Just sharing another crazy page...

[Laurel123]

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Well, I was on call last night and the nurse on the floor pages me.
She tells me the patient had a fem-pop and the epidural came out the day before and she is in pain. She says that the PCA isn't controlling her pain and she doesn't know what to do. So I ask the nurse, what drug is given, what is the interval and what is the dose. She tells me and it seems reasonable. So I ask her if the patient has maxed out her dose every hour during the day.

N: "Oh, during the afternoon she has been only pressing the PCA once an hour.'
me: So, her pain is not controlled, but she has only been using her PCA once an hour?'
N: Yes, and she didn't press it all morning!
me: Why didn't she press it all morning if she is in pain?
N: She was sleeping.
me: So the problem is that you have a patient complaining of pain. She slept all morning and now presses her PCA once an hour. And now she complains of pain.

I didn't even know what to say. Luckily I was in a case with a patient under MAC, so I was polite and simple 'suggested' that maybe the patient should try using the PCA.

 

[cfdavid]

LOL Oh boy. That's the sort of thing that really makes you wonder.....

 

[rmh149]

Thats the problem with PCA's. They sleep....then wake up in pain. Then it is difficult to control (chase) the pain with the lockout limits of the PCA.

Did you ask the nurse if there was a PCA basal rate or break through pain orders?

I always write for breakthrough pain...2-4mg morphine every two hours PRN....to hopefully avoid these calls. It is possible the nurse was hoping for something similar....without actually asking.

Although, if they are comfortable enough to sleep...their pain is controlled in my opinion. Sounds like this patient doesnt want to feel anything at all.....and the nurse was not able to fix it....just dumped it on you. Just be glad it wasnt 2am. 🙂 Or was it?

 

[Laurel123]

Thats the problem with PCA's. They sleep....then wake up in pain. Then it is difficult to control (chase) the pain with the lockout limits of the PCA.

Did you ask the nurse if there was a PCA basal rate or break through pain orders?

I always write for breakthrough pain...2-4mg morphine every two hours PRN....to hopefully avoid these calls. It is possible the nurse was hoping for something similar....without actually asking.

Although, if they are comfortable enough to sleep...their pain is controlled in my opinion. Sounds like this patient doesnt want to feel anything at all.....and the nurse was not able to fix it....just dumped it on you. Just be glad it wasnt 2am. 🙂 Or was it?

No, thank goodness. Just the afternoon, and after I suggested the nurse to teach the patient how to use the PCA (feel pain, press the button) I recieved no more calls. On pain rounds the next morning, the patient was sleeping soundly.

 

[mille125]

Thats the problem with PCA's. They sleep....then wake up in pain. Then it is difficult to control (chase) the pain with the lockout limits of the PCA.

Did you ask the nurse if there was a PCA basal rate or break through pain orders?

I always write for breakthrough pain...2-4mg morphine every two hours PRN....to hopefully avoid these calls. It is possible the nurse was hoping for something similar....without actually asking.

Although, if they are comfortable enough to sleep...their pain is controlled in my opinion. Sounds like this patient doesnt want to feel anything at all.....and the nurse was not able to fix it....just dumped it on you. Just be glad it wasnt 2am. 🙂 Or was it?

You are really going to kill someone one of these days. The lawyers will still find some way to pin it on the surgeon who is "supervising" you. Part of the safety factor for PCA is that the patient asks for or requests the medicine. If the patient is too sedate, he/she will not ask for it. You are bypassing this safety mechanism by giving other sedating meds (like your prn morphine). The vast majority of patients do not require prn meds. A few will require a basal rate (ie laminectomy patient who takes morphine 90 mg/day for relief of low back pain). PCA morbidity and mortality results from a well meaning family member, nurse/CRNA, or physician who bypasses its inherent safety mechanism. Decisions on PCA must be carefully thought out. You cant just simply use "the force".

