Do you prescribe prn narcotic for admitted, NGT/IVF/Observe SBO?

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Sbo management clearly has changed through the years. The old "don't let the sun go down with a bowel obstruction" clearly is not the standard of care anymore. Some patients are admitted and treated with non-surgical observation (IVF/NGT) for days and days depending on the unique clinical scenario and the patient.

So when you admit your SBO, and are not planning an immediate operation, do you still prescribe pain medication?

I ask because I'm a believer that part of the assessment of a patient with an SBO is serially assessing their abdomen and clinical status for signs of worsening bowel iscehmia/gangrene (and hence need for operating room). Pain and tenderness is a big part of this decision. Thus, while pounding on a patients belly with an SBO clearly isn't very comfortable, it shouldn't really have significant tenderness and the patients while clearly feel uncomfortable/bloated, they shouldn't have a great deal of pain. If they develop significant pain/tenderness, then I TAKE them to OR and while that is happening, I of course, treat their pain.

Thus, I've been surprised at how often many of my colleagues admit them with prn morphine.... sometimes relatively high doses (4-6mg morphine q3 hr prn moderate/severe pain). I think some dead bowels may have been missed because of nurses just covering up the discomfort w/prn narcotics and it isn't until fever/wbc/peritonitis that they go to operating room.

Sometimes it gets tricky.... psbo from Crohn's flare... those patients have pain from their Crohn's flare, but are also obstructed. Obviously there is some judgement here.

I'm just concerned with my interns/second years routinely prescribing narcotics to our admitted SBO's and I wonder if you share that frustration/concern... and does it happen where you are at?

Your practice/thoughts?

Originally Posted by europeman

I think some dead bowels may have been missed because of nurses just covering up the discomfort w/prn narcotics and it isn't until fever/wbc/peritonitis that they go to operating room.

Do you really think Morphine or Dilaudid will change a surgical abdominal exam (requiring emergent surgery) into a completely benign abdominal exam?

Personally, I have no problem giving analgesics to patients with acute abdominal pain. There is a decent amount of literature that shows adminstration of narcotics in these patients is safe and does not significantly affect the diagnostic accuracy of the physical exam. Most of that is in the ER literature, which makes sense since ER docs are constantly being berated by us when they give pain meds prior to our assessment.

Not all abdominal pain mandates a laparotomy, and there's no reason to let your patients suffer...especially since pain itself can lead to morbidity/complications.

There are some drugs that I believe mask intra-abdominal catastrophes (e.g. steroids), but morphine isn't one of them. Of course, you can slam someone with high-dose narcotics and make them difficult to examine, but I think routine doses of narcotics are safe and effective.

Agree with SLUser. I don't manage these patients any more but I cannot recall any incident of a real emergent surgical abdomen being so efficiently masked by pain medication that we missed dead gut. The *one* patient we did miss with a perf was on chronic high dose steroids. That doesn't mean that I wasn't trained to examine them before they received any narcs (and to yell at the ED residents when they gave them before calling us), but we never withheld them once they were admitted to us.

As a matter of fact, if a patient is still having acute pain and on narcs, it makes your assessment all that much easier and is supported by the literature.

For bowel obstructions in narcotic naive patients, I tend to write for low dose narcotic (1-4 mg morphine, 0.5- 1.0 mg IV dilaudid) with a clear written order to call me if pain escalates and the low dose is no longer adequate. To me, if the patient is adequately decompressed with an NG, pain should generally get better not worse and if the pain is worse I want to reassess. Not that I'll necessarily rush them to the OR, but I want to know if someone who was fine with 2 mg morphine suddenly is NOT fine. It's not clear to me how well morphine takes care of the crampy pain associated with bowel obstruction, but I feel as though it's cruel to avoid pain relief in a patient. I'd want my family member to have it.

Thanks for your replies everyone.

Except you are all referring to acute abdomens. A small bowel obstruction is not an acute abdomen unless it is strangulated/ischemic/gangrenous. A partial small bowel obstruction that you suspect has a chance of resolving with bowel rest, NGT, and IVF, however, doesn't fit into the category.

I totally agree that acute abdomens (i.e. patients with peritonitis) need narcotics and I further agree that narcotics don't negatively change the treatment/outcome/physical-exam to any degree to justify torturing patients by letting them suffer. 100% agree.

