Palliative Care: IM Dilaudid q30 min...ouch

[seamonkey]

finished up PGY1 year on palliative care, had some overlap with new PGY1s on the floor service...

anyways, have a Ca pt who lost her IV last night and was placed on IM dilaudid q30 min. This lady is A&O, came in with uncontrolled pain but PCA w/ basal+bolus had it covered for >24 hrs, and can take PO with no prob. Already on po methadone for herion w/d coverage. I know the PGY1s are new, hell i was that less than 12 months ago, but you'd think the upper-level would say "hmm...maybe we don't need to turn this poor lady into a pincushion".

Methadone + big doses of po dilaudid do the trick.
You could fill a thimble with what I know, and the ocean with what I don't. Still...
PGY1's are off the hook, but medicine residents should know how to cover this better.

And I love palliative care.

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[Planktonmd]

I did not know that there is a residency called Palliative care!
When did this start?

 

[lobelsteve]

Upper level is an A-hole for punishing her by IM injection, probably due to the heroin.

Why is she on palliative care?

 

[Dejavu]

That is a barbaric thing to do to a human being. That kind of thing went out in the 70's for God's sake.

Get an IV or PICC or something, but quit torturing this lady.

 

[seamonkey]

sorry, let me clarify.

I'm a PGY-1 (CA-1 in a few days), finishing up the year on a Palliative Care rotation, its a consult service. The IM order was written overnight by the patient's primary team, a medicine-based oncology service. The patient has Pancreatic Ca with abdominal and C-spine mets.
She lost her IV overnight and is apparently a very tough stick due to a long hx of heroin use. Came in on maintenance methadone.

 

[lobelsteve]

If 6 months expected, place IT pump now.
If less than 6 mo expected, PICC or Port.


Consider celiac neurotomy first.

 

[Trisomy13]

If 6 months expected, place IT pump now.
If less than 6 mo expected, PICC or Port.


Consider celiac neurotomy first.

all appropriate, but i think the main issue is that the IV was lost at night. at least where i work, the PICC people disappear in the late afternoon, the chronic pain guy is not getting out of bed for an IT pump placement or celiac block, and gen surg would defer til the morning.

i'd consider U/S guided peripheral IV, or something like an EJ. obnoxious, but not as much as repeated IM sticks.

 

[OB1🤙]

I tend to think fentora and fentanyl lollipops suck for most situations, but acute on chronic cancer pain in the setting of a lost PIV at night in an opioid tolerant patient is probably one where they will work well.

Maybe throw on a fentanyl patch, uptitrate long and short-acting PO meds, fentora prn BTP until the duragesic kicks in. Oh, and a bunch of docusate/senna/pharmaceutical prune juice too.

 

[Jeff05]

po dilaudid.
toradol IM.

 

[usnavdoc]

If she is really a heroin addict I bet she can do her own IV better than the night RNs. I actually had a VA patient when I was in med school that would do his own IVs and blood draws b/c he was fed up with the nurses and lab techs.

Some of these patients are really limited in what you can access. We have had several short gut syndrome pts recently with trans hepatic CVLs. Loose that and it means a trip to IR for a new line.

 

[Licoricestick]

See no reason why not orals... but if you really want parenteral - put a subcut line in!
In the hospitals I work in IM opioids are almost never used - oral/SC/IV(via PCA) would be the normal ward routes.

 

[seamonkey]

the IM dilaudid did work...but sub-optimal administration indeed

we gave her big doses of po dilaudid and increased her methadone. This lady is 71yo, on methadone for years, so we figured it was best to go with a 'known known", rather than give her fentanyl or anything else new. We also let her primary team know about the option of sub-cut PCA if it ever happens again.