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pain management in infants with chest tubes

NICU   (4,851 Views | 15 Replies)
by dopeyrn dopeyrn (New) New

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How do you manage pain in infants with chest tubes? I have an infant on nasal cannula now, after being vented, but has had a chest tube for four days now. We gave fentanyl prn when intubated, but now when asked for some kind of pain medication the physician, the physicians say baby is irritable because he is hungry. I agree tha's part of it, but I think pain is a big part of it.

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BittyBabyGrower is a MSN, RN and specializes in NICU, PICU, educator.

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We ALWAYS give pain meds for chest tubes! That is one of the most painful things to have, and I can speak from experience on that one! I thought I was going to come off that bed everytime I moved because it is rubbing the pleura and inbetween your ribs. We had a kid with a chylothorax that had mulitiple tubes for 2 months...we kept that kid on a gtt.

Make sure you are documenting your pain scores and under your problems you need to put that your goal was not met for pain management. I would also get the CNS of your unit involved on this one. That is barbaric IMHO.

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twinkletoes53 specializes in NICU.

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We have the same problem with our docs. being OK with giving narcotics while the infant is intubated; but once the ETT is out...they seem to think that the babies are no longer in pain. Document your pain scores. I will bring a doctor to the bedside, NPASS score in hand, and show him exactly how the little one is over our designated goal. We cannot document a goal of 0-1, then have in infant with an NPASS score of 5 or > without also documenting what we did about it. Ask your MD for a lower dose of Fentanyl or Morphine than when the baby was intubated. Some docotrs just seem to be clueless. I could tear my hair out with them! Narcotic drips help, if the docs are afraid of the side effects of narcotics. By the way, I have rarely seen respiratory depression if the narcotics are dose-appropriate for weight, diluted, and given over 10-15 minutes on non-intubated babies.We also ask for Tylenol for these infants. Does your unit have a SweetEase policy? We use this, too, as a way to soothe the babies, since crying makes the pain worse.

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121 Posts; 2,929 Profile Views

None of our babies on HFOV or conventional vents are ever on narcotics, unless they had a recent perforation/OR and then they wean over 2 days. I don't understand, adults are always sedated. These babes are on the vents for months.

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elizabells is a BSN, RN and specializes in NICU.

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Pain meds for chest tubes? Oh, that would be nice. Most of the time I can't get them to order meds when they're putting the chest tube IN, like not even lidocaine, let alone Fentanyl or somesuch.

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BittyBabyGrower is a MSN, RN and specializes in NICU, PICU, educator.

1,823 Posts; 12,879 Profile Views

OMG....I would be furious! Dont' you all get dinged on chart reviews for your goals in pain management not being met? We were dinged 2 years ago by JaCHO!

Your docs would not want me in their unit, that is for sure! We medicate for intubations, chest tubes, picc placements, use lidocaine for LPs, all HFV and OSC are on fentanyl drips with boluses of versed, sometimes vec. Our pain management has totally evolved in the past two years! We have a pain management committee that meets with the collaborative committee each month and if there are issues with any one attending, it is brought up there.

We are also finding that newer residents and new fellows are big pushers of pain management, because that is how they are being taught. The older ones will balk, but know we will not back down and will go over them if need be.

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elizabells is a BSN, RN and specializes in NICU.

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Oh, bitty, they hate me too. I got called into the principal's office and warned that my Pyxis usage was being monitored because I actually, you know, GAVE PRN's when they were ordered on an ECMO baby.

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Imafloat has 13 years experience as a BSN, RN.

1 Article; 1,289 Posts; 11,603 Profile Views

Oh, bitty, they hate me too. I got called into the principal's office and warned that my Pyxis usage was being monitored because I actually, you know, GAVE PRN's when they were ordered on an ECMO baby.

OMG, are you serious? Don't you wish you could throw the doc down on a bed and intubate, put an NG tube down, use a cold wipe on his bottom, insert a chest tube, do an LP, and a circ, all without pain meds. Maybe then he would get that these procedures hurt or are uncomfortable. Maybe, you could put his intestines in a silo and push on them and see how that makes him feel. Grr...'my' babies being in pain is something that gets my panties in a wad.

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twinkletoes53 specializes in NICU.

202 Posts; 11,888 Profile Views

studies conducted over the past 2 decades have come to the conclusion that premature babies feel pain, and their responses to undermedicated pain can last a lifetime. here are links to a few sites that talk about this.

"premature babies have altered sensory resonses in later life": [color=#0000a0]http://www.sciencedaily.com/releases/2008/12/081222100710.htm

http://www.medpagetoday.com/painmanagement/painmanagement/9984

[color=#0000a0]http://www.medpagetoday.com/painmanagement/painmanagement/9915

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elizabells is a BSN, RN and specializes in NICU.

2,094 Posts; 18,663 Profile Views

You guys, if I told you how hard I had to fight and kick and scream today to get ONE DOSE of PO Tylenol for a kid who'd just been circed, who was lying there going ballistic, PIPP score of 10, with no fewer than FIVE doctors at my bedside watching him lose his mind, all "Oh, he just wants his pacifier" and "Maybe he's hungry!" No, maybe he just got the END OF HIS PENIS CHOPPED OFF.

Jesus mercy, there are three residents and two attendings who are very, very lucky they made it home without having an isolette thrown at their heads today.

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twinkletoes53 specializes in NICU.

202 Posts; 11,888 Profile Views

elizabells, here's a link to a site that describes the pain infants go through during and after circumcision. i'd highlight the pertinent parts, and post it in the mds lounge or conference room, complete with photos. there's also

a video associated with the site.

[color=#0000a0]http://www.circumcisionquotes.com/index20.html

what neanderthals some mds are. hey, doc, let me slice a piece of your finger off (i doubt they'd let me slice what i truly wished to do); pour a dab of alcohol on it (urine touching a newly circumcised penis), and when you curse me out for what i did, i'll just offer you a cheeseburger.:banghead:

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elizabells is a BSN, RN and specializes in NICU.

2,094 Posts; 18,663 Profile Views

yappy, the thing that's frustrating is that we've DONE all that. JHACO hit us hard on our (total lack of) pain management this summer. The issue is a total culture change at this point. The knowledge is there, but the will is not.

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