Pain Management

[Sweeper933]

Since this issue keeps popping up in other threads, I figured I'd just give it it's own thread

Quote:

Originally Posted by Sweeper933

Our docs usually want then sedated to the point where they're not breathing over the HFOV at all...

I'm sorry, I know this isn't that funny and I'm tired, but... :lol2:

That would... never happen. Ever.

I really should report them, huh? The problem, as I see it, is that they have what SEEMS like solid medical reasoning for not sedating. I wonder how that would hold up to JCAHO's decision to make pain a priority. Hmmm. ::elizabells makes thinky face::

A few months ago we had a baby with a pretty severe DH. She went straight to HFOV w/ 20 of iNO at birth, and quickly bought herself a few chest tubes as well... Our docs didn't want her moving a muscle. She was on fentanyl, pavulon, and atavan drips - with prn boluses of pavulon and atavan ordered as well. As soon as she would be moving even the slightest, she would start shunting / desating a ton. The pain meds worked wonders for her. It did take us a long time to get her off of everything - I believe she was on methadone to help taper everything off as well. Point being - she behaved so much better when she was completely sedated. I can't imagine her surviving without them.

Here are a couple of resources that my unit has used to form our pain policy/procedures:

AHCPR (1992) Pain Management Guidelines

McCaffery, M. (1999). Pain: Clinical Manual

Anand, K. (2001) Consensus Statement on the Prevention and Management of Pain in the Newborn.

JCAHO Pain Management Standards

[SteveNNP, MSN, NP]

Would anyone else care to share what their unit does for pain management, such as protocols, pain scales used, meds used, etc?

[elizabells, BSN, RN]

In addition, any specific arguments against the following justifications for undersedation would be so very appreciated:

1) It (sedation) makes pt. support ventilation (like SIMV) less effective because of decreased respiratory effort

2) It promotes ventilation/perfusion mismatch

3) It makes neuro status too difficult to assess

This is going to be an uphill battle for those of us who are trying to change our unit cultures, so any "weapons" you guys have would be so helpful.

[Sweeper933]

We use the NPASS score as far as what we use for evaluating pain. I know you guys are facing a rather large uphill battle, but to me it almost seems like common sense to give adequate pain meds to extremely sick babies... Yes they do affect the respiratory function - but when you have a kid on HFOV or SIMV on a really high rate... it's not like you're going to be extubating anytime soon. It makes no difference if they're not breathing much over the ventilator. It's not like you can tell a baby to just "chill out and not fight the ventilator"...

I'm gone from work until the new year (yay!!!) but when I return I can look more into our protocols and references and whatnot... I will even ask our docs for their opinions / sources...

[MegNeoNurse]

In Re: to pain management. Is it common practice to give a pt. fentanyl ONLY intra-op for a PDA ligation, then ONLY fentanyl post-op Q2hrs and bolus PRN. Seriously? I am beginning to become appalled at my unit's pain management. We do not medicate our vent patients (SIMV, HFOV), we are lucky to get an order for fentanyl PRN agitation.

I'm no RN (yet - 1 semester left!) but talking to the nurses I work with in NICU (I'm a tech/clerk) about patients' pain control after reading the threads on this board has me irate! I couldn't believe that only fentanyl was given during the PDA ligation. The nurse that had that kid reminded anesthesia about the pavulon (she said he didn't need it!) and post-op BEGGED the neo for a drip, but NOPE. Is it just me or is that completely EVIL? Why do we even use NPASS to assess pain if they aren't going to do anything about it, or flat out ignore that because a baby can't talk/scream/complain because he's a baby and can't cry because he's intubated doesn't mean he doesn't hurt!

Interested in what your units protocol or usual meds for this procedure.

(Sorry there was a bit of a vent mingled in with my question.. haha.. just got off work)

[Sweeper933]

As far as our PDA ligation procedures goes, our babies will usually get pavulon and fentanyl during the procedure. I can't remember the dose of pavulon off of the top of my head right now, but they usually get a 10mcg/kg bolus of fentanyl during the procedure. Afterwards, we always have prn orders for fentanyl (as long as they're still vented). If they end up extubating shortly afterwards (like it was the PDA that was keeping them stuck on the vent in the first place) we can usually get prn orders of tylenol for a day or two.

[prmenrs, RN]

I think it's really important to have accurate pain assessment documented. Even if they're paralyzed, their VS will probably be altered. IMO, N-pass is waaay better than PIPP.

If you can get them to help, the NM, CNS, educator, whatever nursing leadership is available is critical. IMHO, you can't win w/o them. Also, you need the nurses in non leadership position who have "power". If you get @ least one of them to crack, you have a toe in. They will help change happen. (what do you remember about psych of change??)

And, I still think JACHO can help. @ the very least, it puts the docs on notice that their pain control practice is NOT the norm of their peers. One would hope that would make a difference, but who knows?