 

[VolatileAgent]

You are really going to kill someone one of these days. The lawyers will still find some way to pin it on the surgeon who is "supervising" you. Part of the safety factor for PCA is that the patient asks for or requests the medicine. If the patient is too sedate, he/she will not ask for it. You are bypassing this safety mechanism by giving other sedating meds (like your prn morphine). The vast majority of patients do not require prn meds. A few will require a basal rate (ie laminectomy patient who takes morphine 90 mg/day for relief of low back pain). PCA morbidity and mortality results from a well meaning family member, nurse/CRNA, or physician who bypasses its inherent safety mechanism. Decisions on PCA must be carefully thought out. You cant just simply use "the force".

apparently the fact that rmh149 is a nurse provides excuse for some people to find any reason to pick on her insinuating that her suggestion is unreasonable. in fact, i've done exactly what she's done as well. i've never heard of a post-op adult dying of a 2-4mg q2h PRN morphine, unless they had an anaphylactic reaction, etc.

i would not suggest using a basal rate on a PCA. i've seen instances where THIS caused overdosing. a better strategy for a PO-taking patient is to prescribe a long-acting sustained-release formulation narcotic. if NPO, you can always try a fentanyl patch in addition to the PCA.

the biggest problem with the PCA is underusage, which is often a result of poor instruction (eg., it being prescribed with the sole instruction being "here's your pain pump, press the button when you have pain"... can't tell you how many times i've encountered this). another pitfall is the non-anesthesia service person who writes the PCA order with a lockout of 1mg q10min for a patient who's been on 90mg ms contin bid prior to coming to the hospital.

PRN orders are safe and acceptable. basal rates are dangerous. supplementing a PCA, in addition to adequate and thorough instruction on its proper use, is good practice. additionally, laurel123's response to the page was perfectly appropriate, but it would've been an extra-nice touch to go see the patient and re-instruct them on how to use the PCA.

 

[Planktonmd]

apparently the fact that rmh149 is a nurse provides excuse for some people to find any reason to pick on her insinuating that her suggestion is unreasonable. in fact, i've done exactly what she's done as well. i've never heard of a post-op adult dying of a 2-4mg q2h PRN morphine, unless they had an anaphylactic reaction, etc.

.

I think it's a he not a she, and that's why he is being picked on, no one will be that mean to a hot female CRNA.
And the fact that you have done exactly what "she" has suggested does not make it right.

 

[VolatileAgent]

And the fact that you have done exactly what "she" has suggested does not make it right.

doesn't make it wrong either.

 

[rmh149]

You are really going to kill someone one of these days. The lawyers will still find some way to pin it on the surgeon who is "supervising" you. Part of the safety factor for PCA is that the patient asks for or requests the medicine. If the patient is too sedate, he/she will not ask for it. You are bypassing this safety mechanism by giving other sedating meds (like your prn morphine). The vast majority of patients do not require prn meds. A few will require a basal rate (ie laminectomy patient who takes morphine 90 mg/day for relief of low back pain). PCA morbidity and mortality results from a well meaning family member, nurse/CRNA, or physician who bypasses its inherent safety mechanism. Decisions on PCA must be carefully thought out. You cant just simply use "the force".

Having been a nurse that has spend countless hours at the bedside watching patients use their PCA morphine pumps in the ICU, step-down, and med/surg floors has given me a unique experience on what works and what doesnt work. I also know the capabilities of the nurses that will be watching my patient. If I am not familiar with them (like the nurse who called Laurel123), I may be more conservative. But adding a PRN 2mg per 2 hours morphine bumb gives the nurses something to work with before they start calling. This wont kill anyone. Additionally, most, if not all, nurses are far more conservative with narcotics than myself, or any other anesthesia provider for that matter.
Basal rates work fine in my experience...as long as it is not set to 10mg/hr. Low doses are safe. Size up your patient and give them what they need. Trust me...I think before I write orders....I'm not an idiot.

Oh, just to clear up the confusion, I am a guy.

