Question/Concern about pt and Dilaudid IVP

jmgrn65, RN · Jun 17, 2008

she obviously is taking alot of pain meds outside the hospital and has built up a tolerance. If her vs are stable than can tolerate, dialduad is fast and shorter acting so it gets through quickly.

ohmeowzer RN, RN · Jun 17, 2008

she must have built up a tolerance for it , she's probably has been in and out of the hospital alot...

i had a patient who took dilauded at home , and took ( no lie) 45mg , yes 45 mg a day.... and she had a history of pancreatits ... and she was very young.. i mean teenager young... she was also on xanax 1mg tid in between ... and a dr put her.... a young girl on this stuff.... i couldn't believe it until her mother showed me the bottles for her med reconcillation sheet.. crazy... and her mom lets her take this ... stuff

i didn't even know diluaded came in dosages that high..

sissiesmama, ASN, RN · Jun 17, 2008

she must have built up a tolerance for it , she's probably has been in and out of the hospital alot...
i had a patient who took dilauded at home , and took ( no lie) 45mg , yes 45 mg a day.... and she had a history of pancreatits ... and she was very young.. i mean teenager young... she was also on xanax 1mg tid in between ... and a dr put her.... a young girl on this stuff.... i couldn't believe it until her mother showed me the bottles for her med reconcillation sheet.. crazy... and her mom lets her take this ... stuff
i didn't even know diluaded came in dosages that high..

Hey - you have to be kidding me!!!! My first thought when I read the start of this thread was OMG!! My dh and I are both RNs with ER experience and I have had my share of pancreatitis patients. Actually, I myself started having pancreatitis when I was 18, and in the hospital for 2 to 3 weeks at a time. My doc was giving me 50mg of Demerol and after GB surgery he bumped it up to 75mg and I thought that was a lot. Apparently not! I've NEVER heard of that much! I would have been nervous about it too.

Anne, RNC:D

happybunny1970 · Jun 17, 2008

I had a patient once who had standing orders for 10mg Dilaudid TID... The doc was trying to get her to take it IM, thinking it would hang with her longer, but she almost always managed to get it IV... with 50mg Phenergan to top it off! And she would still be talking to you... no change on her ECG, no change in her BP or pulse ox... wild how high these tolerances can be.

Thunderwolf, MSN, RN · Jun 17, 2008

Much has to do with the hospital where you work at and if the pain management team is involved. In my current hospital of employ, it is not uncommon (depending on the diagnosis and the doc) to push IV Dilaudid 2-6 mg....and I am giving 12.5-25 mg IV Phenergan as well. Yep, also, depending on the patient and medication history, a patient can often develop a narc tolerance. requiring higher doses to be effective for pain control.

kmoonshine, RN · Jun 17, 2008

The highest dose of dilaudid that I have given was 8mg IVP (patient had sickle-cell disease and had home pain medication management abuse issues). She begged me to "just push it all in". Yeah, sure thing...

If the dilaudid didn't work for your patient, some other medication should have been used (ie fentanyl). Since your patient has several pancreatitis episodes per month, she probably has a very high opiate tolerance. Pain is pain, and there's not a whole lot that we can do in the ED to "fix" it, other than treat it as such (in the ED we can't really follow up, devise a pain management program, or wean patients from opiates...). Was she truly in pain? Perhaps. Was she drug seeking? Perhaps. But rather than get upset about it or complain about it, I find that it's best to work with the patient and do what you can do. At one ED that I worked at, we would develop a care plan for patients that would frequent the ED; this way, we were consistent with their care each and every time they would present to us (and the sickle-cell patient that I gave 8mg of dilaudid to was one of those "care plan" patients, and this dose of dilaudid was included in her care plan).

On a side note and straying from your original question: I would NEVER run KCL through a thumb IV. I would tell the doc to put in a central line or send out for a PICC before running KCL into such small veins. If the vein were to blow, the person could have permanent tissue/nerve damage (KCl is very necrotic to tissues). It is a lawsuit waiting to happen. If I know I'm going to be running KCL, I use an IV site where the vein is stable and I use the smallest catheter possible (for example, lets say a vein in someone's forearm can handle an 18g; if I'm giving KCL, I'll use a 22g instead to minimize any irritation to the vein; this also helps to lessen irritation, since there is more bloodflow around the catheter). To minimize irritation, I've given KCL diluted in 1000ml 0.9%NS; I've also given KCL in 250ml 0.9%NS with lidocaine added by pharmacy. We're all in charge of our own nursing practice, but I personally would never administer KCL at any IV site below the wrist. Having a proper IV site ensures the patient is getting the medication in a timely manner; it's not effective to be running 20 mEq KCL IV over 4+ hours...oh yeah, and if you're running KCL, don't forget to put the patient on the tele monitor :nuke:

TraumaNurseRN · Jun 17, 2008

I'm wondering why he continued to use Dilaudid and didn't choose something else to see if that would have helpd better. We all know, meds don't affect all patients the same way. To continue using something that had NO affect for her pain. After the second dose of Dilaudid did her pain go down @ all?

