and Procedures:
Central Venous Lines Peripheral Venous Lines Medication Management Pain Management: Adult and Pediatric Pyxis Medication System Controlled Medication Management Epidural and Intrathecal Infusion Analgesia Equipment Failure and Safety Hazard Reporting
Commented [AD1]: Neither EPIC nor the Alaris pumps are set up for Pediatric ordering, nor are PCA pumps used for Peds in our hospital
Approved by:
Professional Practice Policy and Procedure Committee Effective: 6/99 Revised: 1/11 Revised: 3/14
Description: This policy and procedure describes the process for patients to receive safe and
effective administration of parenteral opioid analgesics with a via the Alaris patient controlled analgesia (PCA) infusion device syringe module. The goals are: 1. To provide procedures for initiating, checking, and verifying PCA orders. 2. To provide procedures for PCA opioid use, dosage, and safe practice. 3. To standardize monitoring parameters. 4. To standardize documentation.
Commented [AD3]: Change per Alaris Team
Accountability:
1. A physician or allied health provider must order PCA infusions. Initial orders must be written on a pre-printed order form that includesusing an EPIC order set, which includes standard concentrations, dose settings and monitoring parameters. Subsequent PCA orders may be written on a standard physician order form. 2. Opioids or sedatives ordered in addition to a PCA should be authorized by the physician service that wrote the PCA orders before they are administered. This is required to prevent excessive sedation from other systemic controlled substances or sedatives. 3. New PCA orders will be written when a patient is transferred to another nursing unit (e.g., transfer in/out of ICU). PCA orders will be rewritten or renewed every 14 days. 4. All health care professionals (physicians, nurses, pharmacists) are accountable for verifying and checking PCA orders for accuracy. Physicians and nurses are accountable for checking the intravenous (IV) site for patency prior to starting an infusion and may initiate PCA pumps only if appropriately instructed. PACU nurses are accountable for initiating PCA infusions for postoperative patients prior to sending the patient to another nursing unit. 5. Pharmacists are accountable for supplying opioids for PCA in pre-mixed syringes/bags. Any drug wastage from the PCA pump must be witnessed and appropriately independently documented by two nurses, physicians and/or pharmacists as per the UCH Controlled Medication Management policy.
Commented [AD4]: Remove references to paper order forms
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Definitions:
Bolus or Loading Dose: One time dose of medication that may be given at the start of a PCA infusion, or that may be given as an additional dose to supplement PCA therapy. Basal or Continuous Rate: The amount of medication automatically infused per hour. Incremental Demand or PCA Dose: The amount of medication infused when the patient presses the control button. Lockout or Delay Time: Period of time that must pass between the completion of one PCA dose and the initiation of the next. Patient Controlled Analgesia (PCA): Delivery of opioids via an electronic pump which enables the patient to self-administer small doses (usually IV) at frequent intervals, maintaining blood levels of opioids within an effective range. PCA by Proxy: Unauthorized administration of a PCA dose by anyone other than the patient, i.e., family members, caregivers, clinicians. This form of PCA therapy is not allowed at UCH.
Table of Contents:
1. 2. 3. 4. 5. 6. 7. Verification of Orders PCA Opioid Use, Dosage, and Safe Practice Initiation of PCA Therapy Monitoring Documentation Education References
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E. PCA by Proxy is not allowed. Unauthorized administration of a PCA dose by anyone other than the patient, i.e., family members, caregivers, clinicians, can lead to over sedation, respiratory depression, and even death. If a patient is unable to self-administer their PCA dose, notify the physician service managing the PCA. Consideration should be given to discontinuing PCA therapy and utilizing alternate therapy such as IV push. Under no circumstances should anyone else push the PCA button for the patient. If the patient asks a health care provider to push their PCA button for them (e.g., patient cannot reach button), the provider should provide the button to the patient to administer their own dose. F. Initial PCA dosages for acute/postoperative pain in opioid nave adults: Opioid (Concentration) Morphine (1 mg/ml) Hydromorphone (0.2 mg/ml) Fentanyl (10 mcg/ml) Initial Loading 2 mg 0.4 mg 25 mcg Initial Basal Not Recommended Initial Incremental 1-2 mg 0.2-0.4 mg 10-25 mcg Initial Lockout 8 min. 8 min. 8 min.
