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University of Colorado Hospital Policy and Procedure Patient Controlled Analgesia (PCA): Adult and Pediatric

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Related Policy 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: l/l I Revise,-t: lft,X

Description:

This policy and procedure describes the process for patients to receive safe and effective administration of parenteral opioid analgesics via the Algris with-a-patient controlled analgesia (PCA) infusion4eriee syringe module. The goals are: l. To provide procedures for initiating, checking, and verifying PCA orders.

2. 3. 4.

To provide procedures for PCA opioid use, dosage, and safe practice. To standardize monitoring parameters. To standardize documentation.

Accountability: l. A physician or allied health provider must order PCA infusions. Initial
written

orders must be

standardconcentrations,dosesettingsandmonitoringparameterS.@ 2.
3.
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.

4.

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 l4 days. 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. Pharmacists are accountable for supplying opioids for PCA in pre-mixed syringes/bags. Any

5.

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.

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Patient Controlled Analgesia (PCA): Adult and Pediatric

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. herementst Jgggggl!--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 ofthe 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 adminjstration 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. PCA Opioid Use, Dosage, and Safe Practice 3. Initiation of PCA Therapy 4. Monitoring 5. Documentation 6. Education 7. References
Policies and Procedures:

Verification of Orders

1. Verification of Orders All health care professionals who are administering PCA must verify and check PCA orders for accuracy and ensure that the patient is not allergic to the prescribed drug. The
physician's order should contain the following:

A. Name and qoncentration stre*gthof drug (mglml or mcg/ml) B. Bolus or loading dose (mg or mcg) C. Basal or continuous rate (mg/hr or mcg/hr) D. Demand Inerereental-or PCA dose (mg or mcg) E. Lockout or delay time (minutes) F. Monitoring instructions (respiratory rate, sedation, pain intensity,

etc.)

2. PCA Opioid
A.

Use, Dosage, and Safe Practice Suitable candidates for PCA include patients with pain who are mentally alert and able to comprehend and comply with instructions and procedures regarding its use. Patients who may not be suitable candidates include: infants and young children, patients with altered

mental status (confusion, agitation, restlessness), patients with decreased level of

consciousness, patients who are not psychologically stable, and patients without ity to understand and the PCA.
B.

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Patient Controlled Analgesia @CA): Adult and Pediatric

C.

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noted in the box below. These risk factors should be considered when determining who might benefit from the use of mechanical monitoring via continuous pulse oximetry. Having a risk factor does not automatically require continuous pulse oximetry; the severity of the factor(s) and the patient's condition should guide the decision to use continuous pulse oximetry. It should be noted that continuous pulse oximetry may be automatically required by specific nursing unit protocols. Risk Factors for Opioid-Induced Respiratory Depression
Continuous Pulse

D. To reduce the risk of opioid-induced respiratory depression, monitoring of oxygenation by continuous pulse oximetry may be required by provider's order. Risk factors for opioid-induced respiratory depression have been recognized in the literature and are

Oximetry

2. Obstructive Sleep Apnea (OSA), or suspected of having OSA. 3. Pulmonary disease or dysfunction (e.g,, COPD). 4. Obesity, BMI > 35 kg/m2 5. Greater than64 years old. 6. Receiving other opioid or sedative drugs in addition to PCA. 7. Impaired renal or hepatic function.
E. PCA by Proxy is not allowed.

Use of a basal infusion dose in the non opioid-tolerant patient.

The severity ofthese factor(s) and the patient's condition should guide the decision to use
continuous pulse

oximetry

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. Ifa 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 dosaees for acute/postoperative acute/oostooerative pain oain in opioid ooioid naiVe adults:

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Patient Controlled Analgesia (PCA): Adult and Pediatric

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Opioid (Concentration)
Usual

Loading Range

Usual Basal Range

Usual
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Usual

Lockout

Demand Range

Morphine Gj5-/_,ll) Hydromorphone (03f, mg/ml) Fentanyl ({0 mcg/ml)

H. Basal rale is not routinely recommended in opioid-naive patients. I{orvever. if a basal. raje is ordered Tlhe ratio of continuous (basal) dose to incremental (PCA) dose should remain approximatel y I 2_:n_spieid- nglys patients. Optimal opioid analgesic dose varies widely even among opioid-naive patients: adjust dosing based on patient response. 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 agelor 50 kg. The physician service managing the PCA must obtain consent from parenVlegal 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. Usual range ofPCA dosages for acute/postoperative pain in pediatric patients:
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Note: No limitation in dosing is implied by the above tables.

