ortho post op pain control - page 2
At our facility we used to have a pt come from O.R. to the unit with and epidural already infusing. After a few mishaps (pt not being able to feel legs for a day) we are now starting them only when... Read More
Mar 3, '06You may consider starting the epidural or PCA before the patient starts to feel pain. You can do vigilant neuro and blockade level checks and if you see any sign of movement or sensation progressing downward, you hit them with what is available fast. Otherwise, as you found out you are playing a game of catchup and the patient is practically delerious with pain(which always is followed by nausea). Pain management is an art isn't it. Each pt is different of course.
Mar 3, '06I guess our hospital is own the lower of end of pain medication. We very RARELY ever see an epidural on an Ortho patient, however we did just have a patient with one who had a Bilateral Knee Replacement And he ended up with a partial ileus yesterday.... One of our docs gives very little pain medication, the most is about 2-4mg of Morphine IM Q3-4hrs... and then they have Tylenol.... And to be honest his patients seem to do better than those we want to stay gorked out with tons of medication... And he still uses CPM machines on his Knees, and they do great....
Do ya'll reinfuse your knee drains?? If so what kind does your hospital use?
Mar 3, '06Our hosptial uses a GISH type orthoinfuser system.
Most post op knees are given a PCA, started in PACU along with PACU meds titrated until they are comfortable enough. Most have single shot epidurals but no infusion. Alot has to do with the "coctail" given pre-op by th orders of the surgeon. The ones we have use Oxycontin, steroids, nsaids(sometimes). The big problrms with the recall of certain COX-2 inhibitors have made a negative difference in our outcomes. Those worked well. Docs have to be creative and may be very responsive to suggestions, the good ones at least.
Mar 4, '06Our hospital uses stryker drains for reinfusing, and we use them on nearly all of our knee replacements, of which we do nearly 20-25 a week. We also use duramorph in surgery and post-op morphine PCA's, then switch to oral pain pills on POD 1. Scheduled toradol every 6 or 8 hours for 48 hrs is also the norm and is wonderful. Especially for those patients that have PT 30 min before their next pain pill is due. You can just give the toradol and they have a comfortable therapy and can hold out for their next pain pill. We have had great results with this routine. We also have a joint camp program. Does anyone else have a similar program in which patients go to a pre-op class and know every step of the process before they come in? It's great, our patients sometimes go home POD 2 with total hips or total knees. I'm interested to know of similar programs to compare.
Mar 10, '06Yes, wisconsinortho, we have a preop joint class. We are moving towards a total joint camp therapy approach as well.
Our class is 2 hrs long which we offer every other week. We try to get all the info in about the surgery and routines of our unit. The patients' do much better if they attend.
We have the class on powerpoint with a video and now have the ability to send our class to almost every rural medical center in our large geographical state via the satellite. (I teach this class if the regular instructor is gone).
We also use the re-infuse for our TKA, but not for the THA.
Pain mgmt is so individualized...some do great, others not so great.
In the class we have a pain pharmacist talk and they (two for our unit) see the THA/TKA patients once a day and are on call 24/7 for us if we need them, it is a GREAT protocol as they help us manage the side effects too (ie post op puritis from the intrathecals).
We turn off the PCA's POD #1, but we have one doc who has us try oral analgesics first and forego the PCA if we can. His patient's seem to do just as well as the rest.
We use CPM's, but only for a couple of docs who like them.
We rarely use epidurals any more, too many patients with "jello-legs" that we cannot get OOB.
Length of stay is 3-4 days fro TKA/THA.
Mar 15, '06I've worked ortho at 2 different facilities. In one facility, it was not unusual for a post-op to have a morphine or demerol PCA as well as phenergan and Lortabs prn. Also used Marcaine pain pumps quite a bit and they were very helpful in controlling pain. Also utilized stryker autoinfusion drains and CPM's (most patients came back from PACU with the CPM already on).