Commented [AD9]: This table removed per Alaris Team Recommendations to avoid confusion with next table.
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Opioid (Concentration) Morphine (15 mg/ml) Hydromorphone (0.21 mg/ml) Fentanyl (150 mcg/ml)
Note: No limitation in dosing is implied by the above table. H.G. Basal rate is not routinely recommended in opioid nave patients. However, if a basal rate is ordered for an opioid nave patient, Tthe ratio of continuous (basal) dose to incremental (PCA) dose should remain approximately 1:2. I.H. Optimal opioid analgesic dose varies widely even among opioid-nave patients: adjust dosing based on patient response. J.I. For pediatric patients, the decision to use PCA will be based on their individual needs and abilities. Pediatric dosage will be by weight until 12 years of age/or 50 kg. The physician service managing the PCA must obtain consent from parent/legal guardian for pediatric patients under eighteen (18) years. Any special assessment, monitoring, or dose titration parameters should be established by the physician service managing the PCA when the infusion is ordered. K. Usual range of PCA dosages for acute/postoperative pain in pediatric patients: Opioid (Concentration) Morphine (1 mg/ml) Hydromorphone (0.2 mg/ml) Fentanyl (10 mcg/ml) Usual Loading Range 30 mcg/kg 5 mcg/kg 1 mcg/kg Usual Basal Range 0-30 mcg/kg/hr 0-5 mcg/kg/hr 0-1 mcg/kg/hr Usual Incremental Range 10-30 mcg/kg 3-5 mcg/kg 0.2-1 mcg/kg Usual Lockout 8-10 min. 8-10 min. 6-10 min.
Commented [AD13]: Removed per Alaris Team; there is currently no pediatric entry built into the PCA pump or EPICs order sets.
Note: No limitation in dosing is implied by the above tables. J. PCA dosage ranges in the opioid-tolerant patient can be much higher than those listed in the above tables. The Acute Pain Service (APS) 303-266-6493 or the Palliative Care Team (see on-call schedule) may be consulted to determine appropriate PCA dosages in this population. L.K. In addition to opioid nave and opioid tolerant, UCH has a third category of dosing parameters for the Palliative Care patient. The doses used in the Palliative Care/Oncology IV PCA order set are generally much larger than those for opioid nave and tolerant patients, and may require the use of special high concentration syringes/premixed bags of medication. Using this order set results in an automatic consult to the Palliative Care Team; this consult is required to use this order set. M.L. Nurses may adjust pump settings within ranges and give bolus doses as ordered.
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Commented [AD16]: See ISMP list of approved abbreviations Commented [AD17]: Pall care consult required for subcutaneous PCAs
Commented [AD18]: No data in the literature stating this; where did it come from originally? Commented [AD19]: Updated info on subcutaneous placement based on literature; reference below
Commented [AD20]: Updated to reflect current UCH policy re: PCA syringes & concentrations
Commented [AD22]: Per pharmacy Commented [AD23]: Inserted per Alaris Team
Commented [AD26]: Inserted to clarify needed items for large volume PCA dosing
Formatted
Commented [AD27]: Inserted to discuss Alaris Guardrails and appropriate use of patient categories of nave, tolerant, and pall care
Commented [AD28]: Inserted per Alaris Team Commented [AD29]: Changed to reflect new tubing layout
