opioids

We've moved to significantly less opioids after open heart, or even just no opioids at all.  I had visions of patient's in out-of-control pain and resulting nightmare situations, but actually if anything this has resulted in better pain control, or at least an improved perception of pain.

I had noticed that you could certainly over-do it, not just in terms of over-sedating a patient but that if you medicated them to the point where they were a bit (or really) loopy then that just made the perception of pain far worse than if they could rationalize the pain.  When there's pain and someone isn't able to understand why, the perception of it is far worse.  

For the most part, our post-OHS patients get scheduled acetaminophen, PRN tramadol (a quasi-opiate) and that's it.  If they were on opiates prior to surgery then we will typically continue what they were already on, but usually at the same dose.  

Ouch! I had a minimally invasive valve replacement (birth defect) and I was glad to have an effective pain medication. Vicodin I think? With that and Ibuprofen it was manageable and I didn't even have my ribs split! Only for a week, but it really was helpful. Switched over to just Ibuprofen 1 week later, but it sure helped.

There was a study done in a group of Colorado hospital EDs where the hospitals almost completely quit using opiates in the ED. A variety of non-opiate and other strategies were used, and one of the things I remember was that the nurses and providers really worked with the patients on their expectations about pain. Such as: you are in here for a very serious (insert whatever it is) and it's not realistic to expect 100% pain relief. We will make you comfortable. What pain level is acceptable to you?

Generally they could get people comfortable with a 5 out of 10 pain level. It took a LOT of nursing care, as  I recall, to get this done.  I have actually taken that and used it in my ambulatory care setting where I almost never give an opiate, but rely on OTC meds provided by parents for their student.

My experience with previous surgeries and my recent (2 years) hysterectomy reminded me that Dilaudid is pretty much what works for intense pain, morphine makes me ill, and that Ketorolac works much better than any narcotic pain management for me. I especially don't tolerate the codiene.

Just a reminder that there are definitely genetic anomalies that affect how people process pain medication, and one size definitely doesn't fit all.

Toradol is supposed to have the same strength as 10mg of morphine.  There is good evidence for magnesium.  Tylenol and ibuprofen work best when given together.  Gabapentin.  

On 11/10/2020 at 9:17 AM, hppygr8ful said:

As a nurse I would encourage patient to start with the least addictive medication first then move up the chain until adequate pain relief is achieved especially when patient is scheduled  for PT or follow-up procedure and as far as I am concerned if it's the right time and patient is not altered I will give the opioid! Post surgery patients need pain control in order to recover.

As a patient who suffers from chronic almost debilitating  (at times) pain. I would caution you about making assumptions based on how the patient in pain may present. On any given day my pain level is a 5-6/10 and yet I work, exercise, Take care of my family and work n my garden. 

I have been treated by a pain management physician as well as my GP and I do take opioids when it becomes necessary. When I am in the hospital my pain management always includes opoids as the hospital beds are atrociously uncomfortable.  I have to go get ready for work, Please excuse errors in speling an grammer. 

Hppy 

I want to second what Hppy stated. Not everyone expresses pain the same way, and this can even be a cultural difference. I was in significant and worsening pain the first night after a subtalar fusion but was quiet and stoic about it. Due to this, I was accused of drug-seeking and the Residents charged with my care overnight missed the developing hematoma in my ankle. By the time the surgeon himself saw it, my entire ankle was purple and I almost had to go back into the OR. Personally, I worry about attempting bone/orthopedic surgery without opioids as an option. I believe anti-inflammatory medications such as Toradol as also necessary, but there would be no controlling that pain with just Tylenol, Motrin, or the Toradol. Does it require around the clock high doses of IV narcotics? No. That fusion did require a basal MS Contin for a week with Oxycodone for breakthrough pain, however, due to the complication and nature of the surgery. The ankle replacement was far easier and only required Oxycodone for breakthrough pain with Motrin as primary. There has to be some form of sense used when considering the potential needs based on the type of surgery done or the patient's condition and prognosis. I also highly recommend regional blocks if they're possible, but that's a temporary measure. 

First, I do not work with post op patients. However, being a nurse in any setting, I think we can all relate when it comes to the fact that we all have different opinions and styles of practicing. I work with some highly aggressive patients and many of them are prescribed benz os to help manage their anxiety/agitation. Many of them are also patients who struggle with addiction. I work with nurses who will hesitate to administer the benzos or flat out refuse to do so. If I see a patient is agitated, addict or not, I am going to medicate them if they have an active order for the medication. It’s not my job to cure these people of their addictions. It is my job to keep the patient and everyone else on the unit safe during my shift. If the doctor says they can have it, who am I to decide that they can’t? I think the same applies to pain meds. Unless it is a real risk to administer the med (you’re concerned about respiratory distress, for example).... just administer the med. if not, you’re going to make your shift worse having to deal with an unhappy patient who may very well be in pain. Worst case scenario, if you think they don’t need the med and/or they’re abusing it... notify the MD and have the order modified or DC’d. I’ve had conflicts with other nurses over this but I feel pretty strongly about it. I have also notified doctors before that I think a certain med should be DC’d r/t abuse and with it being common knowledge that I’m liberal when it comes to administering meds within order parameters, they almost always DC the med. problem solved. No more arguing with the patients or debating in your own mind... it’s a simple, “you don’t have that ordered.”