MassED, BSN, RN · Jun 17, 2008

okay, i've been trying to look this up online and in my drug books but theres no exact answer, so i was hoping to get some others opinions...
Last week i had this pt, 59y/o (looked more like early 70's), maybe 130lbs max, chronic pancreatitis w/painful exacerbations 1-2 times/mo. pt came in around 9am to ED, pain rated 10/10, constant crying and moaning, (only place we were all able to get an iv was her thumb! four of us tried for over an hour), MD ordered 2mg dilaudid ivp.. ok no prob, half hour later, shes still yelling at us, so is her husband, that hasn't helped her pain at all, MD orders another 1mg dilaudid ivp, half hour later STILL no relief, another mg dilaudid... well this continues on till 1pm, w/in those 4hrs this smaller sized woman has gotten 10mg dilaudid ivp.. VS stable, but K+ is low so we're giving KCL super diluted at only 50cc/hr because its hurting going thru the thumb IV.. well now its not just the pancreatitis, now she wants something for the KCL infusion discomfort, AND saying that shes going to sue us all because we're not doing anything for her pain, even though i stated we were trying everything we could just short of killing her, i reported her c/o pain to the MD and said "frankly im not sure how shes still conscious but i told her i'd tell u about her pain" and hes like, "yeah nothing makes her happy, just do a 4mg IVP of dilaudid, maybe that'll knock her out and she'll be quiet for awhile". well I didn't feel comfortable giving that dose so my preceptor did, putting his pt at 14mg dilaudid IVP w/in 4.5hrs. sure enough, DOESN'T knock the pt out, and shes STILL complaining of pain! luckily my shift ended soon after so i'm not sure what the next shift did w/her but i guess my question/concern is, has anyone ever given that much dilaudid like that before w/the exception of hospice pts? its way more than the recommended doses i've been able to find and honestly im not sure how she was still conscious, most of my pts are out after 1 or 2mg ivp. obviously this lady has quite a tolerance and isn't making much of an effort to just control her pancreatitis in the first place, but after a certain point shouldn't the doc just have said NO, we cannot give u anymore? or am i just way off base?

I would say she has a high tolerance! Ha! I would also be linking that to her lack of veins and what her history was with IVDA. You sound like you did the appropriate thing and the doc was also at a loss. I wonder if at some point it caught up with her.... though I doubt it. Maybe she needed a PCA to appease her.

MassED, BSN, RN · Jun 17, 2008

yes, thought the site in the thumb for K+ was not a wise choice. I've seen it done where I work and if I am assuming care of the patient; I disconnect it and ensure no tissue damage has occurred - and call the MD. Not ok. Though I'm figuring this nurse posting was doing what she/he was told and the MD was probably just wanting it done however it could be done. But that doc should've found a central site.

Altra, BSN, RN · Jun 17, 2008

Agree that it was not the best choice to infuse fluid with KCl through such a small vein.

The doses of Dilaudid given are in line with my experience with patients with pancreatitis, Crohn's, and some other chronic conditions.

Daytonite, BSN, RN · Jun 17, 2008

You didn't say what other medical problems this patient had, but with pancreatitis I'm willing to bet there is a history of alcoholism or drug abuse. There is crossover tolerance when this is present. I worked on a detox and plenty of medical units that had GI patients and this kind of patient is not uncommon. Pancreatitis is also quite painful. I'm wondering why the doc didn't also include a few tranquilizers as well to calm her down. People who are addicted can tolerate huge amounts of drugs. It would be interesting to follow up on this patient to see how she is doing. If she isn't on a detox protocol, her pain meds will be addressed I am sure. She will most likely get a central line as well. This is all assuming she doesn't go AMA. She can probably get better drugs outside the hospital if she is able to tolerate the pancreatitis. Otherwise, feel sorry for the unit nurses who are going to get stuck with her and her threats 24/7.