 

[jetproppilot]

i would not suggest using a basal rate on a PCA. i've seen instances where THIS caused overdosing. a better strategy for a PO-taking patient is to prescribe a long-acting sustained-release formulation narcotic. if NPO, you can always try a fentanyl patch in addition to the PCA.

.

Resident colleagues:

Please read the above part of Volatile's post.

And put it in your long term memory.

Basal rates have the potential for (many) more consequences than benefits.

Especially patients going to the floor (as opposed to the ICU).

I personally know of several lawsuits resultant from hypoventilation secondary to basal rate on a PCA.

A plastic-fellow's brother died after a ventral hernia repair when I was a resident.

Brought on from a basal rate on a PCA.

I never write a basal rate.

 

[rmh149]

What kind of basal rate are we talking about that killed someone?

Say for example.... 90kg 45year old otherwise healthy female s/p TAH/BSO. No significant narcotic use at home.

1.25 hour case...received 250mcg fentanyl, 10mg Morphine prior to extubation, transfer to RR. Nothing impressive.

PCA orders as follows:

Morphine 1.5mg per 10 minutes, 30mg lockout /4hours, 1mg basal/hr, 2mg bolus q2h prn BTP.

Regardless of what happens, this patient will never get more than 30mg in 4 hours.....slowly. As long as I dont couple this with other sedatives....I'm comfortable with it.

Thoughts...

 

[jetproppilot]

What kind of basal rate are we talking about that killed someone?

Say for example.... 90kg 45year old otherwise healthy female s/p TAH/BSO. No significant narcotic use at home.

1.25 hour case...received 250mcg fentanyl, 10mg Morphine prior to extubation, transfer to RR. Nothing impressive.

PCA orders as follows:

Morphine 1.5mg per 10 minutes, 30mg lockout /4hours, 1mg basal/hr, 2mg bolus q2h prn BTP.

Regardless of what happens, this patient will never get more than 30mg in 4 hours.....slowly. As long as I dont couple this with other sedatives....I'm comfortable with it.

Thoughts...

You can write many PCAs that way, I'm sure, with no problem.

But the spectrum of opiod effect on the population is wide....some people can take a milligram an hour of morphine, even when asleep, without a problem. Give a milligram to someone else and it zonks'em out more than you expect.

That, along with the increasing incidence of undiagnosed sleep apnea in this country is enough for me to steer clear of basal rates.

Additionally, a recently performed study revealed that PCAs, even without basals, effects SpO2 more than we think.

SO IMHO the risks outweigh the benefits.

BTW, the dude I mentioned that died during my residency was obese....and 1 mg/hour did him in after he fell asleep the night after his surgery.

Plastics-fellow gets to the hospital on his brother's POD #1 at 6am, goes to check on his brother B4 starting his day, and finds his brother.

Dead.

 

[rmh149]

Absolutely horrible.

Obstructive sleep apnea.....bad.

I understand what you are saying about the basal rate. I will tuck that story of yoru friend in the back of my head when I suspect someone of having OSA....even the smallest possibility. You have probably killed my willingness to write "1" next to "basal rate".

I have known of two cases of PCA's gone bad. First case was a healthy 120kg paratrooper, s/p tib/fib ORIF that gave himself 15mg/hr. Have not thought about it till now. I was a new grad nurse still on internship on the med/surg floor. He had a pretty good snore when we walked by so we, of course thought all was well.....little did we know, his sats were probably in the 70's, his CO2 levels were shooting through the roof. He was coded, intubated, sent to the ICU.....woke up the next day a 4 year old. After 2 months, he was back to normal (probably never going to harvard) except for a permanent humming in his ears (like a C-130 aircraft in the distance).

I knew very little about Obstructive Sleep apnea....most people still dont understand the dangers.

