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?
Specializes in LTAC, Telemetry, Thoracic Surgery, ED.
I had a cancer patient not on hospice getting 240mg of oxycontin BID scheduled 175mcg patch of fent at home and oxy cont + methadone 10mg QID and PRN Dilaudid 36-42mg PO Q3H and 4mg IV Q3H at one point he was on . and he could not have been more than 150-160....
All I know is if I am ever in that kind of pain, put me on a morphine drip and kiss me goodbye. And he was up walking around.
(My two cents) am on meds daily that artificially elevate my tryglicerides (650) and am now having to add tricor to try and help lower before i develop pancreatitis. one thing that i have noticed that after 8 years on this same med (not a narc) i have developed a wicked tolerance to narcs in general (8mg of morphine ivp no issues and no relief) this last time at my own er doc tried demerrol.. no pain control at all 4mg..then we switched to dilaudid i had 4 about every 40 mins because i would chew through it so fast. so maybe her other meds or liver dysfunction are to blame. ps this pain was due to a bad fall during a hypotensive sycopal episode this last sunday because of taking my daily meds off schedule on an empty stomach and trying to work after....wierd things happen i try to treat every repeater's complaints as though they were new because the first time you miss a triple a thinking oh its her again...i would feel awful...again just my two cents (im wierd i know) ps im just a tech in er... (hopeful ns student this spring)
I had a cancer patient not on hospice getting 240mg of oxycontin BID scheduled 175mcg patch of fent at home and oxy cont + methadone 10mg QID and PRN Dilaudid 36-42mg PO Q3H and 4mg IV Q3H at one point he was on . and he could not have been more than 150-160....
All I know is if I am ever in that kind of pain, put me on a morphine drip and kiss me goodbye. And he was up walking around.
amazing what kind of tolerance you can build up when you have pain... poor patient.
Me too with the drip, but I'd like for PAS to be legal (wherever I may be living) so I can choose what I want to do to, and avoid having my family see all of that heartache.
We have this lady come in to the ED several times a week with 'pancreatitis'-- {which she has}, the story of-- "I have appts with my specialists next week, I'm a nurse, blah blah blah} who is very similiar to the OP's patient- demanding, threatening legal action--"just push it all in quick, it works better that way, etc"
Nurse, RIGHT.
Anyway. It is true that people with chronic pain and frequent flyers who are drug seekers build up tolerance and require higher doses of narcotics to help with exacerbations of pain
If our docs suspect drug seeking behavior, they're very good at denying requests fro pain meds but NOT talking to the pt to explain why they're not getting their meds--leaving the fortunate ED nurse caring for these individuals in the middle, the recipient of the pt's wrath.
If the Dilaudid was not effective and your doc WAS trying to treat their pain, next time ask if you can try some other med-like Fentanyl if you can. (drug seekers typically are allergic to everything but their preferred brand)
I've put IV's in thumbs when I could find nothing else, for KCL though I think I would have requested the doc put in a central line. Could also be that the dilaudid was leaking out into the tissues surrouding the IV site, could also be why she was having so much pain with the KCL. Pt's with central lines get pain relief faster because it dumps into the system right away. I've never had to have a central line, I have really, really crappy veins and have had to have KCL before and thought I would die, feels like someone keeps poking ya with a hot poker from the fire!
Specializes in ER/Nuero/PHN/LTC/Skilled/Alzheimer's.
Toradol might have worked better for her pain, sounds like there is some pain med tolerance there also. Sometimes that is quite common with chronic pancreatitis sufferers. I have only given up to 8 mg dilaudid before but that was on a person who had dropped a table on her big toe and it was squashed like a grape. NEVER move heavy furniture while wearing flip-flops.
I did have a patient when I worked on the floor who had broken her legs in a car accident while drunk. When I got report on her from the PACU nurses, they told me they had given her a total of 16 mg dilaudid, 10mg valium, so much Demerol (I can't remember it now), and had finally had anesthesia do a nerve block in her right leg and the patient was still hollering in the background. This was all given in the hour she was in PACU. SHe was a real treat of a patient too when she got to the floor. That is the only patient I ever swore if I saw her outside of the hospital and I was drunk I'd kick her rear-end. But I'm just glad I was not responsible for giving her the 16mg dilaudid.
Try Ativan Next Time, If You Had To Put Her Iv In Her Thumb She May Be A Ivdu Or Substance Abuser Of Some Sort. Ativan Has Been Studied At Sfgh To Relieve Pain. Some Of It May Be Supratentorial And Her Husband May Be A Little Co-dependent As She Does Have A Chronic Disease.
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:
I was wondering about the iv K as well. If she was alert and talking why not give PO KCL. Potassium in a thumb- no way, especially since she was such a hard stick needing pain meds. I never risk blowing an IV. If she was to be an admission I would have asked for an EJ, PICC (our hospital does not do PICC insertion in the ER), or Central line. As far as diludid, I have given and also refused to give 4 mg dilaudid ivp every 2 hours- my drug book states that amount is above the recommended dose range. Every patient is different though. I know in the ER you cannot start a PCA pump, but it sounds like that is what this patient needed and or a combination of drugs. Sounds like a hard day and I feel bad for the OP.
maybe next time get the md to do a deep brachial iv, they usually slip out or blow but its an alternative to thumb ivs or central lines. your doc may find it hard to say no if you bring the ultrasound in with you when you suggest it.