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 populationl

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Patient Controlled Analgesia (PCA): Adult and Pediatric

N.!).__Two RNs must iryJ@endently '*rryql and rate includipfall pump setti

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2. Accepting patient from another floor 3. Changing shift (with off-going RN to oncoming RN) 4. Changing any settings or changing drug

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ainst the orders when:

Initiating the PCA infusion

M.peridine (Demerol) is not available for PCA due to accumulation of an active metabolite, normeperidine, which can cause seizures and tremors. ?-{}" lrlorphine should be used with caution in patients with renal insufficiency due to its more potent active metabolite, morphine-6-glucuronide (M6G). M6G has decreased clearance and increased elimination half-life in these patients.
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manufacturer's instructions in usecl for subcularreous iqiecliqns. bilateral subclavicular chest wall. or nostelior scapular area: the siie should allpu- a fat lbld ol'at least l" ro he pinched betrveen thumb and i ia is not zr contr:rindic:rtir"rn firl access. although available sites maLbe limited. 'llhgsqite is prepped sia+ilar-tosame manner as placing an IV catheter and should be covered with a transparent dressing. Aspiration should NOTresult in blood return. 'I'he site should be monitorod according to tho same par&neie1's as an IV site fbr erythema. indut'ation. lcilking. bleeding. edenra. intbction. or tissue slough. 'lhe {isite should be changed by the nurse minimum every 7 days, or more often if necessary (erythema, edema, leaking). i4.]he administration set and pump-sbeukl be-qlgA!"I) labeled subcutaneous inlusion to prevent mistaking ior an inirar,,enous line. 4.i.Dosing is the same as for IV infusion; however, a longer initial drug onset time, (anproxintate lv-' 20 minutes) must be allowed for duete.slower absorption via the Sy'

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route.

Change PCA bag/syringe every 24 hours for UCH mixed solutions and every 72 hours for pre-mixed solutions. Change the tubing every 96 hours. _ - The key to the PCA pump will be kept within a secured designated area, e.g., Pyxis machine on each unit. :.1-,1,. a patient experiences an adverse event related to sedation or respiratory depression, examine the medication concentration and pump settings to assure they are correct. If no human errors are discovered: l) Retum the PCA pump to Biomed for

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Patient Controlled Analgesia (PCA): Adult and Pediatric

inspection with tae-_The pump must not be retumed to use or to Central Supply; 2) The IV bag and tubing must be returned to the Pharmacy. Contact the Pharmacy Manager on call (303-266-0661) for instructions on disposition of the IV bag and tubing, based on time of day and day of the week.

Initiation of PCA Therapy

A.

Infusion medication and labeling l. Ma*ru{betercr pre &i!'l.?i{"Ue}l_pharmagr pfgpfttpdr.bAlchqd_morphine syringes (30 ml, *l mg/ml)@hydromorphone bat$-tydtggs (510 ml, (+903! ml, *!0 mcg/ml) are stocked in the {l3f mg/ml). and fentanyl Pyxis machine. 'llhese syringes are usecl ibr bqth the opioid narye atd epiOid lOlerant

2.

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Higher concentrations

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requires a lialliative Care Consult order (rhis is a ph),sician to ph),sician coqsult order). 'l his ord(:r sot maJ" be__appropriate tbr palignts u4ro arc exlrenrel-l: opioid ins the end ol lil'e. or are undereoins an extreme nain crisis. The

the HLIB on the Alaris Multidisciplinarv urebsite) Verify compatibility of other drugs being administered

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PCA Initiation: l. Verify physician order 2. Ensure patient meets criteria for use of PCA

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P"9nP.!,nC yith Y connector Syringelb*g with ordered medication

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Sff.e,/=9N9,lY*P9A-q.rger qqt. ip. hsiss,"lwC .(.w-ith-.e"ontinuseq l?ts infusing via the Alaris LVP and demand dose infusing via the Alaris syringe module) , lhe

fbllorving erluipnronl. may bc rcquired: a. Alails PCU een*al{fui*rvith one Large Voluqte Pump (LVP) nroclule and* Alaris PCA syringe module. (See Kaizen Bulletin: How to Administed Controlled Qubstance Infusions in Non-ICU Care Areas) b, _ Alari$, cpntnrlled suhstance tubing c. CADD lockbox
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Patient Controlled Analgesia (PCA): Adult and Pediatric cl. CIADD lockbox
J,1.Wash hands. key

r.(r.Verifo IV or SCI site patency. 7. Follow the manufacturer's instructions for setting up, loading, priming the tubing, and
programming the PCA pump.

