Pain

allnurses Guide · Sep 25, 2007

Had a pt this weekend with severe (9-10/10) pain in a lower extremity, burning, intense, continuous, probably r/t Hx lumbar spine injury. 2mg Dilaudid IV push Q2H gave inadequate relief.
Limited prns available. Toradol gave some relief, but not tolerated in the GI tract. One prn available was Valium, 5mg, IV push Q6H. Until recently, we weren't allowed by P&P to push IV valium on the floor. That has changed, we can give it IV if we monitor BP and resps, but neither I nor my CN nor any of the coworkers I look to for advice was comfortable with that dosage and route. Called service and got order for 5mg p.o.--it didn't really help the pain, but did allow a few hours of sleep. Also got MS Contin 15mg Q12. No immediate miracles there, either.
My question: what do you think of that IV Valium? As nearly as I can tell, it would have been legal, but I tend to concur with the consensus at work that that's a pretty big dose, IV. We use Ativan by the bucketful, but the universal reaction to that valium order might not meet the PG-13 guidelines of this forums TOS. Are we just scaredy-cats?

I looked up the dosing in micromedix and Tarscon's Pharmacopeia. Both gave doses of IV 5mg every 3-4hr prn for muscle spasm. While possibly not what your patient had, the dosage is well within the recommended dosage range.

The other thing about your patient is they obvisously have a pretty high tolerance to drugs...so I am betting that either they take a lot of medications (specifically pain meds &/or are a chronic alcohol). As my one professor says "they have a well trained liver".

One of the things I have learned working with physicians/providers is that the reference books they use and what we use are often quite different. I keep a tarascon's pharmacopeia and a physician's resident's guide in order to figure out where the physician is coming from sometimes. It prevents a lot of miscommunication.

leslie :-D · Sep 25, 2007

i've never given more than 5mg valium ivp.

that was the max.

i hate using the iv rte for this drug.

first, it needs access to a lg vein.

and it still hurts like the dickens.

i would have given it, i think.

with VERY close monitoring of resps, bp...

if he was in that much pain.

you can always call pharmacy and get their input.

leslie

nursemike, ASN, RN · Sep 25, 2007

Appreciate the info. My other concern is that the pain appears to be neuropathic, but, yeah, I hoped relaxing the muscles might take pressure off the nerve. Narcs weren't doing a lot of good. He certainly wasn't opiate-naive. He said he'd been on 4mg Dilaudid IV, Q2H, at another facility, and had been exceeded his prescribe dose of Percs at home for several days prior to hospitalization.

nursemike, ASN, RN · Sep 25, 2007

you can always call pharmacy and get their input.
leslie

they also said "Holy crap!"

but thanks. i'll be more open to the idea, next time, but still very careful

allnurses Guide · Sep 25, 2007

Appreciate the info. My other concern is that the pain appears to be neuropathic, but, yeah, I hoped relaxing the muscles might take pressure off the nerve. Narcs weren't doing a lot of good. He certainly wasn't opiate-naive. He said he'd been on 4mg Dilaudid IV, Q2H, at another facility, and had been exceeded his prescribe dose of Percs at home for several days prior to hospitalization.

I doubt very seriously that normal dosing of anything could OD this person. I have been amazed at how much drugs a normal person can take sometimes...I actually gave one patient in the PACU 60mg of Morphine IVP push over about 2hrs, under the supervision of the anesthesia provider, and the patient had absolutely no effect from it. He was still sitting up straight on the stretcher c/o pain from a very minor procedure.

One thing I have been wanting to try on a patient like this is Ketamine. I have studying Ketamine in anesthesia school and you can use it to reverse opioid tolerance, but is something I doubt that would/should ever be done on the med-surg floor.

sharann, BSN, RN · Sep 25, 2007

I would think that your prior attempts at medicating this patient were well documented and the fact that pain was still high that this is a good doasage for him. I would suggest supplemental oxygen be close by as well as knowing the antidote to reverse this drug (Romazicon). I would also want my patient on an apnea monitor. Has anyone tried a PCA pump on this patient. Perhaps this would help and the doses could be titrated(as ordered) and perhaps a basal rate could be implented. This is such a hard thing to deal with, feeling like you are unalbe tohelp someone! Keep trying.

