PACU pain medication

[Munimula]

I am a new PACU nurse in an ambulatory center (I have been a floor nurse for three years). Even though up to 2 mgs dilaudid (0.5 mg every ten minutes) may be ordered for pain control, patients seem to a) sometimes not respond well, i.e., still have pain after administering the dilaudid, and b) get nauseated and vomit if I go above 1 mg. Some nurses I work with advise not to give over 1 mg due to the eventual nausea, and others medicate up to 2 mg. Sometimes Toradol is ordered if not given during the surgery and patients seem to do well with it. My question is, what do you, other PACU nurses do?

I have also read other postings regarding post-surgical pain. I realize that every patient is different and will respond differently to surgery, anesthesia and pain. Also, that the idea of complete pain elimination post-surgically is not realistic. (We also use ice and elevation depending on the surgery.) I am interested in your opinions.

Thanks!

[meandragonbrett]

The two things in PACU that are going to induce nausea/vomiting are opioids and the volatile anesthetics. Try diluting your dilaudid. 2mg in 10ml NS and then give 1ml q2-3minutes. The key to successful PACU medications are small doses that are titrated to effect. I routine give 2mg of Dilaudid and 200mcg of Fentanyl in an ASC PACU in the first 15-20min if needed. Hydration is another factor relating to N/V in PACU.

And some people will just barf regardless of what you do. Droperidol is a fantastic drug but many facilities no longer have it on formulary.

[brownbook]

In work in an ambulatory surgery center. We do a variety of "routine" common out patient surgeries. I have given dilaudid maybe once in the past few years. Hardly ever morphine. Most often fentanyl is the first drug ordered for pain, maybe 25 mcg for pain 3 - 5 and 50 mcg for pain 6 - 10. (I am just guesstimating these numbers, I'm tired and can't remember exactly what the scale usually is.)

It is really rare to have patients to be in severe pain or even vomit post op. I don't know why? Are our anesthesiologist really exceptionally great and the patients come to us with the pain at a low level and antiemetics already on board when deemed prudent?

I know orthopedics is a whole other world. We seldom do orthopedic surgeries, which are among the most painful post op recoveries. When we do them we do nerve blocks but I know those don't always work. If you are dealing with orthopedic pain the dilaudid makes sense.