Resistance to pain medication

[d_miracle36]

I have run into a situation at my ems service. I myself advocate pain managment when given appropriately and I do not hesitate to give it. Even though we have a pain managment protocol, morphine and fentanyl a lot of the older medics at my service frown upon it. How do I deal with this and approach it? Also I transported a ventilator pt. interfacility who was on a propofol drip but able to respond via hand gestures. I asked the nurse for analgesia and she comes back with 2mg of morphine. during transport I asked if he was still in pain and he responded with a yes in hand gestures and I administerd 50ug of fentanyl and the field training officer told me he already recieved 2mg of morphine, I responded that the pt. was 300 pounds and intubated. Am I wrong here? how do I deal with this?

 

[18G]

Im not even sure if I want to get started on lack of proper analgesia in the post-intubated patient! Nobody seems to get the need and I'm including RN's and physicians. The evidence is there as is the many position papers strongly advocating analgesia.

I run into nurses that think propofol and benzos provide pain relief. I even had an intubated pt. on the cath lab table grimacing with two nurses holding the pt. I ask for fentanyl and one RN say's it's just the patient's reflexes. Luckly, the doctor gave me the order and as soon as the patient received the fentanyl he stoped grimacing and moving.. amazing!

Provide the evidence from the many studies out there. There are physician groups out there with position papers on analgesia in the post-intubated patient. Arm yourself with knowledge and evidence and inform them.

Did you increase the propofol at all?

 

[DrankTheKoolaid]

Wow this is wrong on so many levels.

Intubated and awake enough to answer questions...... I would not have any accepted the transfer until the patient was sedated and received analgesia. and really, 2mg's why did they even bother.

Follow your protocols and QA/QI have nothing to say about it. If they are dinosaurs that dont believe in prehospital analgesia work hard until you can get into a QA/QI position and change the way your prehospital analgesia is viewed within your company by providing educational material. EMS providers either need to evolve along with medicine or get out of medicine altogether as they do more harm then good staying it it.

 

[d_miracle36]

No I didnt increase the propofol but did think about it. I wasnt familiar with propofol drips at the time and was hoping that the fentanly and propofol combined would be enough analgesia and sedation. The pt. relaxed and was comfortable after the fentanyl.

 

[d_miracle36]

Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?

 

[d_miracle36]

I agree with you all the way corky. I am quite distressed over the whole situation. We are a private service and operate under state protocols. Just recently got a medical director who is involved. We have 3 q/a officers and only one is on board with pain control but is afraid to voice his opinions. I dont know how far i will get if I keep arguing with them haha. I really hate this and i dont want their opinions to affect my pt. care and just dont know how to deal with it.

 

[DrankTheKoolaid]

No i personally dont. If you get a chance shadow a CRNA/MD for a while. Also there are plenty of blog/podcasts out there.

Go to Emcrit.com and look for the bad sedation package podcast and give it a listen

 

[bigbaldguy]

I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?

My understanding is that fent doesn't cause as much respiratory as morphine but can still cause it to a lesser extent.

 

[Aidey]

Wow this is wrong on so many levels.

Intubated and awake enough to answer questions...... I would not have any accepted the transfer until the patient was sedated and received analgesia. and really, 2mg's why did they even bother.

The OP never said anything about intubated, just that it was a vent patient.

 

[Tigger]

Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?

Having been on the receiving end of it recently, I think that is perfectly acceptable. 100mcg of Fent was a good start, but it took 200-300 to actually knock down the pain. My understanding is that the 100mcg initial dose is fairly standard in the ER as well.

 

[usalsfyre]

Intubated and awake enough to answer questions...... I would not have any accepted the transfer until the patient was sedated and received analgesia. and really, 2mg's why did they even bother.

I transport quite a few patients that fit this description. They're at the weaning stage of their admission and are going to an LTAC to complete the process. If you snow them you run the risk of setting the process back, and possibly causing your patient to be trached.

Be careful messing around with these patients.

 

[usalsfyre]

The OP never said anything about intubated, just that it was a vent patient.

While I can't speak for the OP, patients who are trached generally don't require sedative infusions.

