Methods to treat post op pain in PACU

[2Fast2Des]

Any tips/advice regarding treating post operative pain in PACU? Our nurses love to induce GA with as much fentanyl/dilaudid as possible because the resting pt can't be left alone and must have zero pain always, and have us sign out pain score of 10 and barely breathing instead. Would love to learn how to use non opioid/multimodal techniques

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[sigrhoillusion]

Depends on the surgery. Try regional.

Also the key is to titrate pain to the NURSES comfort...

 

[sevoflurane]

Any tips/advice regarding treating post operative pain in PACU? Our nurses love to induce GA with as much fentanyl/dilaudid as possible because the resting pt can't be left alone and must have zero pain always, and have us sign out pain score of 10 and barely breathing instead. Would love to learn how to use non opioid/multimodal techniques

Sounds like you need to develop a plan with your charge nurse. Sending a patient off to the floor with a GA induced narcotic doesn't seem like a good solution.
Expectations with regards to a particular surgery is always a talking point. Regional whenever possible. Multimodal includng regional is def. a discussion point.

 

[Noyac]

The best way to treat pain in PACU is to not bring them to PACU in pain. Make the nurses job boring.

Granted, some pts are gonna have some pain. If I don't want them hammered with narcs then I tell the nurses to use other things. One of my favorites is 2gm Mg in 50cc bag and run it wide open. My nursing staff has grown to love this.

On occasion I will give 20-40mg of Esmolol. This usually helps.

And sometimes I just have the nurse switch the narc they are giving. Usually that means they will need to give some Demerol. Women in particular seem to really respond to about 12.5-25mg.

 

[mustang1]

Maximize your non-opioid adjuncts. Toradol if they can have it. I love iv Tylenol otherwise a gram of po Tylenol before rolling back to OR. Ketamine, ketamine and more ketamine. For the patients on a lot of opioids I give 10mg and hour throughout the procedure. As a rescue, 10mg at a time with a max of 20-30mg works excellent!

 

[Planktonmd]

The best way to treat pain in PACU is to not bring them to PACU in pain. Make the nurses job boring.

Granted, some pts are gonna have some pain. If I don't want them hammered with narcs then I tell the nurses to use other things. One of my favorites is 2gm Mg in 50cc bag and run it wide open. My nursing staff has grown to love this.

On occasion I will give 20-40mg of Esmolol. This usually helps.

And sometimes I just have the nurse switch the narc they are giving. Usually that means they will need to give some Demerol. Women in particular seem to really respond to about 12.5-25mg.

Magnesium and Demerol are 2 of my favorite postop medications.
I also try to do some sort of regional block whenever possible, and I give Acetaminophen IV or Ketoralac frequently.

 

[Planktonmd]

Maximize your non-opioid adjuncts. Toradol if they can have it. I love iv Tylenol otherwise a gram of po Tylenol before rolling back to OR. Ketamine, ketamine and more ketamine. For the patients on a lot of opioids I give 10mg and hour throughout the procedure. As a rescue, 10mg at a time with a max of 20-30mg works excellent!

That that whole Ketamine thing is not well supported with evidence!

 

[deleted171991]

That that whole Ketamine thing is not well supported with evidence!

I have had cancer patients with opiate-induced hyperalgesia in the ICU, literally screaming in pain while on elephant-dose opiates, watching TV the next day on ketamine.

 

[bigdan]

Plank - Give that Ketamine a whirl (for your patients, that is). Game-changer.

I'm in an urban academic center, where Suboxone use, long cases, and "looks like we have to convert to open" are daily themes.

Agree with the thought to aim for pre-PACU pain relief, and have come to love:
- Mg2+ 2 grams
- Lidocaine 200 mg
- Ketamine 20 mg pre-incision, then 10 per hr, every hr, to max total dose of 50 mg
- Precedex 4-12mcg, dosed at timing of gases being turned down for emergence.

Will use derivations of the above for PACU rescue analgesia if, for whatever reason, pt has not gotten any of these intraop.

No IV Tylenol on our formulary...

Oh yeah - regional whenever able.

 

[AdmiralChz]

That that whole Ketamine thing is not well supported with evidence!

Can you cite your sources? I've had excellent success with ketamine as rescue.

 

[Urzuz]

That that whole Ketamine thing is not well supported with evidence!

This is just flat out false.