Give the Valium really slowly IVP, even consider 2.5mg then the other half 5 minutes later.

anonymurse · Sep 25, 2007

Had a pt this weekend with severe (9-10/10) pain in a lower extremity, burning, intense, continuous, probably r/t Hx lumbar spine injury.

Here's a short quote from http://www.emedicine.com/neuro/topic516.htm :

"Principles for medical management in the chronic stages of LBP and disability differ in several ways from those in the acute phase.

"Tricyclic antidepressants are useful in chronic LBP to alleviate insomnia, enhance endogenous pain suppression, reduce painful dysesthesia, and eliminate other painful disorders (eg, headaches). In addition, these medications may improve the patient's ability to cope, and they may reduce depression, anxiety, or fatigue associated with chronic LBP.

"Anticonvulsant medications may reduce paroxysmal or neuropathic pain.

"Calcium channel blockers and alpha-adrenergic antagonists are useful for treating LBP when it is associated with a complex regional pain syndrome.

"On occasion, narcotics may be used to maintain function and mobility in a patient who has an acute exacerbation of chronic pain. However, continuous use of opioid analgesia for LBP is generally reserved as a final treatment option. When necessary, long-acting opioids should be given on a time-contingent dosing schedule rather than as needed. Improved function for achievement of vocational, recreational, and social goals are better measures of medication efficacy than subjective estimates of pain relief."

nursemike, ASN, RN · Sep 25, 2007

I did document pain assessment and follow-up with each prn dose, but didn't page for every follow-up greater than 5/10--they were all greater than 5/10, service was aware, and I think they were genuinely trying to find this man some relief. He was also started on Cymbalta and Lyrica, neither of which was helping, initially. I would imagine the dosage of Lyrica will be increased, unless surgery makes it unnecessary.

It's a frustrating situation. I tried to help him establish a goal for what would be a realistically tolerable pain level. Sittting here at the computer, or even this morning with achy feet, you'd think maintaining a 6/10 pain level would be better than 9/10. But if you're the one with the 9/10 pain, you don't much care whether your nurse completes a careplan. All he knows is it isn't as bad for about 45 minutes after the dilaudid. (In effect, he's saying 8/10 pain is his "goal," but I just charted "unable to establish a working goal at this time."

Patient was not interested in a PCA. I guess he'd had one on a prior hospitalization and it wasn't effective. Seems like 0.1 or 0.2 of dilaudid every six or ten minutes would spread the relief more evenly, but I suppose he was too desensitized. (I'm not entirely sure what his history has been, but it sounds like this is one in a series of exaccerbations over the past few years.)

One thing I'm finding is that what bed you're assigned to can make a big difference. My floor is neuro/neurosurg (patient was admitted under medicine, with an NS consult). A year ago, my Dad was admitted for CHF, but the only bed available was on the Onc unit. He got wonderful pain management. My unit keeps the fish happy--we typically give 0.1 or 0.2 of dilaudid and dump the other 1.8 in the cartridge down the drain. It actually scares me to give a whole 1mg, although it was pretty clear my pt wasn't going to OD.

So, I'm asking myself why a cardiac pt on a cancer floor gets better pain control than a cardiac pt on a cardiac floor, and I'm thinking it must be because the cancer nurses are more rabid in their advocacy.

This is making me think that even though I'm happy that our nominal patients usually don't have a lot of pain, I need to find ways to advocate effectively for those who do. Maybe I need to do some on-call on the cancer floor...

PS I understand the pt was to see an attending neurosurgeon today, so hopefully he'll get some lasting resolution, soon. Pain service will be in-house, too. Sometimes nursing on weekend/nights feels like being stuck in the 19th Century.