What do you use for pain control

Just browsing around and seeing mention of some of the things used in your facilities for pain control. I work on a trauma/ortho unit (we don't do elderly total hips, knee replacements, etc--we do 'car crushed my leg' or 'bus rolled over with my arm underneath it and degloved it'.

We use generally MSPCA or dilaudid PCA's postop or upon admit to floor from ER, but I have issues with these, since people bolus themselves until they fall asleep, then wake up with horrible pain and have to be bolused by the RN until they can catch up again. Standard settings start at 1mg MSO4 Q8 minutes, increase to 1.5mg/6min if there are problems. DIlaudid at 0.2mg/8min, increase to 0.3/6min. We usually start MSContin BID as well, and transition them over to 15-20mg oxycodone Q3 hours a day or so postop, unless they are going down for more OR. If oxycodone doesn't work , or there are allergies, we will use PO dilaudid 2-4mg or more Q 3 hours.

We use vicodin or percocet only if it is a pt who we think has only a small amount of pain, never even mentioned for most of our patients.

We also have a pain relief service who is consulted for pts with persistent pain issues. They are fond of methadone for long term relief, and a variety of meds including fentanyl pops or PCA's, demerol PCA (generally a last resort), high concentration MSPCA's, etc. And, almost always, they add RTC tylenol. Ligament knee or elbow issues, or HO excision pts with CPM's get PNC's with bupivicaine to encourage compliance with 23 hours a day in their CPM's.

Just curious--what do you use??

[preciousshelby]

Just browsing around and seeing mention of some of the things used in your facilities for pain control. I work on a trauma/ortho unit (we don't do elderly total hips, knee replacements, etc--we do 'car crushed my leg' or 'bus rolled over with my arm underneath it and degloved it'.

We use generally MSPCA or dilaudid PCA's postop or upon admit to floor from ER, but I have issues with these, since people bolus themselves until they fall asleep, then wake up with horrible pain and have to be bolused by the RN until they can catch up again. Standard settings start at 1mg MSO4 Q8 minutes, increase to 1.5mg/6min if there are problems. DIlaudid at 0.2mg/8min, increase to 0.3/6min. We usually start MSContin BID as well, and transition them over to 15-20mg oxycodone Q3 hours a day or so postop, unless they are going down for more OR. If oxycodone doesn't work , or there are allergies, we will use PO dilaudid 2-4mg or more Q 3 hours.

We use vicodin or percocet only if it is a pt who we think has only a small amount of pain, never even mentioned for most of our patients.

We also have a pain relief service who is consulted for pts with persistent pain issues. They are fond of methadone for long term relief, and a variety of meds including fentanyl pops or PCA's, demerol PCA (generally a last resort), high concentration MSPCA's, etc. And, almost always, they add RTC tylenol. Ligament knee or elbow issues, or HO excision pts with CPM's get PNC's with bupivicaine to encourage compliance with 23 hours a day in their CPM's.

Just curious--what do you use??

We use PCA's too but not only the demand dose (where the patient has to push to receive the meds) but also the basal dosing, this is programmed in the PCA to receive an hourly dose (say 1mg/hour) in addition to their demand dose, that way when they are sleeping the basal is still in their system and they don't wake up in horrible pain, I cannot imagine doing a whole ortho floor any other way (or any other floor for that matter) due to it taking up the RN's time. Pain control is one of the vital signs and if it is not being controlled then maybe your facility needs to look into other ways, the outside service you mention would be much more costly I think then just programming the basal in the PCA with the demand dose. When the pt is awake and eating clears we usually will trial them on PO meds (percocet, vicodin etc) of course, with the PCA on "hold" while the PO meds kick in.

[alyca]

We use PCA's too but not only the demand dose (where the patient has to push to receive the meds) but also the basal dosing, this is programmed in the PCA to receive an hourly dose (say 1mg/hour) in addition to their demand dose, that way when they are sleeping the basal is still in their system and they don't wake up in horrible pain, I cannot imagine doing a whole ortho floor any other way (or any other floor for that matter) due to it taking up the RN's time. QUOTE]

We don't generally do the basal dose (pain relief service will, on occasion) because of the enormous amounts of meds our patients generally are using. It is quite common to be taking 40-50+ mg of MSO4 per 8-hour shift, or 10-15mg dilaudid via the PCA. A 1mg basal isn't really going to touch these guys. Our PCA's come with standard orders including narcan, but we would prefer not to have to use it. On the other hand, a small basal dose is better than getting nothing at all, so I see your point, but our docs here are pretty leery about adding the basal in. PRS is the only service that will let us do that, and they are pretty big on either giving massive demand doses via the PCA or adding a good dose of a -contin or switching to PO meds altogether.