I can't tell if you're joking or not because ketamine use in opioid tolerant patients is very, very well supported by evidence.

 

[Planktonmd]

This is just flat out false.

I can't tell if you're joking or not because ketamine use in opioid tolerant patients is very, very well supported by evidence.

That is correct! Ketamine in subanesthetic doses is helpful for opiate tolerant patients... but we are not discussing opiate tolerant patients... are we?

 

[deleted171991]

That is correct! Ketamine in subanesthetic doses is helpful for opiate tolerant patients... but we are not discussing opiate tolerant patients... are we?

Have you never used it in a C-section with imperfect neuraxial coverage, to buy time? Of course it's great for analgesia, it just isn't always enough by itself, at the subanesthetic dose.

 

[Planktonmd]

Can you cite your sources? I've had excellent success with ketamine as rescue.

I did not say it didn't work! Actually I use it frequently but unfortunately the evidence supporting it's use in subanesthetic doses for post op pain in non opiate tolerant patients is not that great.

 

[Planktonmd]

Have you never used it in a C-section with insufficient neuraxial coverage?

That's anesthetic doses man... we are talking about subanesthetic doses post op... or at least I think we are!

 

[deleted171991]

That's anesthetic doses man... we are talking about subanesthetic doses post op... or at least I think we are!

It's not. I am talking about up to 0.5 mg/kg. Anesthesia begins way above that.

Even assuming it's pure placebo, who cares, as long as the patient feels better?

 

[Planktonmd]

It's not. I am talking about up to 0.5 mg/kg.

Then... yes absolutely! it will work like magic and most of the time they will enjoy the ride as well.
But they will also have some hallucinations occasionally and sometimes unpleasant dreams.
What I was referring to is low dose infusions of ketamine over hours or days post-op which people are using for opiate tolerant patients.

 

[Urzuz]

That is correct! Ketamine in subanesthetic doses is helpful for opiate tolerant patients... but we are not discussing opiate tolerant patients... are we?

Well, the post you said "For the patients on a lot of opioids I give 10mg and hour throughout the procedure. As a rescue, 10mg at a time with a max of 20-30mg works excellent!" and you responded by saying "That that whole Ketamine thing is not well supported with evidence!"

So, yes, I thought we were discussing opioid tolerant patients.

 

[Planktonmd]

Well, the post you said "For the patients on a lot of opioids I give 10mg and hour throughout the procedure. As a rescue, 10mg at a time with a max of 20-30mg works excellent!" and you responded by saying "That that whole Ketamine thing is not well supported with evidence!"

So, yes, I thought we were discussing opioid tolerant patients.

Sorry... I missed that part! my bad!

 

[Planktonmd]

That's not far from that 10 mg/h they quoted. The usual infusion for opioid tolerant patients is about 0.1-0.2 mg/kg/h.

Anecdotally this works as we all know... but the literature is still lacking on the bolus treatment for post op pain.

 

[deleted171991]

There is minimal difference between bolusing and infusing such a small amount. I mostly bolus even intraop, if the surgery is not long; never noticed a difference. Do you think anybody will do a good study about bolus vs infusion?

And so... I'm done with splitting hairs. 😛

 

[Consigliere]

The best way to treat pain in PACU is to not bring them to PACU in pain. Make the nurses job boring.

Granted, some pts are gonna have some pain. If I don't want them hammered with narcs then I tell the nurses to use other things. One of my favorites is 2gm Mg in 50cc bag and run it wide open. My nursing staff has grown to love this.

On occasion I will give 20-40mg of Esmolol. This usually helps.

And sometimes I just have the nurse switch the narc they are giving. Usually that means they will need to give some Demerol. Women in particular seem to really respond to about 12.5-25mg.

Could you please explain how/why this works? Thanks.

 

[deleted171991]

Could you please explain how/why this works? Thanks.

NMDA antagonism.

Magnesium (2g) is one of the most benign infusions in the hospital. Don't believe what people say, give it a try. Unless you forgot to reverse the muscle relaxant...

 

[Consigliere]

I'll give it a shot. What the hell.

 

[drmwvr]

Agree with the thought to aim for pre-PACU pain relief, and have come to love:
- Mg2+ 2 grams .

Ever had problems with weakness or do you avoid muscle relaxant when you do that?

 

[Shimmy8]

Recently did a thoracotomy for Ewings on a 19 yo patient with platelets in the teens so no epidural.

