiolytics often work synergistically w/opioids...

usually r/t the anxiety that pain can elicit.

but since the pt is being titrated downward r/t resp depression, i'd skip the anxio.

however, phenergan, compazine/thorazine, all have anti-anxiety agents in them.

i esp like the effects of compazine/thorazine.

get mixed results w/phenergan.

haldol works well too.

if he's getting the dilaudid iv, make sure injection is very slow.

too fast = lgr risk of depression.

RedhairedNurse, BSN, RN · Mar 29, 2009

I use compazine for severe nausea, that is, if zofran isn't doing the job. Works very well IMO. Also relaxes the pt and helps with sleep. IV phenergan is not used at my place of employment because it's so irritating (vesicant) to the veins.

leslie :-D · Mar 29, 2009

I use compazine for severe nausea, that is, if zofran isn't doing the job. Works very well IMO. Also relaxes the pt and helps with sleep. IV phenergan is not used at my place of employment because it's so irritating (vesicant) to the veins.

i like compazine too, britney.

zofran for the birds.

don't like phenergan, r/t vesicant properties and not antiemetic of choice when r/t opioids.

leslie

Medic09, BSN, RN, EMT-P · Mar 29, 2009

We often gave Phenergan with Morphine for long EMS transports. Works well. The Phenergan allows for a smaller dose of Morphine in most cases. Our medical director always liked it. Still likes to use it in the ER, except we recently received orders from on high that we can give only 12.5mg Phenergan IV in hospital. (I bet many of you have changed to the same protocols.)

We often use a bit of Ativan with patients where we think the anxiety level is exacerbating the pain response. Hard to judge, but doesn't usually hurt.

What are your docs ordering?

WalkieTalkie, RN · Mar 29, 2009

In what type of situation?

Precedex works great for sedation and when a patient is on it, they don't require as much analgesic. It doesn't cause the respiratory depression that Versed and propofol do.

blondy2061h, MSN, RN · Mar 30, 2009

I had an end of life patient I was caring for the last few days. She was on a morphine drip, then I would give IV pushes of Ativan + Compazine intermittently. You could do some morphine/compazine/ativan combo. You could also add benadryl in there. We often use benadryl and ativan as antiemetics, and they both have known anxiolytic effects.

Using an opoid drip for pain, instead of intermittent dosing may be more effective for managing pain with lower doses by avoiding peaks and troughs. Or a PCA with a basal. Or a fentanyl patch.