Tell me about your continuous infusions

[ErinS, BSN, RN]

What kind of medications do you commonly use and what route? (We use morphine and versed-as an anxiolytic, not for sedation and give it subQ).

How do you titrate your infusions? Do you have standard orders for titration (like increase 50% for uncontrolled sx)? Do you call and get orders prior to changing pumps, or do you call the doc after you change pumps?

Thanks for your sharing!

[AtlantaRN, RN]

we use oral and rectal preparations.....if we use iv anything it is to appease family members-usually ivf, 1liter or 2, run real slow like 30-42ml/hr....

we have used morphine drips--usually for families that just don't "understand" WHY we don't use pumps "when he has a port...." we try to do everything as NON INVASIVE as possible-but some folks are used to hospital setting with pumps and ivs and such.....YES, we call doc, or text him to get an ok to increase-we usually tell him what we want to do and increase and write the order---we have all been RN's for 15+yrs, so he knows we aren't going to do anything unsafe..... i usually use a conversion online site so if patient was on 60mg bid-i find what the equivalent is for iv route and start there....unless patient is in a pain crisis-may do a 1/4 dose q15min.......

some folks have a mental block when using roxanol=they'll say "it just doesn't work," then you find they have only been giving a drop or two instead of a full ml giving 20mg...we have standing orders for the roxanol=== 5mg q1h for mild pain, 10mg q1h for moderate pain, and 20mg/hr for severe pain (we write it that way to appease the nursing homes).....

hope this helps...

[AtlantaRN, RN]

http://www.hopweb.org/

this is a good conversion website--johns hopkins.....

[tewdles, RN]

We frequently have continuous infusions...most often Morphine or Dilaudid. We have standing medical orders which allow RNs to titrate pain meds up prior to the collaboration with the MD...but they still must call to notify of a change in the setting. Our infusions may be subcutaneous or intravenous, depends upon the med and the patient.

[okielpn75, ASN, RN]

We have never used any infusions in my 8 years with hospice. We either use sublingual, topical or rectal meds for symptom management. I am interested in those that do use infusions. Did you see a better outcome for the patient? What are the pros / cons in your opinion of using infusions vs not?

[ErinS, BSN, RN]

Thanks for your replies. We have had a vague policy for years and a nurse was just fired because of it.

Okielpn- Our medical director has been pretty resistant to rectal meds- and I am glad of it. I would be fairly traumatized if I had to give a family member meds rectally while they were dying. We use lots of sublingual and topical meds, but sometimes you are increasing meds so quickly, or a pt is needing such frequent meds that for the pt or family sake we use subQ infusions, or run them through a central line. They are much easier for family to manage than hourly sublingual morphine doses. We also have a lot of younger patients, and they sometimes need 20-100mg of morphine an hour, which can not easily be given in any other form than infusion.

Cons of pumps- fairly expensive, can be intimidating for families- especially with things like changing batteries, occlusions, meds running low. Not ideal for someone who is not bed bound, or who may try to remove lines.

I am not sure what our percentage of patients that end up with infusions is, but we had 19 deaths in the past 2 weeks and 1 pt with an infusion.

[AtlantaRN, RN]

We have never used any infusions in my 8 years with hospice. We either use sublingual, topical or rectal meds for symptom management. I am interested in those that do use infusions. Did you see a better outcome for the patient? What are the pros / cons in your opinion of using infusions vs not?

with ivf-i've seen more pain and increased secretions....

as for iv morphine and dilaudid and such-didn't really see a difference....it is just easier to use sl/po/pr and topicals (although my current employer doesn't use topicals 2nd to questionable absorption and cost)

[tyler3222]

I work in a INPT setting. Iv's are rarely used, and not for pain or symptom control, usually because a family wants to continue it ( from hosp) and is having hard time letting go. Most Iv's that I have seen in hospice setting do more harm then good, fluid in, that body cant handle, hence: fluid in lungs, edema, etc etc.

As far as pain meds, mostly subq butterflies. work well and allot of Sub lingual: morphine, dilaudid, ativan, thorazine.

Just a side question: anyone heard of silverado hospice? I want to move to warmer climate and they seem to be big. Any input?

thanks

[rngolfer53]

I work INPT now, too. We use morphine/dilaudid PCA's often. Occasional versed, or ativan. SQ or thru an existing port, picc, etc. Hardly ever a peripheral IV, unless they come from the hospital with a usable one and they need meds stat on arrival. We'll then start a SQ as time permits. IVF are very rare, and should be rarer still, imho. They usually start doing harm quickly. But some families just don't/won't understand.

Before inpatient, I did overnight home call. We had a few PCA's which families often had difficulty managing. With a couple particularly inept families, I'm sure if I did a "most visited" on my GPS, they would come right above "home." We would usually be out there once or twice a shift, while I only went home once after work.