Mag, Lidocaine, Ketamine, and Precedex infusions worked like a charm. Very little opioid needed for the long case and extubated very comfortable.

If muscle relaxant used do you all wait to use Mag post op or use early in case?

 

[dhb]

I'll give it a shot. What the hell.

Learned the trick here from Noyac and it's freaking awesome. I usually use it as a rescue when everything has been given. Works every time

 

[Planktonmd]

Ever had problems with weakness or do you avoid muscle relaxant when you do that?

I usually use Magnesium intra-op if I expect trouble with post-op pain control or if the patient is a heavy opiate user.
There is definitely some augmentation of the effects of the muscle relaxant but all you need to do is monitor the twitches more closely and use smaller doses.

 

[fakin' the funk]

The culture of pain control in the OP's PACU needs to change from the top down.

Agree that 10mg ketamine is a great way to "break" the hyperalgesic pt.

 

[AdmiralChz]

The mag trick is delightfully old school, plus it helps with bronchodilation. Nice suggestion, I'll have to use it some time.

 

[vector2]

echoing above. iv tylenol, toradol, lidocaine, precedex, ketamine, and mag...you will need minimal narcotics if any, even for a big belly or chest case

 

[bigdan]

I usually use Magnesium intra-op if I expect trouble with post-op pain control or if the patient is a heavy opiate user.
There is definitely some augmentation of the effects of the muscle relaxant but all you need to do is monitor the twitches more closely and use smaller doses.

Exactly.

You know how every attending has his or her "thing"? I have three.
1) Please tape the eyes before laryngoscopy
2) Please don't place adhesive tape directly on the lips
3) Please don't empty the entire vial of muscle relaxant into the patient each time you dose it.

I place the Mag and Lido in a 50 cc bag, and run it in on a microdripper, over the course of a couple of minutes, and it's almost always in before incision is made. Then dose the Roc to twitches.

 

[sigrhoillusion]

Exactly.

You know how every attending has his or her "thing"? I have three.
1) Please tape the eyes before laryngoscopy
2) Please don't place adhesive tape directly on the lips
3) Please don't empty the entire vial of muscle relaxant into the patient each time you dose it.

I place the Mag and Lido in a 50 cc bag, and run it in on a microdripper, over the course of a couple of minutes, and it's almost always in before incision is made. Then dose the Roc to twitches.

Just wondering do you usually also use lidocaine on induction? And with the mag/lido cocktail are you doing this for every case? Do you still use narcotics? Less? By how much?

Ditto on your big three.

If I had to add a few of my things they would be
1. Always reverse. Unless you're not planning on extubating or its been well over 4 half-lives since dosing
2. Always check twitches after giving sux. Just once... just for peace of mind.
3. Triple airway maneuver. Oral airways should only be used when they are needed.
4. If you do an inhalation induction, do your best to maintain spontaneous ventilation. It's much harder to kill a spontaneously breathing kid...

 

[sigrhoillusion]

Just wondering do you usually also use lidocaine on induction? And with the mag/lido cocktail are you doing this for every case? Do you still use narcotics? Less? By how much?

Ditto on your big three.

If I had to add a few of my things they would be
1. Always reverse. Unless you're not planning on extubating or its been well over 4 half-lives since dosing
2. Always check twitches after giving sux. Just once... just for peace of mind.
3. Triple airway maneuver. Oral airways should only be used when they are needed.
4. If you do an inhalation induction, do your best to maintain spontaneous ventilation. It's much harder to kill a spontaneously breathing kid...

I forgot...
5. If you are obese/have OSA you are most likely getting a nasal airway. And when the nurses take it out on arrival to PACU, I warn them not to throw it out cause they might be needing it... The patient's will take it out when they are awake enough to take it out themselves...

 

[2Fast2Des]

Great tips! So the magnesium bolus doesn't have to be given as 1mg/hr as the smart pump is programmed in pacu? And in the OR how much/how long can you do mag infusion for? I have heard of running it at 500mg/hr. Should we be following baseline Mg levels and serial ones through case or pacu?

Regarding ketamine, can running it as an infusion in pacu be of some sort of stop gap instead of bolusing only while they hang around waiting for bed? We'd have to turn it off when going to the room since my institution won't allow infusions anywhere but icu.

 

[2Fast2Des]

Is clonidine a good measure to get someone under control pain/anxiety/spasm wise as well?

