Post op patients who take narcs at home

[sharann, BSN, RN]

A problem we are encountering more and more is the post op patient(in the PACU and beyond) who is on vicodin or Norco or something similar for months or even years who then has surgery. WHOA! They are soooo difficult to manage pain wise. Is there a protocol or suggestions for this because our anesthesiologists and surgeons are clueless about this. We need to have a better plan than constantly medicating like crazy to play catch up so the patient stops screaming(literally). These are NOT what people call drug seekers, they simply have an extrodinarily high threshold for narcotics due to the long term use.

Are there things they can take pre-op that may help? Any insight would be great. Thanks.

[yoga crna]

I do a lot of anesthesia for patients who are taking various analgesics at home for various conditions. They are fairly easy to manage during the anesthetic, because of the nature of the anesthesia meds, monitors and techniques. For post-op, my recommendations depend on the type of surgery they have had. If they have a procedure which is painful, we give them a strong opiate, such as morphine or dilaudid. We are also very big on pre-emptive pain control and have the surgeon inject local anesthesia in the surgical site. If it is not painful and they are going home, we tell them to take a stronger dose of vicodin or to take it more frequently. Surgery is not the time to detoxify a patient for narcotic use. Post-operative pain control is important in healing, in maintaining normal vital signs and patient acceptance of the surgery.

Yoga CRNA

[sharann, BSN, RN]

Thanks Yoga. I agree that post op is not the time for detox nor is it my concern. I am trying really hard to get the docs with the program. People who take alot of narcotics at home have different post op pain needs than the opioid naive patient. Toradol is a great adjunct to most but many of the docs are afraid of bleeding from it. The use of local is a good idea and some docs are on that one fortunately.

Take care

[tjb6929]

sharann, i agree with yoga crna- we frequently use morphine or dilaudid in PCA form to help control post-op pain. Both are very strong opiates that usually are very helpful even to long-term narcotic users. Toradol is excellent as well, since much of the pain is caused by swelling. there is usually a 6 day limit on toradol, however it is helpful during the initial post-op period which is usually the most painful. hope this was helpful.

[kaylaRN]

Ask the patient pre-op what doses they take at home of both long acting and breakthrough pain meds. Then use an equianalgesic chart to find out what dose of IV medication they would need to equal what they take at home. If you are using a PCA, this dose would be their continuous, or baseline requirement. Basically, you want to get them at the level of opiod that they are used to. Additional pain meds would have to be ordered post op to account for surgical pain, which will be in addition to their chronic pain. Another REALLY important tip is to make sure they take their long acting pain meds (or the equivalent) pre-op on the day of the procedure... if they are NPO they should take it with a sip of water. If they miss their regular long acting med they will be way behind on their pain by the time their surgery is over.