Pain Not Controlled With Dilaudid Pum

Specialties Hospice

Published

Hi everyone,

Long time lurker here. I have a question for all you nurses our there. I have a PT in pain crisis and is on a dilaudid pump. She is allergic to morphine in all forms. The problem is I have never had anyone on 42mg/hr and still be lucid and in pain. She is getting Ativan and Valium. Do any of you have any suggestions for controlling her pain. We are all stumped at my office and are pretty sure that she is not metabolizing the drugs. The needle was changed today and the pump is working properly. We even had the pharmacy send out a new bag to be sure that, that was not the problem. Any ideas???

Thanks

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Specializes in Hospice, Palliative Care, Gero, dementia.

What is her terminal dx/source of pain? What is the nature of her pain? Have you tried any adjuvants? Is there a nuropathic component to the pain?

What has her titration been like? Many titration orders are not written appropriately -- they go up by the same amount (say 2 mg) each time when it should be a percentage -- usually 50% to 100% for moderate to severe pain. (see fast fact http://tinyurl.com/6zjtas)

Also, could she be suffering from hyperalgia? It may be that an opioid rotation is in order -- fentanyl or, if you have someone knowledgeable about managing it, methadone might work for her.

If nothing else works, would it be possible to consider an in-patient stay, maybe short term palliative sedation?

good luck!:redpinkhe

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Wow. That is a huge dose for IV dilaudid. What is the pain source? Is she on any adjuvants?

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i agree about getting her inpt.

we use methadone quite frequently, with amazing results.

but it really has to be closely monitored.

is she stating any relief at all?

leslie

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We have started her on Duragesic and are trying to titrate the Dilaudid down. She has an admitting dx of Lung Cancer. She has numerous tumors encircling her organs and blood vessles. We have also ordered Valium since the Ativan that she has been on is no longer working. She is no longer able to swallow as well and is having intractable nausea. We are going to try her on a BAD infusion (benedryl, ativan and decadron). We were going to try ABHR but she is allergic to reglan. She has numerous allergies to all the good medications. She has allergies to phenergan, compazine and of course the reglan. We have spoken to the family that if we cannot get her controlled by today, we will have to place her inpatient. Family understands but it is their and her wish to die at home. So we will give her another 24 hrs. The MD was also contacting a cancer specialist and pain specialist for a consult for her pain and nausea. Will let you know and thanks for the suggestions.

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Specializes in Hospice, Palliative Care, Gero, dementia.

Have you tried haldol for the nausea?

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Have you tried haldol for the nausea?

We are trying that now.

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Specializes in Hospice, Palliative Care, Gero, dementia.
We are trying that now.

ah. Good luck. Hopefully the specialists can offer some good ideas.

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Sounds like a very challenging case. I hope you are able to achieve comfort for her soon. Sounds like her whole CNS system is super sensitized to all stimulation at this point.

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thorazine is another agent that is effective for nausea, anxiety, agitation.

leslie

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Thanks to all of you who have responded. We have started her on a B.A.D. infusion and so far that seems to be allowing the dilaudid to work. Keep your fingers crossed!!:yeah:

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That's terrific news! Got 'em crossed that it continues! :yelclap:

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