In fact, when patients come in with a lot of pain, for example a child with suspected appendicitis, I have personally found narcotics to help with the specificity of my exam because rather than not allowing me to touch/feel anything previous to the pain med, the patient will allow me to actually examine them and hence come up with something more tangible.

Don't get me wrong, I don't mind giving 2mg morphine or something a little here and there mostly to make the RN happy because of the whole discomfort of the NGT, bloated belly, situation, etc.

I am just suspect of writing the same pain regimen for a pSBO admitted for ivf/npo/ivf as for a diverticultiis or pancreatitis (i.e. where your goal is to make them as completely comfortable and pain free as possible).

Blue2000, I like your idea of CLEAR orders which makes it obvious that escalating pain necessetates a call, though I'm not sure 1mg of dilaudid in a narcotic naive patient is low dose (that's about equal to 6.5mg morphine!).

I agree w/you all that a true acute abdomen is not masked by low/moderate does of narcotics. I totally agree.

I'm just wondering what the logic behind writing pain meds for psbo is, if, in fact, the puropse of admitting them is to serially assess them for increasing pain/discomfort which is a trigger for failed therapy and need to go to OR.

I should say, to conclude, that I bring up this idea because I know it is not something clear cut. Several (most) of the attendings at my institution and the visiting hospital we rotate at are firm believers thta narcotics should NEVER be given to an admitted sbo for the reasons above. Other attendings however claim never to have heard that logic and have no problem with it. Hence my confusion, this post, and the ideas I'd like to hear from others around the country!

Thanks!

For clarification purposes, I/we used to treat pSBO the same way as any abdominal pain: assess, give narcs and assess for any change in examination or increased use of pain medications. Almost all get better (and when they don't, the narcs aren't going to mask that).

I don't recall any of my attendings telling us to deny *any* patient (peritonitis, pSBO, etc.) pain medications (although I am aware that *some* do).

(NB: and yes, in response to 1 mg Dilaudid for a narcs naive patient: I recently received 0.25 mg IV for a migraine [first time ever in the ED for a migraine] and was FLYING! Then again, I'm a small framed woman but I cannot imagine what I would have been like with 1 mg. )

Originally Posted by europeman

Thanks for your replies everyone.

Except you are all referring to acute abdomens. A small bowel obstruction is not an acute abdomen unless it is strangulated/ischemic/gangrenous. A partial small bowel obstruction that you suspect has a chance of resolving with bowel rest, NGT, and IVF, however, doesn't fit into the category.

I'm just wondering what the logic behind writing pain meds for psbo is, if, in fact, the puropse of admitting them is to serially assess them for increasing pain/discomfort which is a trigger for failed therapy and need to go to OR.

I should say, to conclude, that I bring up this idea because I know it is not something clear cut. Several (most) of the attendings at my institution and the visiting hospital we rotate at are firm believers thta narcotics should NEVER be given to an admitted sbo for the reasons above. Other attendings however claim never to have heard that logic and have no problem with it. Hence my confusion, this post, and the ideas I'd like to hear from others around the country!

I interpreted SLU/WS/blue's stances to mean SBOs can get some analgesics because a little morphine is not going to mask an acute abdomen. I understand conceptually not wanting to "mess up" the exam with pain meds. But I think giving reasonable doses of narcotics doesn't alter things much. If I get called by nursing that my pain med dose suddenly isn't cutting it anymore, then I know something is going on with the patient that requires my attention.

If you are going to NPO/NG/IVF and observe a run-of-the-mill partial SBO (non-septic, benign exam, the scenario you are asking about), over time, they either:
1. resolve,
2. still look benign but don't resolve, or
3. worsen (i.e. develop an acute abdomen or otherwise get worse).

2 mg of morphine is not going to make me unable to determine which of categories 1-3 the patient falls into. I think this is the point the others were trying to make. NG tubes aren't comfortable. Patients are stuck in uncomfortable beds. Their abdominal cramping gets better but still may happen from time to time. They get pains, headaches from beeping IV poles, etc. Let them get something to make them more comfortable. Just about every patient I see in the ER (including the SBO patient on initial exam!) has gotten pain meds before I see them, but I can still elicit exam findings consistent with appendicitis or cholecystitis.

