Routine use of opioids?

ginger58, ASN, RN · May 6, 2007

IMHO, I think it should be given before surgery for an amputation, except when the amp is due to vascular disease. Since I don't work PACU I can't answer but from a personal standpoint I think it's a good idea.

In veterinary medicine, some vets will give pain meds before the end of surgery. I think when you're expecting pain, give it.

skipaway · May 6, 2007

Do you use any opioids intraoperatively and toward the end of a case when the procedure is obviously going to result in severe pain when the patient awakens? I would like to know if it is routine to only give anesthesia without any narcotic use at all during a surgery. Some of you may know I work in PACU so this is a practice question that we have. Thank you.

I give narcotics intra-operatively to all my patients who receive a general anesthetic. I use Sufenta up front and then give Dilaudid or Morphine towards the end of the case to help with post-op pain. I also use a lot of Ketamine to supplement their pain relief. I know that all of my collegues practice similar techniques and that we all give narcotics during a case. If a patient gets a regional ie...SAB or epidural, I still use narcotics, though in smaller doses. This helps them keep comfortable while lying still during the case.

I'm interested in why you asked.

bwt02 · May 6, 2007

I cant imagine any anesthesia provider not giving opioids during a case especially when it is a case known to have high postoperative pain.. I cant think of a case were I have not given opioids outside of strictly a regional technique.

sharann, BSN, RN · May 6, 2007

Thank you for your answers to this question. Skipaway, I asked because my co-workers and I have been fighting for months to end this practice of general aneshtetic only and NO supplemental narcotic given throughout the case or prior to waking the patient up. When the patient arrives in PACU they are often writhing or crying and moaning in pain, and it takes us twice as long to relieve the suffering. I call it needless suffering because a couple doses of an opioid before coming out of surgery could prevent this. It is inhumane. The same person who does this actually did an amputation of a lef on a patient using propofol only, no regional, and no supplemental narcotics. We are trying to stop this. YES, we have been writing each incident up for months, spoken with admin, etc. I am ready to go further up the food chain.

Thank you. I am sick over this.

zrmorgan · May 7, 2007

Sharann-

Remember there is no routine/ cookie cutter style to an anesthetic...it is patient / procedure dependent. It is not absolutely necessary to give a patient opioids because they are getting a general anesthetic. I give opioids if I anticipate that a patient will have pain or an elevated adrenergic response to airway manipulation probably 99 % of the time, it is by no means mandatory if I think the opioids will be detrimental to them. I will admit to you, there are times when I heavily depend upon our PACU staff to play catch up with a patients comfort in exchange for a safe emergence for the patient. Unfortunately, we have not yet perfected analgesics to allow us to give them indiscriminantly...including ketorolac and non opioids.

I do understand where you are coming from, I had an attending or two that were very anti-narcotic in school, and any time I asked them why, they were very happy to give their rationale. Maybe you should discuss this with the anesthesia providers before you plan on writing them up (a nice pacifier that will get you nowhere), or talk to the chief of the anesthesia group if they don't listen. Also take into consideration that the best thing for your patients continuum of care will be a trusting relationship between you and the anesthesia providers...so you need to protect this as well.

Just some insight from my perspective, good luck.

sharann, BSN, RN · May 7, 2007

Thank you for your reply and explanation zrmorgan. I am not by any means advocating a cookie cutter ,one size fits all approach. I am not an anesthesiologist, but I am an expert in pain(having it and treating it) with many years in this area and this guy IS the chief. It is not for the patients benefit. His ratonale for his practice is that this would take him longer and he doesn't want to because he says so thats why. He seriously is not a good person, and we feel he is masochistic and the patients(many are young children) are paying for his lazyness.

Also, I really understand that the safely of the patient is extremely important and I agree that in some cases it is safer to catch up as stated. IT shouldn't happen every time.

The problem is he is routinely not adequately(at all) giving opioids(or Versed or ketamine). Propofol is his only drug and it can be traced back to hundreds of cases. So this is not a witch hunt I promise, just a quest for info so we can know how to proceed. My dog got better pain control than my patients.

Have a good week everyone!

CRNAGAL · May 7, 2007

There are a few general cases that I may try not to use narcs if they are planning to discharge quickly and its not typically a very painful procedure. One example is knee arthroscopy, I give toradol up front and the surgeon injects well with with local, and I have a comfy pt. waking up.

We also have a few attendings who are anti-narcotic, and I agree with zrmorgan that you should ask their rationale. "Writing up" an anesthesia provider is likely to go into the circular file. I suggest speaking to the offender directly or talking to the director of the anesthesia department regarding your concerns.

Personally, I love dilaudid, and give narcotic when necessary, but as a previous poster stated, the patients health, body habitus, airway status, etc., all play into our decision-making regaring the amount and timing of narcotics given, things PACU staff may not be aware of. Keep us posted.

TrudyRN · May 7, 2007

It sounds like you will have to involve the Chief of Staff, Chief Surgeon, maybe the Board of Trustees, who knows?

I applaud your courage and your concern for your patients. I hope ALL of your colleagues will stand with you. Otherwise, you risk going down. Are the patients suffering enough for you to take that risk? If not, just take care of them the best you can and be quiet. Pray for the day this doctor will, himself, experience severe unnecessary pain. Then, maybe he'll understand.

Has your boss or anyone else ever talked to him?

sharann, BSN, RN · May 7, 2007

My colleages will stand with me because I am right and they have been traumatized by watching patients cry in pain until we can catch them up. I am not going down, and if they tried then I would be going down for a good reason and would take every media outlet with me and I would TALK.

skipaway · May 7, 2007

My colleages will stand with me because I am right and they have been traumatized by watching patients cry in pain until we can catch them up. I am not going down, and if they tried then I would be going down for a good reason and would take every media outlet with me and I would TALK.

You could always advise your patients to write a letter of complaint to the hospital administration or to their surgeon about their pain issues. Joint Commissions is serious about patients and the relief of pain. They could also get a nice note and if the hospital gets visited, the pressure may be applied to this particular MDA who only seems to want to not work. Can you address this with any of his collegues? Good luck. I'm sorry you're in this postion.

catcolalex · May 8, 2007

It is very rare that there would be a case where narcotics would not be used. In fact, most of the sickest patients ie cardiac surgery depend mostly upon narcotic as it is less cardiac depressive than gas or induction drugs. I see no reason whatsoever, no matter how short the procedure is, to not use narcotics, the idea of anesthesia is to prevent or releve pain, and if you dont give medications to do that then you are not giving anesthesia.