What made your jaw drop

[DextersDisciple]

Pt had moderate sedation and was brought to recovery drowsy but arousable. PCA started but no other drugs administered by nursing. Pt begins snoring and becomes completely unaroausable. Friend at bedside asked how frequently the pt was pressing PCA button. Friend was indeed pressing the button for the patient q6mins.

Pt received over 7mg Dilaudid and had to be reversed.

What's something that made your jaw drop?

[macawake, MSN]

Are you from the UK? I thought I read that in one of your posts before.

I'm Swedish :) Eleven years of nursing and despite having administered analgesics by the gallon, I haven't administered a single dose of hydromorphone.

Dilaudid is given during procedure many times as well. I'd say the typical single dose of the drug is 0.5mg (during THIS procedure) and goes in increments of 0.5mg (0.25 mg is lowest dose). The friend admitted to doing this every 6 mins for the pt bc she "thought" she needed it. Friend was educated on the severity of their actions and the purpose of the PCA. I won't go into specifics but the results of her actions extended the pts recovery time significantly as a result of the reversal.

The dose was given over the 3 hrs so the pump functioned correctly. All of this made my jaw drop!

No need to get into the specifics, it's probably best not to. I can imagine what the consequences of having to administer an opioid antagonist might have been for the patient. I was only thinking out loud when I mentioned not knowing the specifics of this patient's case. I don't need to know them, I was just trying to make sense of why many posters seem to agree that the PCA pump had been programmed incorrectly.

It's my opinion that PCA's are a very good way of managing post-operative pain. When patients have control over their own pain relief, it alleviates a lot of stress/anxiety and they usually end up using less opioids than when they have to ring a call bell and hope that the nurse will get there "in time".

As I said, I don't have experience with this particular medication but I don't think the allowed hourly dose of 2 mg (= 0.2 mg every 6 minutes) seems wildly excessive. Towards the high end perhaps, but there could be a number of patient-specific circumstances that would affect what would be considered a suitable dose. It's not my place to second-guess.

I guess my main point is that PCA's have a built-in safety apart from the maximum allowed doses and frequency (the lock-out function), and that's the patients themselves. When they get really sleepy/drowsy they won't keep pushing the button. But that "built-in" safety feature doesn't work if a family member/friend/visitor overrides it.

[DextersDisciple, BSN, RN]

Any friend/family member/Joe Shmoe from off the street who got caught pressing PCA button on my patient would be kicked out of the hospital. We have a ginormous obscenely-colored sign on our PCAs that state no one is to press button for patient.

2 mg/hr seems like a pretty high dose.

I wanted her kicked out as well! I am surprised that many here think 2mg/hr seems high. THere is a higher concentration dose however I can't recall the exact numbers. This procedure and pt population are extremely unique (if not exclusive) To this hospital so maybe that is why the dose doesn't seem high to me?

[DextersDisciple, BSN, RN]

What time span are you talking about? Unless OP has edited the original post no time span was mentioned.

We use Dilaudid PCAs all the time for post op pain. The typical settings are 0.2 mg per dose with 8 min lockout and 1.6 mg hourly limit. It would take about 4 1/2 hours to get 7 mg of Dilaudid even if the patient fell asleep pressing the button.

In OP example 7 mg over 3-4 hours (per later post) is not excessive in the general scheme of things but apparently too much for this patient. The settings did prevent a hideous overdose as is the intent even when a well-intentioned but ill-informed friend took control of the button.

Yes I should have made the duration clear in the OP. I wasn't in recovery until later so before I did the math I didn't know how much time had passed.

[smf0903]

I wanted her kicked out as well! I am surprised that many here think 2mg/hr seems high. THere is a higher concentration dose however I can't recall the exact numbers. This procedure and pt population are extremely unique (if not exclusive) To this hospital so maybe that is why the dose doesn't seem high to me?

I have yet to see dosing at our facility higher than 1mg/hr. I could imagine scenarios with higher dosing but for relatively opioid-naive populations I can also see that dosing heading them to the pooper!

I (total personal opinion inserted here) think we (U.S.facilities) waaaaay overuse dilaudid. I had never even heard of dilaudid until I went to nursing school. Now it's prescribed like Tylenol I swear. Stubbed your toe? 0.5mg dilaudid Q3hr. It's crazy. Ok, short rant over :)

[DextersDisciple, BSN, RN]

I have yet to see dosing at our facility higher than 1mg/hr. I could imagine scenarios with higher dosing but for relatively opioid-naive populations I can also see that dosing heading them to the pooper!

I (total personal opinion inserted here) think we (U.S.facilities) waaaaay overuse dilaudid. I had never even heard of dilaudid until I went to nursing school. Now it's prescribed like Tylenol I swear. Stubbed your toe? 0.5mg dilaudid Q3hr. It's crazy. Ok, short rant over :)

Preach! Were you aware of the "nationwide shortage" of dilaudid we're experiencing? The hospital completely ran out of IVP dilaudid (but still able to make PCA doses for some reason) and said it's due to a "shortage". Is there a nationwide shortage at all??

[nursepolice]

What made my jaw drop, since you asked, (unless we're still beating the PCA example to death), were the nurses telling each other in report that the patient slept all shift. Different nurses each shift, no continuity of care. Slept all day. Slept all night. For 2 days. One nurse finally did an actual assessment, patient had stroked.

[smf0903]

Preach! Were you aware of the "nationwide shortage" of dilaudid we're experiencing? The hospital completely ran out of IVP dilaudid (but still able to make PCA doses for some reason) and said it's due to a "shortage". Is there a nationwide shortage at all??

Yes! We were on a nationwide shortage of morphine, so our facility substitutes with dilaudid. The waste was ridiculous with a capital "r". We were wasting 3/4 of a vial of it at a time because they're single-use vials. Then there was the dilaudid shortage (gee, I wonder why?) and we were using fentanyl. In my opinion, dilaudid and fentanyl should be those meds used so rarely that you have to look them up when prescribed (I mean for run-of-the-mill post ops and such "normal" things people get admitted for). But then again, we are in a heavy heroin area so now it's a vicious cycle since you may as well throw an M&M in an IVDU mouth if you use what would be normal pain control for the non-drug use population. I don't know the answer/solution, but man have we gotten into a mess.

[smf0903]

What made my jaw drop, since you asked, (unless we're still beating the PCA example to death), were the nurses telling each other in report that the patient slept all shift. Different nurses each shift, no continuity of care. Slept all day. Slept all night. For 2 days. One nurse finally did an actual assessment, patient had stroked.

Oh my gosh!

[smf0903]

Mine was an end-of-life patient (but still full code) who was heavily sedated, on a LOT of pain medication, and intubated. Family wanted them "woken up and the tube taken out" so that they could discuss bills, where the will was at, what life insurance policies there were, etc. Uh, nope.

[DextersDisciple, BSN, RN]

What made my jaw drop, since you asked, (unless we're still beating the PCA example to death), were the nurses telling each other in report that the patient slept all shift. Different nurses each shift, no continuity of care. Slept all day. Slept all night. For 2 days. One nurse finally did an actual assessment, patient had stroked.

Yes that really was the point of my post! Wow, what kind of floor was the pt on??

[Penelope_Pitstop, BSN, RN]

I'm Swedish :)

In my brain, you've always been Australian.

[Horseshoe, BSN, RN]

What made my jaw drop, since you asked, (unless we're still beating the PCA example to death), were the nurses telling each other in report that the patient slept all shift. Different nurses each shift, no continuity of care. Slept all day. Slept all night. For 2 days. One nurse finally did an actual assessment, patient had stroked.

Oh my GOD.