Because we are a teaching hospital with tons of residents or interns (read: new people with little or no trauma/pain knowledge), we love having the PRS team. Many of our residents sit down with them and really gain a great understanding of theories in pain management. It is nice to have someone whose only goal is to get your pain under control. Since one of our target or priority patients is the drug abusing patient, it is nice to have people who have a firm grasp on pain management.

[preciousshelby]

We use PCA's too but not only the demand dose (where the patient has to push to receive the meds) but also the basal dosing, this is programmed in the PCA to receive an hourly dose (say 1mg/hour) in addition to their demand dose, that way when they are sleeping the basal is still in their system and they don't wake up in horrible pain, I cannot imagine doing a whole ortho floor any other way (or any other floor for that matter) due to it taking up the RN's time. QUOTE]

We don't generally do the basal dose (pain relief service will, on occasion) because of the enormous amounts of meds our patients generally are using. It is quite common to be taking 40-50+ mg of MSO4 per 8-hour shift, or 10-15mg dilaudid via the PCA. A 1mg basal isn't really going to touch these guys. Our PCA's come with standard orders including narcan, but we would prefer not to have to use it. On the other hand, a small basal dose is better than getting nothing at all, so I see your point, but our docs here are pretty leery about adding the basal in. PRS is the only service that will let us do that, and they are pretty big on either giving massive demand doses via the PCA or adding a good dose of a -contin or switching to PO meds altogether.

Because we are a teaching hospital with tons of residents or interns (read: new people with little or no trauma/pain knowledge), we love having the PRS team. Many of our residents sit down with them and really gain a great understanding of theories in pain management. It is nice to have someone whose only goal is to get your pain under control. Since one of our target or priority patients is the drug abusing patient, it is nice to have people who have a firm grasp on pain management.

Do you mind me asking where you practice nursing? (Like what city and state???) Thanks

[alyca]

Do you mind me asking where you practice nursing? (Like what city and state???) Thanks

Harborview Medical Center, Seattle Washington. We are a level 1 trauma center serving the Pacific NW/Canada

[P_RN, ADN, RN]

I'm on the "east coast" in SC. I'm retired now but here is what we used.

MS 1mg/6min demand 40mg q 4h max with a 5mg/h basal on our type patient TKA/THA/TSA/TEA some trauma, some back surgeries.

Never demerol The sickle-cell patients sometimes overflowed to us so Demerol was their docs usual choice.

Sometimes Dilaudid-like maybe once every month or so on an allergic patient.

Postop for ovenight most of the LE surgeries would have a continuous epidural pump with a small demand . Duramorph/Bupivicaine.

At 5 AM the epidural was pulled by the nurses and Oxycontin po started BID-I don't recall the dose...it's really expensive and in the news a lot so that's probably changed. Tylox for breakthrough. Home on Tylox or Darvocet or even plain Tylenol-except one doc who wanted to see ANY fever in his patients. They got Talwin-useless drug I think. Anesthesia pain service covered the 1st 24h in the epidural patients. We hardly ever had to call as we too had all the standard orders.

CPM depended on the doc...some while awake. Some thought that it was a waste of money.

Oh and let me say I'm happy to see more ortho nurses here.

[rngreenhorn]

Last week I had a patient come back from a TAH with a pump infusing lidocaine via a perforated catheter implanted directly into the wound. The patient was also on a morphine PCA. She was up and ambulating that evening.

Side note: The doc had implanted these pumps in all his patients that day... and none of us had seen them before. No orders or anything. It seemed to work though.

[alyca]

Last week I had a patient come back from a TAH with a pump infusing lidocaine via a perforated catheter implanted directly into the wound. The patient was also on a morphine PCA. She was up and ambulating that evening.

Side note: The doc had implanted these pumps in all his patients that day... and none of us had seen them before. No orders or anything. It seemed to work though.

Is this the On-Q system?? We use that on a rare basis, but have found that it is only useful in pt's with incision-related pain. It doesn't help with bone pain from fractures. It helps with the incision pain, but since almost all of our pts have massive fractures, we stick with a broader, more system-acting pain relief program. I like the concept though, and as RN's, we don't do a thing with it except check to see that the clamps are open and it hasn't been yanked out.

