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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 High Alert Medications
Approved by:
Professional Practice Policy and Procedure Committee Effective: 6/99 Revised: 1/11 Revised: 4/14
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.
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
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)
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Commented [AD9]: This table removed per Alaris Team Recommendations to avoid confusion with next table.
Initial Loading 2 mg
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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 [AD15]: See ISMP list of approved abbreviations Commented [AD16]: Pall care consult required for subcutaneous PCAs
Commented [AD17]: No data in the literature stating this; where did it come from originally? Commented [AD18]: Updated info on subcutaneous placement based on literature; reference below
Commented [AD19]: Updated to reflect current UCH policy re: PCA syringes & concentrations
Commented [AD21]: Per pharmacy Commented [AD22]: Inserted per Alaris Team
Commented [AD25]: Inserted to clarify needed items for large volume PCA dosing
Formatted
Commented [AD26]: Inserted to discuss Alaris Guardrails and appropriate use of patient categories of nave, tolerant, and pall care
Commented [AD27]: Inserted per Alaris Team Commented [AD28]: Changed to reflect new tubing layout
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