Originally Posted by europeman

Thanks for your replies everyone.

Except you are all referring to acute abdomens. A small bowel obstruction is not an acute abdomen unless it is strangulated/ischemic/gangrenous. A partial small bowel obstruction that you suspect has a chance of resolving with bowel rest, NGT, and IVF, however, doesn't fit into the category.

I totally agree that acute abdomens (i.e. patients with peritonitis) need narcotics and I further agree that narcotics don't negatively change the treatment/outcome/physical-exam to any degree to justify torturing patients by letting them suffer. 100% agree.

Not true. We're not referring exclusively to acute abdomens....at least I'm not. I'm referring to all patients with abdominal pain, and whether or not narcotics eliminate the ability to diagnose an acute abdomen. PSBO absolutely fits into that category, since that's the whole hypothetical reason to withhold narcotics.

I don't think there's any controversy re: whether or not it's okay to give a patient with peritonitis a shot of dilaudid.

I agree with you that this subject is not clear-cut. Determining the need for laparotomy in a patient with a SBO requires surgical judgment, and the old cookbook approach (sun rising and setting) is not appropriate. The best way to address your junior residents is to ask them why they are writing those orders, and what possible things can be masked, etc. If you explain the reasoning in detail, they usually listen: "My concern is that high-dose narcotics will be given by the nurses indiscriminately, and we won't know if the patient's condition has changed. Instead, I prefer you to write lower doses, and be notified if the pain intensity changes so we can re-examine the patient." However, giving them a one-liner or old-school anecdote just doesn't work.

Originally Posted by SLUser11

Not true. We're not referring exclusively to acute abdomens....at least I'm not. I'm referring to all patients with abdominal pain, and whether or not narcotics eliminate the ability to diagnose an acute abdomen. PSBO absolutely fits into that category, since that's the whole hypothetical reason to withhold narcotics.

I don't think there's any controversy re: whether or not it's okay to give a patient with peritonitis a shot of dilaudid.

I agree with you that this subject is not clear-cut. Determining the need for laparotomy in a patient with a SBO requires surgical judgment, and the old cookbook approach (sun rising and setting) is not appropriate. The best way to address your junior residents is to ask them why they are writing those orders, and what possible things can be masked, etc. If you explain the reasoning in detail, they usually listen: "My concern is that high-dose narcotics will be given by the nurses indiscriminately, and we won't know if the patient's condition has changed. Instead, I prefer you to write lower doses, and be notified if the pain intensity changes so we can re-examine the patient." However, giving them a one-liner or old-school anecdote just doesn't work.

I think you have all changed my view on this. Thank you. In particular your statement ""My concern is that high-dose narcotics will be given by the nurses indiscriminately, and we won't know if the patient's condition has changed. Instead, I prefer you to write lower doses, and be notified if the pain intensity changes so we can re-examine the patient" was perfectively put.

As far as the ED/medicine goes, I haven't seen people really get annoyed by a little morphine or dilaudid. What's annoying is when the patient has received like 3 of dilaudid and some ativan before we get there. It's kind of hard to do a good assessment when the patient has received conscious sedation prior to your arrival. In the end that kind of thing can hurt the patient, because when in doubt, we are likely to err on the side of the OR (unless they gave the patient a sandwich too, which happens).

Originally Posted by cpants

As far as the ED/medicine goes, I haven't seen people really get annoyed by a little morphine or dilaudid. What's annoying is when the patient has received like 3 of dilaudid and some ativan before we get there. It's kind of hard to do a good assessment when the patient has received conscious sedation prior to your arrival. In the end that kind of thing can hurt the patient, because when in doubt, we are likely to err on the side of the OR (unless they gave the patient a sandwich too, which happens).

On the flip side, though (and not to the sandwich - that's not kosher), is some patients are in enough pain that they get the 3mg of Dilaudid, and are still in moderate distress. I am going to be quite sanguine and candid here - depending on the nurse, and the doctor, it is not unheard of for the nurse to cow the doctor into ordering another dose of analgesic, and to not stop harping on the doc to order it until the doc does (even if the pt is on an even keel). That can lead to the "conscious sedation" to which you refer.

