Is this the norm in PACU? Have I been spoiled before????

[MomRNof2]

I recently left a PACU job of 8 years to venture into a new one. Where I left the same anesthesia was on the case from pre-op to dc and I found that patients came to me with minimal post-op pain and if present it was usually controlled fairly quickly with a couple of doses of prn meds. This new job is a whole new ball game and I am not adjusting well. In my previous job they were often given IM Demerol at the end of the case and given pain meds upon extubation. In this new job they may go through a 2 to 3 hour surgery (back surgery, rod placed in bone or tendon repaired) and have had no meds for pain since induction and often no block or even local injected. When I get them they are in extreme pain and I am trying to keep them contained while making a mad dash for meds that haven't had time to be scanned to pharmacy yet. My last patient required 10 doses of pain meds and finally Versed to get his pain where he wasn't crying, cussing and shaking. Was I spoiled with my last job? What is the norm? I loved PACU before but not liking it so much anymore.

[wannabecnl]

What you describe happening now sounds like every day to me; I just assumed it was the norm for everyone!

Is the case mix different in your new job? I find I see a range of patient pain experiences, even within the same surgery, though there are patterns that emerge with time (a certain surgeon doesn't allow blocks, some CRNAs are heavier-handed with narcs than others, etc.). My TKRs with a CSE can be out in 45 minutes as long as their BP holds steady (if not, we play the ephedrine or neo game for who knows how long). My heavy-drinking shoulder repairs with no blocks need Ativan, Dilaudid, and everything else I can throw at them, and they still leave in more pain than they should. Bellies are all over the map; some are fine when they come out and stay that way, and others are miserable and end up with post-op epidurals! A colleague pointed out that when 40-something women have surgery on their "girl parts" (we see a lot of hysterectomies and mastectomies), they usually need some Ativan; anticipating that ahead of time has helped me address their anxiety quickly, which helps with pain, too.

Do you have more ambulatory patients now? Our ambulatory pts tend to have shorter surgeries and often less long-acting narcotic on board, so they are in more pain... and I can't give them the long-acting stuff and feel safe sending them home. Thus their acuity is lower, but their LOS isn't much shorter than inpatients unless they got a lot of local inside!

Finally, the "mood" about narcotics at your facility is going to affect what happens in the OR. If CRNAs feel like someone is watching over their shoulder all the time, they will be tempted to go light on narcs lest they endanger their license. This leaves you in the unenviable position of managing pain that should have been managed proactively (and with people watching over your shoulder, too!).

A few strategies: first, realize that (depending on your facility policy) CRNAs can often medicate the patient in PACU before they leave if the patient is screaming in pain as they roll through the doors. Most of our CRNAs will do this if they have anything left in their pockets from the OR (if they've used everything up, they can't, so I go on to strategy 2).

Second, one of the very first things I do in the EMR after taking report is releasing orders. I don't know how your system works, but ours separates out post-op orders that are from anesthesia, so I can quickly find them and release them. Then I go back and put in times, initial assessments, etc. Of course, I don't do this while taking report or before I introduce myself to the pt, but it is number one on the list after that. This also lets me deal with any labs or Xrays that have to get released early to happen in a timely manner!

Talk to your colleagues or watch them to see how they get around this. The fact that you worked PACU for 8 years suggests to me that something is fundamentally different about the patient population or case mix from the old place to this one (unlike a newish nurse like me who is more likely to get overwhelmed by the tasks that are second nature to you). I could be wrong, and in any case, I wish you luck and hope these strategies help you!

[Hopecascade]

It sounds like your anesthesia providers are not providing opioids during their cases. Talk to your manager and the CRNA's.It might be your patient population, are they chronic pain patients? Trying to play catch up in the PACU is rough. I don't see IM Demerol used anymore. We use IV Demerol only for a one time dose for shivering/rigors. Some surgeons don't like blocks and use local sparingly. All of your patients should not be coming out of anesthesia writhing in pain. It sounds like you worked with a better group of anesthesia providers who managed pain much better in your old job. Good luck.

[TraumaQueen57]

An anesthesia provider that does not provide pain control during surgery should be fired. JMO. Uncalled for unless there was a specific medical reason, and those are rare.

[MomRNof2]

Thanks everyone. It just seems like once they come out and regain consciousness with pain a 9 or 10 and no meds for 2 to 3 hours it is very difficult to get it under control. Just didn't know if pain control while under and upon completion and not just during induction was rare since I don't have much to compare it to. I much prefer the previous break-through control and not the latter though!

[azhiker96, BSN, RN]

I've worked in two different PACUs and would say the anesthesia provider makes a big difference. My current job is at a level 1 facility with a burn center. The burn patients can take a lot of narcotics to get pain to a tolerable level. I remember one pt who had 500 mcg fent and 2 mg Dilaudid during the case. I gave 500 fent, 4 dilaudid, and 10 morphine in PACU with the pt still oxygenating well and A&O x 3.

In some cases I've given nothing because anesthesia provided the right quantity of analgesics during the case. When that happens I make sure to let them know so they get positive feedback and hopefully will do that again.

[Pacu.teletriagern]

Wow you guys, NOT normal!!! At one major facility I was at there was a special block team that did the pre op blocks. Then if your patient needed a block post op just call them, they check it out, and almost always do a block. Regionals, Tap blocks, femoral, pops, you name it. It was GREAT. Way less narc usage, patients had better recovery, and faster since they were comfortable and not all doped up. Other places I have worked its a mixed bag, some blocks, though perhaps not as many as they could, and scattered medication usage throughout the cases, but never NO meds during the length of the case, no wonder your patients feel horrible and need so much post op medication! Sorry, that sounds awful!!!