 

[mille125]

apparently the fact that rmh149 is a nurse provides excuse for some people to find any reason to pick on her insinuating that her suggestion is unreasonable. in fact, i've done exactly what she's done as well. i've never heard of a post-op adult dying of a 2-4mg q2h PRN morphine, unless they had an anaphylactic reaction, etc.

i would not suggest using a basal rate on a PCA. i've seen instances where THIS caused overdosing. a better strategy for a PO-taking patient is to prescribe a long-acting sustained-release formulation narcotic. if NPO, you can always try a fentanyl patch in addition to the PCA.
the biggest problem with the PCA is underusage, which is often a result of poor instruction (eg., it being prescribed with the sole instruction being "here's your pain pump, press the button when you have pain"... can't tell you how many times i've encountered this). another pitfall is the non-anesthesia service person who writes the PCA order with a lockout of 1mg q10min for a patient who's been on 90mg ms contin bid prior to coming to the hospital.

PRN orders are safe and acceptable. basal rates are dangerous. supplementing a PCA, in addition to adequate and thorough instruction on its proper use, is good practice. additionally, laurel123's response to the page was perfectly appropriate, but it would've been an extra-nice touch to go see the patient and re-instruct them on how to use the PCA.

First of all let me tell you that one of the contraindications to the fentanyl patch (duragesic patch) is management of acute pain/post-op pain. This is written in big bold letters on the package insert and on the duragesic website (their drug reps will tell you this as well). I know that some people still tend to use it in the post-op setting. If you want to use it despite all of the warnings and flags, especially when suitable alternatives are available, be my guest. You are making it easy for the trial lawyers and will likely save the courts a lot of money by having a short trial......



Your warning about basal infusion rates is very accurate. For the most part basal infusion rates should be avoided unless dealing with a highly opioid tolerant patient. I agree with the warning to residents. This is definitely something that I would clear with the acute pain attending prior to starting.


To set the record straight, I am not on a personal mission to attack RMH because he is a nurse. I am in agreement with some of the things he says. I am not in agreement with him on this issue. I will get to that next..........

 

[mille125]

Having been a nurse that has spend countless hours at the bedside watching patients use their PCA morphine pumps in the ICU, step-down, and med/surg floors has given me a unique experience on what works and what doesnt work. I also know the capabilities of the nurses that will be watching my patient. If I am not familiar with them (like the nurse who called Laurel123), I may be more conservative. But adding a PRN 2mg per 2 hours morphine bumb gives the nurses something to work with before they start calling. This wont kill anyone. Additionally, most, if not all, nurses are far more conservative with narcotics than myself, or any other anesthesia provider for that matter.
Basal rates work fine in my experience...as long as it is not set to 10mg/hr. Low doses are safe. Size up your patient and give them what they need. Trust me...I think before I write orders....I'm not an idiot.

Oh, just to clear up the confusion, I am a guy.

I dont think that you are an idiot. I think that you are well meaning and trying to help prevent post-op pain in your patients. However, many well meaning health care providers have caused significant morbidity and mortality with basal PCA infusions. I was not trying to be mean. I am just trying to make the point that you have to be careful when using basal infusions. Opioid naive patients can be highly sensitive and can die (even at you 30 mg/4hr analogy). There are many papers discussing very bad outcomes (ie death/coma/etc) when basal infusions are used in opioid naive patients. If you are interested you can find them fairly easily. Many were written in the early to mid 90's. If you have trouble finding them, I can give you some references.....


Even though it appears that volatile agrees with your prn morphine along with a PCA, I still must say that I dont understand the practice. Why not just let the patient use their PCA if they are not in their lockout period. If they are in their lockout period, do you really want to give them an IV dosage. You really are just tampering with a mode of delivery that is inherently safe. The PCA dosage is not set in stone and can be increased if needed.