I would much rather the ER be a little too generous with the narcs than not give anything at all. Too many old school folks got it beaten into them by the surgeons not to give anything, then I am faced with a patient in agony who can no longer give me a good history. As long as they don't end up needing to be tubed I think the physical exam in combination with stuff like labs and vitals can lead me in a good direction even if they are a little sleepy. And even that consciously sedated person will give you a peritonitis exam if one is present (unless there is a reason they wouldn't-missing much of your fascia takes away from many of the peritoneal signs)

I tend not to admit the pSBO's because medicine admits them unless they had a recent surgery, or are young without any hint of a medical problem, or we are particularly worried about them. I do agree that starting doses of pain meds are appropriate and a low dose as a prn is fine. We haven't really run into too much trouble with people suddenly progressing during the day or overnight and we certainly aren't running to their room every 4 hrs for serial abdominal exams. The people who have gotten worse and needed an operation are typically those that we were already worried about but wanted to give a chance at non op. The bigger problem I run into is people who don't get their NGT quickly or have it not reach the stomach and have their dilation progress enough to perf or get ischemic, but the pain meds don't usually factor in.

Originally Posted by dpmd

I tend not to admit the pSBO's because medicine admits them unless they had a recent surgery, or are young without any hint of a medical problem, or we are particularly worried about them.

While this is how things happen in the real world, what do you think about this process in a training program?

One of the benefits of a well-rounded surgical residency is feeling comfortable taking care of complex patients. I personally don't like medicine being involved in my patient's care unless it's 100% necessary. During my GS training, the surgery service admitted the vast majority of SBOs. Reserving admission for the small subset of patients with a recent surgery or "young without any hint of a medical problem" sounds a lot like orthopedic surgery.....

Originally Posted by SLUser11

While this is how things happen in the real world, what do you think about this process in a training program?

One of the benefits of a well-rounded surgical residency is feeling comfortable taking care of complex patients. I personally don't like medicine being involved in my patient's care unless it's 100% necessary. During my GS training, the surgery service admitted the vast majority of SBOs. Reserving admission for the small subset of patients with a recent surgery or "young without any hint of a medical problem" sounds a lot like orthopedic surgery.....

Agreed. You learn from every patient you admit.

All pSBOs came to the surgical service, as did most pancreatitis and diverticulitis (except at the community hospital we rotated at).

Originally Posted by SLUser11

While this is how things happen in the real world, what do you think about this process in a training program?

One of the benefits of a well-rounded surgical residency is feeling comfortable taking care of complex patients. I personally don't like medicine being involved in my patient's care unless it's 100% necessary. During my GS training, the surgery service admitted the vast majority of SBOs. Reserving admission for the small subset of patients with a recent surgery or "young without any hint of a medical problem" sounds a lot like orthopedic surgery.....

We have so many pSBO's that don't end up needing anything but an NGT (as well as plenty of diverticulitis and pancreatitis that never needs an operation) that I don't think we lose out on anything. Even if the patient has a billion medical problems, if we think they are going to need an operation we keep them. For those we don't admit, we basically run the show until they resolve so really it just frees us from having to write for daily labs and do the discharge summary (unless they have uncontrolled medical issues, then it frees us from having to fix them while in house). On the other hand, we take care of really sick patients after surgery and hardly ever consult another service, so I feel we get well trained on how to handle complex patients (we don't call ID unless we can't get a restricted med from clinical pharmacy, we don't call renal unless we want dialysis, we don't call endocrine unless we are bored dealing with sugars or if they are going to need outpatient follow up-easier if they have already been seen, and we don't call IM unless we are done with the patient and can't get them home-except for some occasional exceptions of course). We are a small program and if we are carrying a bunch of patients that we really aren't doing much for it takes away from our ability to care for patients we are going to do something for (this is why I sign of on GI bleeders as quickly as possible-we get consulted on every single one because some medicine team once failed to resuscitate appropriately and the patient died, now I have to put a note in on each one telling them to get scope, serial H/H and transfuse as needed).

