Postoperative Pain Management Vocabulary

Incision-Site Continuous Infusion Pump ("Intra-cavity" Technique)

• Device & Contents

  • Small, portable pump pre-filled with a local anesthetic (usually lidocaine) in liquid form.
  • Designed to continuously drip anesthetic directly into the surgical wound/incision.
  • Has a simple ON/OFF button; remains in place post-operatively until emptied or removed by the physician (≈ 1 week after surgery).

• Primary Goal

  • Keeps tissue bathed in anesthetic, maintaining numbness → minimal to no perceived pain → reduced need for systemic opioids.

• Typical Clinical Uses

  • Same-day hysterectomies, abdominal surgeries, some orthopedic procedures (e.g.
    out-patient hip repairs).
  • Research phase: lumbar & cervical spinal surgeries (e.g.
    discectomy, laminectomy) to explore post-laminectomy pain control.

• Classification & Mechanism

  • Falls under "intracavity" analgesia methods (local agent delivered directly into a body cavity/wound space).
  • Eliminates systemic side-effects while providing focal pain relief.

• Practical / Ethical Notes

  • Enhances early discharge protocols (“same-day surgery” trend).
  • Promotes patient comfort without heavy narcotic exposure ➔ lowers risk of opioid dependency.

IV Analgesia – Two Major Modalities

1. IV Push (Bolus)
   • Rapid manual injection by an RN only.
   • Common medications: Toradol (NSAID), Morphine, Dilaudid (Hydromorphone).
2. Patient-Controlled Analgesia (PCA)
   • Computerized pump delivering pre-programmed IV narcotics on demand.
   • Empowers patient autonomy while incorporating built-in safety limits.

IV Push Specifics

• Why RN-restricted?
  • Immediate onset, high potency ➔ demands vigilant monitoring for respiratory depression & hemodynamic shifts.
• Typical Contexts
  • Post-op or acute pain spikes when PCA is not yet effective.
• Key Nursing Actions
  • Observe for infiltration, patency, and allergic reactions after administration.

PCA (Patient-Controlled Analgesia) — Principles

• "Patient-Only Button" Rule

  • Neither nurse, family, nor visitors may press the button ➔ prevents inadvertent overdose, preserves ethical autonomy.

• Ideal Timing of Use

  • Immediately post-surgery when continuous pain control is needed but frequent professional boluses are impractical.

• Potential Initial Gap

  • Patients waking from anesthesia may be too groggy to self-dose ➔ may need an RN-delivered bolus until cognitively ready.

Anatomy of the PCA System

• Hardware

  • Desk-sized electronic pump or compact home version.
  • Medication reservoir: IV bag or large syringe loaded with Morphine or Dilaudid.
  • Tubing connects reservoir ➔ pump ➔ IV access site.

• Medication Choices & Rationale

  • Morphine: gold-standard, well-studied.
  • Dilaudid (Hydromorphone): 5–10× morphine potency, favored for lower volume/greater concentration.
  • Demerol (Meperidine): largely obsolete due to seizure risk from neurotoxic metabolite (normeperidine).

PCA Programming Parameters (Displayed as a Numeric String)

Typical format: \text{Bolus}\,/\,\text{Basal}\,/\,\text{Lockout}\,/\,\text{4-hr Limit}

1. Bolus (Demand) Dose
   • Quantity delivered each time patient presses the button.
2. Basal (Continuous) Rate
   • Optional hourly amount infused automatically, even without button presses.
3. Lockout Interval
   • Minimum time (minutes) between allowable bolus doses to prevent stacking.
4. 4-hour Upper Limit
   • Max cumulative dose machine will deliver in any rolling 4-hr window.

Morphine Example

• Preset string: 1\,/\,0\,/\,6\,/\,30
  • 1 \text{ mg} per button press.
  • 0 \text{ mg hr}^{-1} basal (none).
  • 6 \text{ min} lockout.
  • \le 30 \text{ mg} total/4 hr.

Dilaudid Example

• Preset string: 0.2\,/\,0\,/\,10\,/\,2
  • 0.2 \text{ mg} per demand.
  • 0 \text{ mg hr}^{-1} basal.
  • 10 \text{ min} lockout.
  • \le 2 \text{ mg} total/4 hr.

Adding a Basal Component (e.g., Terminal Care)

• 1\,/\,1\,/\,6\,/\,\varnothing
  • Patient receives 1 \text{ mg hr}^{-1} continuously plus 1 \text{ mg} on-demand.
  • Lockout remains 6 min; no 4-hr cap (\varnothing) appropriate in hospice/terminal scenarios where suffering outweighs addiction concerns.

Nursing Assessment & Troubleshooting

• Verify Programming

  • Cross-check each numeric field against physician orders.
  • Inspect tubing for leaks, kinks, infiltration.

• Button-Press Audit

  • Pump stores attempted vs.
    delivered doses.
  • High attempts, low deliveries ➔ inadequate pain control; consider shorter lockout or higher bolus.
  • Low usage with vocal pain ➔ patient education (“push when pain starts, not when unbearable”).

• Physiological Monitoring

  • Level of consciousness, respiratory rate, oxygen saturation.
  • Watch for sedation scores > 2 or SpO₂ < 92\% ➔ may need naloxone titration or basal reduction.

• Documentation

  • Record cumulative dose, observations, education provided, and communication with prescriber.

Ethical, Philosophical & Practical Considerations

• Patient Autonomy vs. Safety
  • PCA respects self-determination yet embeds mechanical safeguards.
• Opioid Stewardship
  • Local anesthetic pumps + judicious PCA use aim to minimize systemic opioid exposure.
• Quality of Life at End-of-Life
  • Removal of 4-hr limits & higher basal rates considered ethical to alleviate terminal suffering.
• Same-Day Surgery Revolution
  • Technology (incision pumps, PCA, minimally invasive techniques) enables rapid discharge, reducing hospital-acquired complications.

Research & Future Directions

• Ongoing trials evaluating continuous local-anesthetic pumps for lumbar & cervical spine surgeries (post-laminectomy/discectomy) to curb post-op neuropathic pain.
• Trend toward home-based PCA units, promoting recovery outside inpatient settings while ensuring adequate analgesia.