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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
Approved by:
Professional Practice Policy and Procedure Committee Effective: 6/99 Revised: 1/11 Revised: 1/14
Description: This policy and procedure describes the process for patients to receive safe and
effective administration of parenteral opioid analgesics with a patient controlled analgesia (PCA) infusion device. 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.
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 [AD2]: 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 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 (15 mg/ml) Hydromorphone (0.21 mg/ml) Fentanyl (150 mcg/ml)
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H. The ratio of continuous (basal) dose to incremental (PCA) dose should remain approximately 1:2. I. Optimal opioid analgesic dose varies widely even among opioid-nave patients: adjust dosing based on patient response. J. 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 (15 mg/ml) Hydromorphone (0.21 mg/ml) Fentanyl (150 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 [AD5]: Updated opioid concentrations
Note: No limitation in dosing is implied by the above tables. L. 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 may be consulted to determine appropriate PCA dosages in this population. L.M. In addition to opioid nave and opioid tolerant, UCH has a third category of dosing parameters for the Palliative Care patient. These doses 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. M.N. Nurses may adjust pump settings within ranges and give bolus doses as ordered. A second RN verification is NOT required for bolus doses. N.O. Two RNs must independently verify drug, volume, concentration, and rate including all pump settings against the orders when: 1. Initiating the PCA infusion
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Commented [AD6]: Discuss existence of palliative care order set Commented [AD7]: Make it very clear that two RNs not needed for PCA boluses
Commented [AD9]: No data in the literature stating this; where did it come from originally? Commented [AD10]: Updated info on SC placement based on literature; reference below
3. Initiation of PCA Therapy A. Infusion medication and labeling 1. Manufacturer pre-mixed UCH pharmacy prepared morphine syringes (30 ml, 15 mg/ml) and UH pharmacy prepared, hydromorphone bags syringes (530 ml, 0.21 mg/ml), and fentanyl bags syringes (10030 ml, 150 mcg/ml) are stocked in the Pyxis machine. These syringes are used for both the opioid nave and opioid tolerant PCA order sets. 2. Higher concentrations of all PCA opioids are only available on an as ordered basisusing the Palliative Care order set. The use of the Palliative Care order set requires a Palliative Care Consult order (this is a physician to physician consult order). This order set may be appropriate for patients who are extremely opioid tolerant, are nearing the end of life, or are undergoing an extreme pain crisis. The Palliative Care order set may also be appropriate if the patient is requiring greater than one full syringe of medication every four hours. 3. Verify compatibility of other drugs being administered before connecting the PCA line. 4. PCA tubing must be connected into a continuously running maintenance IVA continuously running maintenance IVF or carrier IVF must be connected into the PCA tubing. B. PCA Initiation: 1. Verify physician order 2. Ensure patient meets criteria for use of PCA 3. Gather equipment: a. PCA pump with lock box and keyAlaris Central Unit with one Large Volume Pump module and one PCA module a. Alaris PCA key b. Two replacement batteries c. PCA tubing with Y connector d. PCA extension tubing e. Syringe/bag with ordered medication 4. If a large dose continuous infusion per Palliative Care has been ordered, the following equipment may be required: a. Alaris Central Unit with one Large Volume Pump module b. Alaris controlled substance tubing c. CADD lockbox d. CADD lockbox key 4.5.Wash hands. 5.6.Verify IV or SC site patency. 7. Follow the manufacturers instructions for setting up, loading, priming the tubing, and programming the PCA pump. 6.8.UCH Alaris pumps are fitted with Guardrails to help ensure correct dosing of all IV medications administered to patients. These Guardrails include hard and soft maximum and minimum ranges for PCA basal rates, demand doses, boluses, loading doses, and lockout times. There are three different categories of patient under these Guardrails: opioid nave, opioid tolerant, and palliative care. (Please refer to a UCH
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Commented [AD11]: Updated to reflect current UCH policy re: PCA syringes & concentrations
Commented [AD16]: Inserted to clarify needed items for large volume PCA dosing Formatted
Commented [AD17]: Inserted to discuss Alaris Guardrails and appropriate use of patient categories of nave, tolerant, and pall care
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