Published Oct 16, 2001
I am interested in hearing about what other hospitals are doing to manage pain in post-CABG patients. The hospital that I work for is working on a new pain management protocol and I am interested in pain management specific to my unit (CVICU). Thank you for your input!
Our hospital started using a new drug about 9 mo ago. You may have heard of it. It is called Precedex. It is a combination analgesic/sedative that doesn't have the drowsy narcotic
effect on the patient. We can use it on intubated or nonintubated patient. Works wonders for those who have pain management issues!!! Also is better for the intubated patients than dipravan. (diprivan has always been an issue of mine d/t the lipid base.) You can wean and still keep pain under control. We have standing post-op orders where we can give up to 10mg of morphine every two hrs. We can also use tordol which I have found works for some patient actually better than the morphine. If they are allergic to, or if the morphione just doesn't work, we can also use demerol. Sometimes we use a combination of things. (oh yeah,..can use morohine with the precedex) Hope this helps,...any questions,..just let me know!!! :) :)
In our hospital pts are usually given a morphine PCA.
Whilst intubated, a background (usually 0.5 mg/hr) is used plus nurse initiated boluses (1-2mg).
Once extubated, paracetamol is incorporated. If allergic to morphine, fentanyl PCA is used. Once CVL comes out (post 36-48 hrs) tramadol is given in conjunction with paracetamol. If pt can't tolerate tramal, panadiene/forte is used. If still uncomfortable, Endone may be prescribed.
Ofcourse it still hurts when they cough (or laugh), if someone sawed thru my sternum I would be uncomfortable too!!
Mind you, often the grafts, if used, cause more pain.
That should read...
"often the LEG grafts, if used, cause more pain"
I forgot, sometimes pleural blocks are used too, but not very often.
Hope this helps Megan
In our CVICU we use fentanyl IV push for immediate post-op pain. Because our pts are extubated within six hours (usually four) we are able to start po meds very quickly. When the pt is po we have Vicodin or Darvon available, as well as IV fentanyl for the really tough stuff (also available is extra strength Tylenol). Even though the meds are officially PRN, we give them on a scheduled basis to keep on top of the pain.
Demorol, Morphine, Dilaudid, vicodin, percocet, tylenol, toradol, T3, non pharmacological methods etc. I guess we give the patients the meds that work for them. I always give patients IV meds until the chest tubes comes out, then I try to go to the pill form, unless they need IV, or course it depends.
We also use PCA's, but usually our post op CABS get 4-10mg Morphine IV every 4 hours, plus Toradol and Tylenol.
I work in a CTICU in the immediate post-op period our patient's get indocin times 3 doses which aids with inflammation. While they are intubated Morphine is used then Vicodin is the drug of choice. I have also noticed that our younger patients have a much lower pain threshold and it is diificult to control their pain.
Our facility also is using Precedex, although the drug is gaining considerably distrust from our surgeons, as extubation times seem to be prolonged (we shoot for 6 hours or less). Often times, when patients aren't quite recovering from anesthesia and are hypotensive, we typically d/c it=) I do not remember the cost of Precedex, but it sticks out in my mind as being a lot more expensive than the good ol' cheap realiable morphine.
Interesting thing is, that the same dose of Precedex (It is bolused in the OR, then set to run at 0.4mcg/kg/hour(I believe thats the correct dosage), and we turn it down to 0.2 mcg/kg/hour on arrival to CVICU) that is used on a 36 year old patient is also the same dosage used on an 84 year old patient! One day Anesthesia will answer that question for me=)
On the flip side, for those patients which are unstable/labile/bleeding, we'll leave the Precedex at the 0.4 dose until the postop complications are corrected.
Our drugs of choice: Morphine, Percocet and Darvocet. Sometimes Toradol is used with patients with normal renal function that aren't bleeders, with an intial dose of 30mg, then 3 to 4 doses of 15 mg 6 hours apart(and it usually works great!)
hoolahan, ASN, RN
BoBorn, the hospital where I moonlight is also having distrust of precedex, for the same reasons. In fact, I think they have decied not go use it anymore at all.
Our usualy protocol is that the pt comes out on diprivan, once they are warm, we follow an extubation protocl, if pt meets all criteria, CT drng is WNL, POx OK, CO WNL, etc..., we wean off diprivan over 30 minutes, reverse and extubate, usually within 4 hours.
We start a MSO4 IVP q3h around the clock (ATC) as soon as possible. ONce extubated for 4 hours, and not nauseous, we start perc's 1-2 q4h ATC, yes we wake people up for it. IT is quite effective. For pain unrelieved by the perc's, we also have a prn MSO4, the ATC MSO4 is D/C once we know the pt can tolerate po perc's. For LIMA's we find that toradol first dose 60mg, followed by 30 q6h x 3 works extrememly well, pt must have good renal function and not be bleeding or "oozing."
Interesting to see how everyone else does it. Of course, if anyone has allergies, we modify the drugs as appropo.
I work on a cardiac unit and we get post CABG patients usually 24hrs post op. Our surgeons usually use Morphine, Darvocet, and Percocet. I don't think I have seen them use a PCA or anything else like that with any of the open heart patients. We are usually able to manage the pain quite successfully with these patients. The younger (usually male) patients do seem to have a lower pain tolerance and are more challenging, but as long as we stay on schedule with the pain meds they do okay.
In our CTICU we use mainly Morphine and Ketorolac for those who do not have GI complications. If they are onthe early extubation pathway, Morphine 4-6 mg/iv and Fentanyl 50-100mcg (depending on size) x3. Once extubated, morphine until taking po well then Percocet or Darvon.
I have found that Torodol is GREAT and really helps with the chest tube irritation.
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