An Example:

Lets take the standard 70 kg patient with a morphine PCA. PCA dosage will be 1.6 mg with lockout 8 min, 30 mg 4hr max, loading dose of 3.2 mg. If you add 2-4 mg IV prn q2hr, what are you really accomplishing? You have given at most one-two more dosages per two hour period (why not just push the button when it is likely faster than waiting on the busy nurse). I would argue that if the patient needs this, "rescue", then you need to simply increase the PCA dosage.


I just dont understand your reasoning behind these prn boluses. I would be happy to hear your explanation (volatile, rmh, or any other users of this strategy).

 

[rmh149]

I would argue that if the patient needs this, "rescue", then you need to simply increase the PCA dosage.

I just dont understand your reasoning behind these prn boluses. I would be happy to hear your explanation (volatile, rmh, or any other users of this strategy).

I agree the PCA does need to be adjusted....the prn dose is to give the nurses something to work with to avoid calling you at 2am. I would rather adjust the PCA when rounding than in the middle of the night. Also, if the patient woke up in pain and is behind on the dosing...it gives the nurse the ability to push the button...giving them 1.5mg, then giving them an additional dose of 2mg on top of that 1 push....to catch them up. Then push again in 8-10 minutes. That makes 5mg given slowly in a 9-11 minute period to control the pain. Its just adds a little flexibility to the nurses.

 

[mille125]

I agree the PCA does need to be adjusted....the prn dose is to give the nurses something to work with to avoid calling you at 2am. I would rather adjust the PCA when rounding than in the middle of the night.

ah...for your own convenience....i see

On our standard PCA forms the nurse is allowed to increase the PCA dosage by a given percentage if there is inadequate analgesia. They are allow to do this once and then are required to call the physician. It works well and prevents some calls to the on call doctors.....

 

[rmh149]

That is a good idea. How much would you go up for the above patient you described if pain was not controlled?

 

[mille125]

That is a good idea. How much would you go up for the above patient you described if pain was not controlled?

In the patient that I described the nurse would be allowed to load again and increase PCA dosage by 10% (which in this case would be 1.8 mg).

 

[mille125]

...

 

[johankriek]

You are really going to kill someone one of these days. The lawyers will still find some way to pin it on the surgeon who is "supervising" you. Part of the safety factor for PCA is that the patient asks for or requests the medicine. If the patient is too sedate, he/she will not ask for it. You are bypassing this safety mechanism by giving other sedating meds (like your prn morphine). The vast majority of patients do not require prn meds. A few will require a basal rate (ie laminectomy patient who takes morphine 90 mg/day for relief of low back pain). PCA morbidity and mortality results from a well meaning family member, nurse/CRNA, or physician who bypasses its inherent safety mechanism. Decisions on PCA must be carefully thought out. You cant just simply use "the force".

Im with you totally on this one. I very rarely write for basal rates.... and if i do I do it very hesitantly.. but rmh is a nurse. he or she really doesnt understand.. when he or she offs someone he or she will blame it on the surgeon or the "supervising anesthesiologist" and so will counsel for the plaintiff.

 

[rmh149]

In the patient that I described the nurse would be allowed to load again and increase PCA dosage by 10% (which in this case would be 1.8 mg).

I rarely load because I usually make sure they are pretty loaded before I leave them in the PACU. Are we talking about another 5mg Load and a 10%increase?

 

[mille125]

I rarely load because I usually make sure they are pretty loaded before I leave them in the PACU. Are we talking about another 5mg Load and a 10%increase?

3.2 mg load and 10% increase

 

[cfdavid]

I think it's a he not a she, and that's why he is being picked on, no one will be that mean to a hot female CRNA.
And the fact that you have done exactly what "she" has suggested does not make it right.

Dude, I dated one, and took another out. Both hot... Yup, cf's got some game....lol j.k.

 

[epidural man]

Absolutely horrible.

.....woke up the next day a 4 year old. After 2 months, he was back to normal (probably never going to harvard).....quote]

We should be very clear...

He probably could be a neurosurgeon and maybe an orthopod, he might struggle with ENT, but he definitely never could be an anesthesiologist! 😀