 

[vector2]

Exactly.

You know how every attending has his or her "thing"? I have three.
1) Please tape the eyes before laryngoscopy
2) Please don't place adhesive tape directly on the lips
3) Please don't empty the entire vial of muscle relaxant into the patient each time you dose it.

I place the Mag and Lido in a 50 cc bag, and run it in on a microdripper, over the course of a couple of minutes, and it's almost always in before incision is made. Then dose the Roc to twitches.

I always said I'd be one of those attendings who doesn't spaz about the little things, but those 3, especially 1 and 2 drive me absolutely nuts. The institution I'm at currently doesn't freakin have half-inch tape so literally everyone with a tube has 1" clear tape all over their vermilion border bc ppl are too lazy to tear it in half.

 

[deleted171991]

Great tips! So the magnesium bolus doesn't have to be given as 1mg/hr as the smart pump is programmed in pacu? And in the OR how much/how long can you do mag infusion for? I have heard of running it at 500mg/hr. Should we be following baseline Mg levels and serial ones through case or pacu?

You can give those 2 g of Mag in 10 minutes without a problem. I wouldn't follow Mag levels unless I give more than 4 g.

Regarding ketamine, can running it as an infusion in pacu be of some sort of stop gap instead of bolusing only while they hang around waiting for bed? We'd have to turn it off when going to the room since my institution won't allow infusions anywhere but icu.

You could give 0.1-0.2 mg/kg boluses every hour prn, instead of an infusion, even for days, supplemented by other analgesics (including low dose opiates) as needed.

 

[Planktonmd]

You can give those 2 g of Mag in 10 minutes without a problem. I wouldn't follow Mag levels unless I give more than 4 g.


You could give 0.1-0.2 mg/kg boluses every hour prn, instead of an infusion, even for days, supplemented by other analgesics (including low dose opiates) as needed.

The problem with bolus injections of Ketamine is that you will see the Psychotropic effects of the drug which could be considered undesirable for prolonged post-op use.
But 0.1-0.2 mg/kg is probably OK.

 

[deleted171991]

The problem with bolus injections of Ketamine is that you will see the Psychotropic effects of the drug which could be considered undesirable for prolonged post-op use.

At 10-15 mg every hour? I wouldn't think so.

 

[Planktonmd]

At 10-15 mg every hour? I wouldn't think so.

I just edited the post since I missed your dose... man it's tough getting old 🙂

 

[sevoflurane]

I use it shortly after induction on cases that are expected to be painful or those that are enrolled in our multimodal program. However, it works well for post-op shivering.
I use 4 gms.

I like this article. Good one to read.

Magnesium: A versitle drug for anesthesiologists.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726845/

 

[deleted171991]

I just edited the post since I missed your dose... man it's tough getting old 🙂

No problem. Happens to me all the time. It's very easy to just gloss over other people's posts once one is convinced they are wrong. 🙂

 

[deleted171991]

I use it shortly after induction on cases that are expected to be painful or those that are enrolled in our multimodal program. However, it works well for post-op shivering.
I use 4 gms.

I like this article. Good one to read.

Magnesium: A versitle drug for anesthesiologists.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726845/

From your link:

A recent report by Tramer and Glynn [28] also showed that the pretreatment of magnesium sulfate in patients undergoing ambulatory ilioinguinal hernia repair or varicose vein operations has no effect on postoperative analgesia for the first three postoperative days. However, in this study, a single dose (4 g) of magnesium sulfate was used instead of the loading dose plus continuous infusion.

😉

 

[sevoflurane]

From your link:

😉

Haha... Good eyes.
But I don't use it for hernias or vericose vein operations!

 

[Planktonmd]

No problem. Happens to me all the time. It's very easy to just gloss over other people's posts once one is convinced they are wrong. 🙂

You are definitely not one of those I assume to be wrong usually!

 

[Planktonmd]

You guys are giving 4 grams bolus?

 

[sevoflurane]

You guys are giving 4 grams bolus?

I get mine in this form:

I put it on a mini dripper and infuse it over 15-20min.

Remember they run this stuff like water up in OB... at much higher doses than we are talking about here.

 

[deleted171991]

You are definitely not one of those I assume to be wrong usually!

And the other way around. 🙂

 

[deleted162650]

And as an added bonus, Sevo hasn't seen an eclampic seizure in the spine room in years.