Specializes in Emergency/Trauma/Critical Care Nursing.
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:
Trust me i absolutely HATED the idea of her having to get it through her thumb vein, we had five diff. nurses work for 2 hours trying to get a vein on this woman, and the doc was just so blaise about it i was irritated, but i'm still on orientation what was i supposed to tell my preceptor that we shouldn't run it until we get the doc to put a central line in, and then tell the doc hes a moron, and to go do it? lol i dont think i would've lasted there much longer had i done that. and yes i'm sure this woman has a HIGH pain tolerance, my only issue is that we could NOT work out any plan of care with her, anytime u said anything to her all she'd respond is "pain pain pain" and start moaning and sighing, but we'd see her resting quietly from our desk and the minute one of us walked by the room she'd start back up with it. then the son got into it w/all of us claiming that we weren't treating her, and she started yelling at us as well saying we just wanted her to suffer bla bla bla its so frustrating! eventually i just said "look mam i know ur in a lot of pain, but you have a very high tolerance to this medication, and just because you do, doesn't mean we can give you an unsafe dose! frankly we're suprised ur still awake as it is, so i want u to know that we ARE doing everything we can, but screaming and yelling at us instead of trying to relax and rest in a more comfortable position will NOT help your pain".. i should've saved my breath coz she went right back to PAIN PAIN PAIN.. if i see her again i'm runnin the other way! i should've told her to start taking better care of herself and she wont need to be in the ER 4 times a month!
Trust me i absolutely HATED the idea of her having to get it through her thumb vein, we had five diff. nurses work for 2 hours trying to get a vein on this woman, and the doc was just so blaise about it i was irritated, but i'm still on orientation what was i supposed to tell my preceptor that we shouldn't run it until we get the doc to put a central line in, and then tell the doc hes a moron, and to go do it? lol i dont think i would've lasted there much longer had i done that. and yes i'm sure this woman has a HIGH pain tolerance, my only issue is that we could NOT work out any plan of care with her, anytime u said anything to her all she'd respond is "pain pain pain" and start moaning and sighing, but we'd see her resting quietly from our desk and the minute one of us walked by the room she'd start back up with it. then the son got into it w/all of us claiming that we weren't treating her, and she started yelling at us as well saying we just wanted her to suffer bla bla bla its so frustrating! eventually i just said "look mam i know ur in a lot of pain, but you have a very high tolerance to this medication, and just because you do, doesn't mean we can give you an unsafe dose! frankly we're suprised ur still awake as it is, so i want u to know that we ARE doing everything we can, but screaming and yelling at us instead of trying to relax and rest in a more comfortable position will NOT help your pain".. i should've saved my breath coz she went right back to PAIN PAIN PAIN.. if i see her again i'm runnin the other way! i should've told her to start taking better care of herself and she wont need to be in the ER 4 times a month!
I have put thumb/finger IV's in people before, but like I said, I would never run potassium through a thumb IV (let alone any site below the wrist). Most people who need IV potassium will be admitted, and I have had no problem saying to a doc "we can't give the potassium through the IV we have; wanna do PO instead and have the admitting doc send for a PICC in the am, or do you want to do a central line here in the ED?" And there is nothing that says you have to follow what a doctor says, should you believe it would cause harm to the patient. I have no problem saying "I refuse to give that medication, so if you want to give it, you can." 99% of the time, the docs don't want to take the risk that they were so willing to pawn off onto you. I understand that you were with your preceptor and its difficult to decide when to interject - its just something to think about. People have lost fingers due to potassium infiltration, and a lawyer would eat that up (loss of work, productivity, blah blah blah). And what if the med was given at the wrong rate, or what if the wrong dose was mixed - and now you suddenly have a critical patient with only a thumb IV to work with?
For myself, I've found that the biggest timesaver in the ED is to think "what is the worst that can happen, and how can I prevent it from happening?" Some of the worst things that can happen with IV potassium includes cardiac abnormalities and IV site infiltration with tissue necrosis - and this can be prevented by having a proper IV site in a "hearty" vein, having another nurse double-check IV pump settings, and keeping the patient on continuous cardiac monitoring. If it infiltrated, how much time would be spent calling pharmacy, restarting an IV, filling out an incident report, etc.? Sometimes "doing the right thing" takes more time and other staff may object (often because it requires more work on their part). But there will be a time when it pays off and we all should adhere to high practice standards because it is the best for the patient and will stand up in court should a lawsuit arise.
As far as the family goes - I do not tolerate yelling and I will tell the person "you cannot yell at me". I have had family removed by security for yelling at me and I have no regrets. I'm a very kind and tolerant person, but a family member being upset and frustrated is different than yelling and being verbally abusive towards staff. Its ok to be frustrated, its ok to be upset. But its not ok to yell, and I do not tolerate that behavior. End of story.
Boston-RN, RN
501 Posts
I had a cancer patient not on hospice getting 240mg of oxycontin BID scheduled 175mcg patch of fent at home and oxy cont + methadone 10mg QID and PRN Dilaudid 36-42mg PO Q3H and 4mg IV Q3H at one point he was on . and he could not have been more than 150-160....
All I know is if I am ever in that kind of pain, put me on a morphine drip and kiss me goodbye. And he was up walking around.