 

[d_miracle36]

Sorry about the confusion. This pt was intubated. I had a pt recently that I gave fentanyl to and it took up to 125 before he had enough relief from pain.

 

[DrankTheKoolaid]

I transport quite a few patients that fit this description. They're at the weaning stage of their admission and are going to an LTAC to complete the process. If you snow them you run the risk of setting the process back, and possibly causing your patient to be trached.

Be careful messing around with these patients.

While this is true, nobody said to "snow" the patient. Stick a garden hose in the back of your throat for any reason and tell me what you think about it. And tell me you dont mind that kind of constant stimulation. Proper analgesia should never be withheld.

And true, i only assumed it was a intubation and not a trach patient, i should have clarified that from the start.

I also transport quite a few intubated on vents patients but it is always to definitive care. Transport times are 1hour from podunk bandaid station to the nearest Level 2. That also factors into my thought process on the subject, OP's situation could be different with a short ETA. But my opinion will always be never ever ever withold analgesia in a vented patient.

 

[Aidey]

Since the patient was alert enough to answer questions with hand gestures I figured they weren't receiving the full anesthetic dose. The pt could always be on the drip as a comfort measure for transport if they don't tolerate the vent well.


Edit: Nevermind, the intubated part was at the end of the post. I really need to get my prescription updated...

 

[usalsfyre]

While this is true, nobody said to "snow" the patient. Stick a garden hose in the back of your throat for any reason and tell me what you think about it. And tell me you dont mind that kind of constant stimulation. Proper analgesia should never be withheld.

And true, i only assumed it was a intubation and not a trach patient, i should have clarified that from the start.

50mcgs of fent was wholly appropriate. But don't be so quick to condem someone being awake on a tube till we know the whole story.

I really like fent infusions, but the controlled substance issues seem to drive people bonkers.

 

[DrankTheKoolaid]

50mcgs of fent was wholly appropriate. But don't be so quick to condem someone being awake on a tube till we know the whole story.

I really like fent infusions, but the controlled substance issues seem to drive people bonkers.

Oh no I wasnt condeming him, I hope it didnt come across that way as that was not my intention

 

[jjesusfreak01]

No i personally dont. If you get a chance shadow a CRNA/MD for a while.

Burn unit nurses might as well be CRNAs...they're about as good at providing proper analgesia as anyone else in the hospital.

 

[DrankTheKoolaid]

Burn unit nurses might as well be CRNAs...they're about as good at providing proper analgesia as anyone else in the hospital.

Absolutely agree there. That is a specialty of medicine that truely knows about pain control

 

[systemet]

Also one more question, do you think 100ug of fentanly is too much for someone in severe pain?

No, not for most patients.

What's too much is a dose that causes hypotension, respiratory depression, apnea, or loss of control of airway reflexes. For most people this will be more than 100ug.

I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?

Fentanyl can cause respiratory depression / apnea as well.

For most people 10mg of MS isn't too much for severe pain. What's too much is a dose causing hypotension, respiratory depression, apnea, or loss of control of airway reflexes. A reasonable analgesia dose of MS is somewhere around 0.1 mg / kg, which for a larger person is close to 10mg. Most of us have just been terrified into giving smaller doses, e.g. the homeopathic 2mg MS IVP.

You have to accept that there's a huge amount of interpatient variability. You will see some people get very very sleepy with even a relatively small dose of morphine or fentanyl. And it's not always the 45 kg geriatric patient, sometimes it's the big 110kg ex-football player.

There's also a lot of unpredictability if you are mixing benzodiazepines with opiates. If you're going to do this, you need to be aware that they're synergistic, and a small amount of the two in combination go a long way.

I think an intelligent approach is to give moderate quantities on a repeat basis until the pain is manageable. You can always give more, but you can't take it back if you give too much.

I've given 30mg of MS IVP to an end-stage cancer patient with chronic pain (*After consulting with a palliative MD). I've also given a four year old child 14mg of MS after they poured a pot of boiling water over themselves. There's no fixed magic number that's "too much", it depends on the patient in front of you, and how they respond to initial and subsequent doses.