By Lynn Razzano RN, MSN, ONCC (Clinical Nurse Consultant)
A recent article by Gregory Hickman, MD. in Outpatient Surgery entitled: “Pump Up Your Pain Pump Knowledge: How much do you know about the potential for post-op complications?” is an eye-opener to reinforce our need to learn what we need to know in order to prevent postoperative complications.
Dr. Hickman points out that we do not always know all we need to know about patient-controlled analgesia (PCA) and continuous pain pumps.
If pain pumps are ordered as patient-specific and in accordance with individual risk factors for potential respiratory compromise up to and including depression and ultimately respiratory arrest, they provide postoperative pain relief and allow Activities of Daily Living (ADLs) to be tolerated and increase patient satisfaction.
Two incorrect beliefs about pain pumps that may harm patients
1. “If a pain pump doesn’t have a bolus, patients can’t deal with break-through pain.”
This is a false statement. As Dr. Hickman points out:
“A bolus may be the ideal way to manage breakthrough pain, but pumps with boluses are also more expensive. The pump we use doesn’t have a bolus, but it lets patients control the rate of infusion. I start my patients at 4 ccs an hour, but the pump goes up to 14 ccs/hr. If they’re experiencing breakthrough pain, I’ll tell them to run it at 12 or 14 ccs for an hour. The effect is basically the same as that of a bolus.”
The main goal of a pain pump, from a clinician’s perspective, is to enable patients to control the infusion rate to their own satisfaction safely and under the supervision of clinicians. To prevent possible opioid adverse events, I would clinically want to see a pain assessment scale from the patient with his/her reported level of pain.
In addition, the clinician should reassess the patient based on baseline risk factors as well as review their level of sedation. I would also recommend that a reversal agent or Narcan be present at the patient’s bedside. These steps ensure the patient is safe when they adjust the infusion rate to manage pain.
2. “It’s normal for patients with pain pumps to feel a little light-headed from time to time.”
This statement is likewise false. As Dr. Hickman says:
“Light-headedness can be an indication of local anesthetic toxicity, possibly because the medicine is being delivered to a vein. We tell patients to call us right away if they start feeling light-headed or confused. Other indications that the medicine is hitting a vein include ringing in the ears, numbness in the tongue or a bad taste in the mouth. But we have never had a toxicity issue after placing over 7,500 continuous catheters.”
Light-headedness could indicate a systemic effect of the pain medication or local anesthetic entering the patient’s bloodstream. It could also be because the patient is experiencing a vaso vagal effect from the medication delivered in the pain pump.
The other concern is that the pain med has crossed the blood brain barrier in enough quantity to have the patient complain or exhibit signs of dizziness or light-headed feeling.
Four action items that all clinicians should consider to keep patients safe while using pain pumps
- Institute a team-based approach to establish uniform and standardized Cardiac Monitored Care Process (CMCP) to clinically monitor care. This creates a clinical pathway that uses appropriate monitoring for the actual care being delivered.
- Individualize monitoring parameters specific to the individual patient and their baseline risk factors. Review reassessed risk factors for opioid related adverse events.
- Conduct daily lead changes and skin care prior to ensure that leads remain on the patient, thereby reducing the frequency of false alarms.
- Discontinue continuous electronic monitoring based on a well-defined protocol. This should include pre-defined criteria to assess the patient’s risk factors post discontinuing the monitors and a verbalized pain score.
Clinician-related surveys and questions create thoughts as well as misconceived notions in health care delivery of opioids via pumps. The gained knowledge helps us to better understand our clinical practice and where potential pitfalls may arise that may cause for patient concern.
Questions that come to mind
- What is the actual tolerable level of pain that does not impede patient functioning or level of care satisfaction? Is this level in accordance with the patient’s tolerance of pain, cultural factors and socioeconomic status?
- Has any clinician heard of the use of nasal Narcan that is kept at the patient’s bedside? What is the rationale for this, how are patients being monitored, and how is the drug safely secured to prevent inappropriate use?
- What types of opioid risk factor assessments are used in your facility and why are they clinically selected?
I applaud Dr. Hickman for his effort to raise our awareness of the need to better understand pain pumps in order to ensure the safety of our patients, and I encourage readers to use this as a start to learn more about these devices.