How the division of labor got started I don't know, but it keeps me from being too busy to actually learn so I am happy. Medicine gets to learn, we get to teach, the patient gets cared for, so everyone wins in this situation. If medicine wasn't receptive to our recommendations and was hurting the patient that would be a different story. And if we had no involvement that would also be bad for us (it is nice to see the ones that resolve quickly and figure out what is different in those that don't resolve). And since it is how it is done in the community I think it is really important for medicine to learn how to manage theses things with our help so that when they are your hospitalist they aren't trying to learn from scratch.

why is your institution getting so many Sbos? It's just the most common pathology in he world. I'm at a huge institution and we get one or two new admissions for sbo a day MAYBE.

I dunno... sbo is a surgical problem in my opinion, period. At my institution medicine can't even handle NG tube problems though!

Originally Posted by europeman

why is your institution getting so many Sbos? It's just the most common pathology in he world. I'm at a huge institution and we get one or two new admissions for sbo a day MAYBE.

I dunno... sbo is a surgical problem in my opinion, period. At my institution medicine can't even handle NG tube problems though!

One or two a day would add up quick when I only have one or two residents on my team.

At some places all diverticulitis, pancreatitis (not just gallstone), diabetic foot infections, thrombophlebitis, and other things would go to surgery primarily. If we were a big program with PA's and NP's to help with the work, social workers in addition to case managers for any placement needs, and funded patients with no placement issues I guess I wouldn't mind taking them all. Instead I consult so I can see if things are getting worse (in which case I can easily take over) or getting better (in which case I can easily sign off and leave medicine to deal with their cirrhosis, uncontrolled diabetes, COPD, alcohol withdrawal, renal insufficiency, home health needs or whatever that can often lead to extended hospital stays). And just because medicine may have troubles managing something does not mean it should automatically come to surgery (there was talk of us admitting all GI bleeds because sometimes medicine wasn't resuscitating them well enough, would you want that at your institution?) Following a patient with them allows us to teach them so that when they are in a community setting and are taking care of your patient for you (at some hospitals in this community medicine admits appys and the surgeon consults on them later-like in the morning) they do the right stuff.

Originally Posted by dpmd

One or two a day would add up quick when I only have one or two residents on my team.

At some places all diverticulitis, pancreatitis (not just gallstone), diabetic foot infections, thrombophlebitis, and other things would go to surgery primarily. If we were a big program with PA's and NP's to help with the work, social workers in addition to case managers for any placement needs, and funded patients with no placement issues I guess I wouldn't mind taking them all. Instead I consult so I can see if things are getting worse (in which case I can easily take over) or getting better (in which case I can easily sign off and leave medicine to deal with their cirrhosis, uncontrolled diabetes, COPD, alcohol withdrawal, renal insufficiency, home health needs or whatever that can often lead to extended hospital stays). And just because medicine may have troubles managing something does not mean it should automatically come to surgery (there was talk of us admitting all GI bleeds because sometimes medicine wasn't resuscitating them well enough, would you want that at your institution?) Following a patient with them allows us to teach them so that when they are in a community setting and are taking care of your patient for you (at some hospitals in this community medicine admits appys and the surgeon consults on them later-like in the morning) they do the right stuff.

I doubt the medicine residents see things the same way that you do. Just like you, they are also busy, and probably don't appreciate extra unnecessary work, even if it allows them to be taught by the surgery resident...imagine how we would feel if a medicine resident tried to lecture us on a subject.

Anyway, I think if you are "basically running the show," then you should just admit the patient. Otherwise, it seems like you're just dumping on the medical services, and exposing the patient to too many cooks in the kitchen.

Different strokes for different folks, but I think there's still an educational benefit to admitting patients with pancreatitis, SBO, diverticulitis, etc....even if the patient won't require an operation. It doesn't mean your program is wrong, by any means. It's just different than how I like it.

Originally Posted by dpmd

I tend not to admit the pSBO's because medicine admits them unless they had a recent surgery, or are young without any hint of a medical problem, or we are particularly worried about them.

As others have stated, this would be a little unusual at my program. The vast majority of SBOs are admitted by surgical services here - the exceptions would be those patients without a history of previous surgery who are getting worked up for an obstructing mass.

I'm also in the camp of people who give reasonable amounts of narcotics for abdominal pain patients - I've never missed a case of peritonitis from a patient being over-narcotized, though I've missed two in patients who were on high-dose steroids. I don't believe in withholding narcotics in an SBO patient who may or may not need an operation.