The current facility where I work generally uses either morphine or dilaudid PCA's which are normally discontinued at noon POD 1. Some patients also have a basal rate from 10P to 6A on the PCA's. They are immediately started on vicodin es, which we also administer 1 hour prior to the patient attending therapy. We hardly every use Marcaine pain pumps or CPM's, and I have never seen an autovac used here. A good many patients are now receiving femoral nerve blocks in PACU which lasts about 8 hrs then whoa nelly! Some groups are using a cocktail consisting of ms contin bid, tylenol, celebrex, and roxycodone prn. Only problem is the ms contin can cause over sedation, confusion, and of course upset stomach, so a lot of patients prefer not to take it. We also use toradol (a wonderfull but underutilized medication) unless they are on lovenox. Anticoagulation is another issue. We normally use either coumadin protocol or lovenox bid, but one group is switching over to ASA 325mg bid.
I try to medicate everyone Q4hrs just to keep the pain under control. Many patients appreciate that.
Mar 16, '06Our ortho unit has approx. 20 total joint replacements weekly. They are soon going to be required to attend the "Joint Class" preoperatively, thank goodness. Aneshesia has started using something better than Duramorph called "Depodur". If used in conjunction with say, a Marcaine spinal (which typically wears off in 4 to 6 hrs) pain control is almost perfect. No PCA's can be used, or any other narcotic, for 48 hrs. due to resp. depression. Can use Toradol, usually limited to 4 doses (q6 hrs prn) and Tylenol 1 Gm q6 hrs. The worst side effect is resp. depression after a Depodur, sometimes necessitating the use of a narcan drip. Our unit has improved dramatically since the addition of a Nurse Practitioner for the total joints and hip fractures. We currently have about 10 ortho docs in our city of 150,000, but not all do joint replacements, so there is usually a several month delay in getting your surgery done. With improvements in earlier mobility (day of surgery) and pain control, our average length of stay for a knee is down to 2 days postop, sometimes 3 days.
Mar 16, '06I forgot to add that some doctors here like using the reinfusion drains (cell-savers they're commonly called) within the first 6 hrs. of insertion (otherwise, the RBC's start to break down) after surgery. But the ones who don't like them cite various studies that link fatty emboli to the use of reinfusions. So everytime I use one, like every day, I wonder if I could possibly be adding to their troubles!
We recently had a patient have a fatal thrombocytopenic reaction to Lovenox (Enoxoparin, or, low-molecular-weight-heparin) Very upsetting.
Jun 21, '06We only get our total knee patients back with epidurals infusing. THey are basically bedridden for 3 days. We just started getting patients with Femoral and sciatic block that work great also we are going to be getting some patients with a new drug called depodur it is a long lasting morphine type injection that they get pre-op
Jul 6, '06I work on a very busy 52 bed ortho floor. We do probably 30-40+ total joints a week. Our pain protocols have been tweeked over the years by a team of ortho docs and anesthesiologists. Patient's are given Oxycontin prior to surgery, along with a cocktail of other meds to decrease incidence of nausea. They are given intrathecal injections. Oxycontin is started immediately postop and continued X 2 days. There is hydrocodone and oxycodone available for breakthrough pain. If these don't help, Morphine or Dilaudid can also be given. We rarely have anyone with pain out of control. We almost never use PCA pumps. All meds are either po or IV. I can't tell you the last time I gave an IM pain med. Times have really changed in the last 20 years! When the pain is controlled well, patients move better. We are now discharging a good percentage of total hip/knee patients in 2 DAYS!
May 9, '11"we have a specific pain relief team that is consulted as needed, which is great. they can get pretty creative with their med orders."
you are very fortunate to have a pain relief team! i am a first-year night nurse on an ortho/neuro unit. when pain control is a problem it causes me a lot of stress i have asked several co-workers for tips - they each seem to have different approaches. can anyone suggest a resource to help me learn and grow in this area?