Sedation scaleMoline-Roberts Pharmacologic Sedation Scale 5 = wide awake 3 = sleeping arousable 1 = not able to arouse 4 = drowsy 2 = difficult to arouse 1None to minimal sedation Awake, aware, alert; spontaneous sustained interaction 2Anxiolysis Restful, drowsy, dozing, lightly sleeping; soft voice, no tactile stimulus required or light touch, sustains interaction 3Moderate Sedation Sleeping, soft to normal voice, light touch, limited interaction 4Moderate Sedation Sleeping, normal to loud voice, light touch, follows simple commands 5Deep Sedation Sleeping, airway and ventilation may be impaired, loud voice, intense to noxious tactile stimulus, purposeful response or non-purposeful movement 6General Anesthesia Sleeping, airway and ventilation likely impaired, loud voice, noxious stimulus, no response/unarousable B. Increasing somnolence can be a key indicator of pending opioid induced respiratory depression. C. Assess the patients pain intensity at least every 4 hours and within 1 hour after bolus doses or rate/medication changes. D. Assess the patient for the following side effects and treat as needed: 1. Nausea and/or vomiting 2. Pruritus 3. Urinary retention 4. Constipation E. Immediately notify the ordering service for respiratory rate less than 10 per minute, sedation level of 2 or less 5 or more(difficult to arouse), or inadequate pain relief. F. If respiratory rate less than 8 per minute or sedation level of 16 (not able to arouse), stop infusion and administer naloxone 0.1 mg IV STAT, may repeat every 3-5 minutes x 3 doses to a total of 0.4 mg. G. The above monitoring parameters are minimum standards and should be increased as warranted by patient condition and orders. 5. Documentation A. The nurse is responsible to document the following on the appropriate patient information record: 1. Heart rate, blood pressure, temperature and pulse oximetry every 4 hours. 2. Respiratory rate and sedation level every 1 hour x 12 hours , then every 2 hours x 12 hours, then every 4 hours. 3. Two RNs must independently verify drug, volume, concentration, and rate including all pump settings against the orders when: a. Initiating the PCA infusion
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Commented [AD30]: Changed to reflect new sedation scale in use; reference inserted below Formatted: Centered Formatted Table
4. 5.
6. 7.
6. Education A. Where appropriate, provide patient education sheet Patient Controlled Analgesia (PCA) (DOD# PED00105-0902 available in Spanish). Review with patient and family the principles of PCA therapy and proper use. Identify that no one but the patient is to administer a PCA dose. REFERENCES: 1. Parker, M. & Henderson, K. (2010). Alternative Infusion Access Devices. In M. Alexander, A. Corrigan, L. Gorski, J. Hankins, & R. Perucca (Eds.), Infusion Nursing: An EvidenceBased Approach (pp. 516-521). St. Louis, MO: Saunders Elsevier. (LOE ?) 1.2. American Pain Society (2008). Principles of Analgesic Use in the Treatment Of Acute Pain And Cancer Pain (6th Ed.). American Pain Society, Skokie, IL. (LOE VI) 2.3. Lehmann, K. (2005). Recent developments in Patient-Controlled Analgesia. Journal of Pain and Symptom Management. 29(5S) S72-S89. (LOE I) 3.4. Institute for Safe Medication Practice Newsletter (2009). Beware of basal opioid infusions with PCA therapy. March 12 issue. (LOE V) 4.5. Macintyre P. (2005). Intravenous patient-controlled analgesia: One size does not fit all. Anesthesiology Clinics of North America. 23, 109-123. (LOE VI) 6. McCaffery, M. & Pasero, C., (2010). Pain Assessment and Pharmacologic Management. St. Louis: Mosby. (LOE VI) 5.7. Moline, B. & Roberts, M. (2012). Validity and interrater reliability of the Moline-Roberts Pharmacologic Sedation Scale. Clinical Nurse Specialist. 26(3):140-148. (LOE ?) 6.8. Pasero, C. & McCaffery M., (2005). Authorized and unauthorized use of PCA pumps. American Journal of Nursing, 105(7), 30-32. (LOE VI) 7.9. Pasero, C. (2009). Assessment of sedation during opioid administration for pain management. Journal of Perianesthesia Nursing. 24(3):186-190. (LOE VI) 8.10. Patient controlled analgesia by proxy. Sentinel Event Alert. Dec 20, 2004. Available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm. Accessed 9/8/2005. (LOE V) c158411
Commented [AD32]: Reference for subcutaneous infusions. NEEDS LOE! Formatted: Font: Italic
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