pain management after surgery

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62 y/o female

hx; djd, htn, & gerd- she takes 2 vicodin every 4 hours, and 1 micbo BID

s/p total knee replacement with a CEA continuous epidural of fentanyl and bupivacaine with a 2mg demand rate every 30min. 5mg of continuous infusion, total 1 hour dose of 9mg.

I get the patient at 12:00, she states no pain, within 1 hour (with husband and daughter at her bedside) she states pain as a 10/10. She is crying, gripping the bedrails, body stiff. I give 15mg. of Toradal-no relief. Call and get orders to give 1 vicodin-still no relief. The husband is now mad. He goes against my advice and reasssurance that I am calling the MD in charge of the CEA and he calls the surgeon, who then calls the MD in charge of the CEA, and we get new orders to increase the CEA settings to 2mg demand with a continuous rate of 7 mg., which is the max that I have seen on our unit -still no relief. MD in charge of the CEA comes to the floor and tops off the epidural-finally patient is able to rest

so the husband and family leave. One hour later (can you quess what is coming) patient states she is having pain 10/10. It is now shift change so the oncoming nurse has to begin my original process all over again!

Fentanly and bupivicaine usually keeps most patients pain free. Why did this patient not get adequate relief? Are these patients expecting to be totally pain free and are the MD's feeding them false information about pain levels? Did the family play a part in the drama of the situation? What could I have done differently?

I had the worst day yesterday between this patient, another patient with pain issues who actually ended up close to crashing, and a 1 day post op who was bleeding enough to drop his H&H by 2 points in less than 6 hours. Please, someone give me some sounds advice.

Rachel

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I am not familiar with all the meds but did you try any non-pharmacological routes such as guided imagery or progressive relaxation? I'd go that route if the max doses of meds aren't working.

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If it is any consolation to you, I've had days like this. AH, the life of a nurse. At least these days are in the minority.

Just a thought: Did anyone consider muscle spasms causing the pain instead of surgical pain? Pt may have benefited from a relaxant of some sort. Maybe even some valium. ;)

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Specializes in Utilization Management.

Had a patient who was not getting adequate pain relief with the epidural once.

The line was kinked. Patient wasn't getting the med. To compound the problem, the pump never alarmed.

Just a thought if you have to give an enormous amount of pain med and patient gets no relief. Mechanical failures happen.

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Specializes in home health, neuro, palliative care.

I'm not sure what your trying to say. Are you implying that your patient was exagerating her pain? A favorite quote is from pain expert Margo McCaffrey, MSN,RN, FAAN: "Pain is whatever the experiencing person says it is, and exists whenever he says it does." I read something about pain management last night on the Skyscape Nursing Connections. It talks about all the barriers we have to deal with when assessing and treating pain, including cultural differences around expressing pain. Maybe your patient didn't feel like she could say anything to you until her family was there to support her.

Pain is such a personal thing. I am very sensitive to pain, and I have always needed maximum post-surgery pain relief. I have also had to call my doctor from my bed because I wasn't getting relief. It sucks, because I always feel that somehow it's not okay to ask for pain meds. Like I'm drug-seeking or something. It's something I always discuss with my doctor prior to surgery.

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Specializes in ER, OR, Cardiac ICU.

Try unwrapping and re-wrapping the dressing if you encounter this again- sometimes the docs get gungho an turn these things into pressure dressings. Make sure your surgeon won't get made at you before you do this but I've seen it work.

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Fentanyl is an agonist, Toradol is an anti-agonist, in other words the toradol and fentanyl were to some degree canceling each other out. Also if I was understanding you correctly this pt was used to getting vicodin on a regular basis before surgery which means post-surgical she could require a higher dosage of meds than the usual pt.s you get on your unit.

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Specializes in Trauma/ED.

I have had some epidurals become inaffective after the line had worked it's way out of place. Also have had some that were never in the right place to start with (had one particular anesthesiologist that was famous for having inaffective epidurals).

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Fentanyl is an agonist, Toradol is an anti-agonist, in other words the toradol and fentanyl were to some degree canceling each other out. Also if I was understanding you correctly this pt was used to getting vicodin on a regular basis before surgery which means post-surgical she could require a higher dosage of meds than the usual pt.s you get on your unit.

I think you are confused about the pharmacology of ketorlac (toradol) Read the following pharmacology information. It is not an anti angonist drug.

"Ketorolac or ketorolac tromethamine (marketed as Toradol® - generics have been approved) is a non-steroidal anti-inflammatory drug (NSAID) in the family of propionic acids, often used as an analgesic, antipyretic (fever reducer), and anti-inflammatory. Ketorolac acts by inhibiting bodily synthesis of prostaglandins"

You may be thinking of nalbuphine (nubain) or similar drugs that are agonist-antognist drugs. Ketorolac is commonly used in anesthesia in conjunction with other analgesics with good results. The only negative I see is decreased platelet action which can cause post-op bleeding.

I agree with the posts about checking the postion of the epidural catheter and perhaps re-inserting it. Also, it was an excellent suggestion about redressing the operative site to a loose dressing that allows for better circulation and less pain. I have found in my anesthesia practice that co-administration of valium or versed helps relax the patient and makes the pain less intense. It is a very important problem and I have found that there is not one solution that always works.

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Had a patient who was not getting adequate pain relief with the epidural once.

The line was kinked. Patient wasn't getting the med. To compound the problem, the pump never alarmed.

Just a thought if you have to give an enormous amount of pain med and patient gets no relief. Mechanical failures happen.

I checked the line, the tubing and the insertion site....all were patent and effective. I cannot understand why she was still in pain. I do believe that pain is whatever the patient states it is. I know she was taking vicodin on a daily basis, but the medication we were giving her is much stronger than vicodin. I just do not understand why she was still in pain. Other than putting her to sleep and inserting a breathing tube there was nothing else to give her. It was a frustrating situation which was pushed to extremes due to her and her family's anxiety. I'm at a loss.

She also had valium listed as a daily medication but the doctor refused to co-administer it with the amount of fentanyl and buprivicaine that she was getting.

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Specializes in Day Surgery/Infusion/ED.

Sometimes people are less than truthful about what they take at home, be it prescribed or recreational. If your pt. isn't opiate naive, it's possible that she has a tolerance built up already and would need higher than usual doses of pain medication.

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I agree with Ca43. How long had the patient been taking narcotics before the surgery? I had back surgery last year. Prior to that surgery, I had been taking Lorcet 10/750 and Tylox for the 6 months that I was in physical therapy. Luckily, my surgeon allowed for the tolerance that I had built up, and I had successful pain relief after my surgery. I also agree with a prior posting. If a person is crying and grimacing, then this is an excellent indicator of pain. With all of the meds that we have available, I don't think that anyone should have to suffer needlessly. Every person's body chemistry is different, and people respond to medications differently. The first priority should have been in relieving the patient's pain. Questioning whether the patient was actually experiencing that amount of pain or if the family was encouraging the pain complaint of the patient should not have even been an issue. No one want's to see their loved one's suffer, and I am sure that it was very frustrating for them to watch someone they loved in so much pain. If a person states that they are in pain, they as far as I'm concerned, they are in pain.

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