Venous Access for Pain Control by Neal Little, MD

Neal Little, MD

To what extent would you go in getting venous access deliver meds to help relieve pain not related to medically serious disease, e.g. migraine, or needed to get positioning for imaging to detect major problems(e.g. fractures)?  Let’s say a young person (use any number you want, based on your own age) who may need their veins down the road for other medical problems with their usual bad migraine, with or without vomiting, who has tried some home meds and either they don’t work or can’t be held down.  Would you put in a central line if no peripheral access were found, and subject the patient to the risks of central lines?  Is this a special case for ultrasound guidance for a peripheral IV, or would that also potentially “use up” good peripheral access?  Intra osseous? Let’s also assume the patient has had experience with IM injections which have not done well and is not anxious to start there- what would you do?  How about ODT ondansetron?  What if that was a med tried at home?  Should we refer them for a PIC line from the ER , or is that not a decision for us?

I’d love to hear comments, cases, protocols etc.

Comments

[Mike]

I cannot imagine a time where you would get a difficult venous access only for pain control (procedural sedation is another story). Subcutaneous dilaudid (and morphine and demerol) are pretty great if you use enough and the time and discomfort involved in poking around for little veins or penetrating bone just wouldn't be worth it.

But the larger issue of IV access, central lines, clysis with hyaluronidase and US guided lines merits comment. I'll do it in the next month or two.

[Sue Ieraci]

Very different practice in Australia - most anangesia for severe pain is titrated intravenous narcotic (mostly morphine, sometimes Fentanyl - we've almost got rid of demerol due to abuse potential in the community). IV access is still mostly a medical task, rarely have problems getting access. Generally don't have to poke around too much, and can't recall ever penetrating bone! A single IV stab is much more comfortable for the patient needing ongoign analgesia than multiple SC needles.
Sue