[Brickman]

To me it seems cruel not to use the basal dose. In theory the basal dose should be set at the minimum for effective pain control and the on demand should be used for breakthrough pain only. Setting a patient up where they will be in agony every time they wake up is just wrong. I have never had a PCA without a basal rate on any of my patients and would be all over a doc who tried to order it that way. Perhaps your docs need to be patients sometime?

[rngreenhorn]

Is this the On-Q system?? We use that on a rare basis, but have found that it is only useful in pt's with incision-related pain. It doesn't help with bone pain from fractures. It helps with the incision pain, but since almost all of our pts have massive fractures, we stick with a broader, more system-acting pain relief program. I like the concept though, and as RN's, we don't do a thing with it except check to see that the clamps are open and it hasn't been yanked out.

Could be On-Q system. I am a rehab nurse (and new at that) was floating to the med/surg unit. Found out, though, exactly what you said: nurses don't need to do anything with it. And you are right, I imagine it wouldn't do much for bone pain, being a local anesthetic. However, if you have a degloving requiring muscle grafts etc., in theory the catheter could be inserted deep into the wound during surgery... as an adjunct to systematic pain reliever. But, I think it is only used for abdominal surgeries. And I'm not a doc, and really know nothing of the possible complictions.

On a related note: I was in a horrible car accident (prior to becoming a nurse). I shattered the bones in my LLE, also had a degloving of most of the tissue from mid calve down. I underwent numerous surgeries: skin, muscle, and bone with months and months of rehab. Anyway the surgeries were agony. I wasn't a nurse then, but I know nothing the nurses used seemed to work while I was awake. The only time I was comfortable was when they gave me a strong enough dose of something to knock me out. Of course, the psycological aspect of knowing my body was trashed could have added to the pain. Maybe psych drugs: ativan, valuim etc. might not be a bad idea in the acute phase.

Sorry, I guess my post has more questions than answers.

[preciousshelby]

Ok, it has taken me some days to post here again due to myself being very upset about the pca not being used with a basal dose. I reread your original over and over about how your doctors (in seattle area, Harborview) do not like using the basal on the PCA because they are "leery of using the basal". I think there is a need of education on their part, and possibly the nursing staff as well. You need to stand up for your patients and their comfort. Pain control is one of the vital signs now a days and it needs to be addressed NOW, not waiting for some pain control service to step in. Harborview is a teaching hospital, but it sounds like MORE teaching in the pain area is IN NEED!!! I worked at a couple of hospitals in the Seattle/Bellevue area and have NEVER came across not using the basal. ( I never did work at Harborview and it looks like I will not want to now). I have worked in hospitals all along the I-5 corridor down to Salem and currently in Portland Oregon. There is mandatory pain classes we have attended to and signs in every patients room about pain control. This is a big issue!! There are articles in every nursing magazine about pain control issues and making it a priority. JCAHO even wants to know about your pain control policy and how do you reassess it etc. I cannot believe the doctors have "narcan on our protocal" but not a basal. Seems like they are more concerned with a lawsuit than comfort. Also, some of your patients go through "40-60 mg of MS in an 8 hour shift" Based on what you wrote about 1 mg q 8 minutes or up it to 1.5 mg q 6 minutes, then that patient is in pain for most of the 8 hour shift because they are having to push the button that often to get up to 40-60 mg in an 8 hour shift, how awful is that???? At least with a basal they are continuously getting some relief (and good sleep!!), it can be anywhere from 1-3 mg an hour basal depending. And you wrote that you are from the trauma/ortho floor ---(ouch!!!) the unit that NEEDS pain control issued!! The 40-60 mg in 8 hours is nothing if the pain relief is not taken care of, the paramedics use 10 mg of morphine at a time on a trauma patient (and that can be in 5 minutes!!). Sorry to go on and on but pain control is a big issue for me, I cannot and will not stand by while patients are in pain!!! I am quite proud to be in the Northwest where our care is "progressive", but I am quite embarrassed to say that we do have a hospital that is not as progressive in pain management as it should be (and no, the pain clinic service does not count)----So Alyca, I hope you are not offended by this but there is a need of education up there, if it is not done soon it will eventually be done. You say the PRS likes to "give massive demand doses". Again, that is not solving the problem, pain is not to be taken like a roller coaster, up and down, you need steady control of it (ie; basal).

[P_RN, ADN, RN]

Shelby I agree in basic with your statement that pain control is VERY important. But please note that Alyca is only reporting what she sees.