c,.f,tJCll r\laris numps are$t*ed-+vitfi-use Guardrails safety softwardhdfail$hrr hclp ensure con'ect dosing ol all IV medications adrninistered to patients. 'Ihese Guardrails
inclucle hard and so{-t maximum and mininrum ranges ibr: PCA basal rates. clenrand doses. boluses. loacling doses. and iockout times. '['lrere arrl three dilibrent catesories oi patient undErr: these Guard:rails: opieid-nAlyg_opiqicl tolerant. and palliative care. (Please rel'er lo a LJCI-I phannacist or a smart pump technolosy team member an
a-[s-L"e{-"-c-u{t-e"n.t-(juar-drails $aldard$J }Vh-e-n-prrgnmmi-ngth-e-.pilry& the correct catego-ry ol'patient$ust be sgleqtqd in clrder lbr tho anpropriate Gualdrailq to aoply. 4,!..Label tubing with date and time and sticker.

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independently verifu drug, volume, concentratiotrtrkT[l Ittterv'al and rate including all pump setti inst the orders. 9,f 1,_Connect t!9, PCA- tubing to the $

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l0, j?-."".Instruct the patient and family/significant other on the use of PCA.

4. RecommendedMonitoring
A.
Recommended patient monitoring includes assessment and documentation of vital sigrrs, sedation level, and pain intensity per PCA orders. Recommended monitoring parameters
are:

2. 3.

l.

4.

Heart rate, blood pressure, temperafure and pulse oximetry every 4 hours Respiratory rate and sedation level every I hour x 12 hours, then every 2 hours x 12 hours, then every 4 hours until the PCA is discontinued. If the PCA dose is increased (basal rate started or increased, demand dose increased, lockout frequency decreased, RN bolus given), temporarily increase the respiratory rate and sedation level monitoring to every 30 minutes x 2. Assessment of the sleeping patient: a. Respiratory status should be observed without awakening the patient. Arousal will stimulate respiration and potentially mask pending problems. b. Observation should include the depth and regularity of respirations and listening for snoring. Shallow respirations, periods of apnea, or snoring may be a sign of over

c.
d. e.

sedation or respiratory trouble and the patient should be awakened to further assess, If there is any question about whether the patient is sleeping normally or is sedated, they should be awakened to further assess. If respiratory rate and status are assessed as normal as noted above, it is not required to awaken the patient to assess sedation.

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Patient Controlled Analgesia (PCA): Adult and Pediatric

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l--'NonS to minimal sedation Arvake. arvare. aleft: sDontaneous sustained interaction

Rest{ul. dror.vsy. dozing" lightly sleepingl soft voice. no tactile stimulus reauired clr lisht touch. susta.ins intemction 3---Moderate Sedation Sleeninp. soft to normal voice- lisht toLrch- limited interact.ion 4--"Moderate Sedalion Sleepins. normal to lor"rd voice- lisht touch. lirllorrys simnle conrmands S-*-Deep Sedation Sleeping. ainva), and ventilatiorr mav be impaired" loud vclice. intense tcr noxious tactile stimulus. purnosolirl rosoonse or non-Dul.rloseful movement 6*-General Anesthesia Slseping. aj!1va,v and ventilation likely impaired. krud voice. noxious stimrrlus. no resnonse/unarou sable

B.
C. D.

Increasing somnolence can be a key indicator

of pending opioid induced respiratory

depression. Assess the patient's pain intensity at least every 4 hours and within
doses or ratelmedication changes. Assess the patient for the following side effects and treat as needed; Nausea and,/or vomiting

hour after bolus

E.

2. Pruritus 3. Urinary retention 4. Constipation

l.

Immediately notify the ordering service for respiratory rate less than l0 per minute, sedation level of 2 or less (difficult to arouse), or inadequate pain relief. F. Ifrespiraiory rate less than 8 per minute or sedation level of I (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 I hour x 12 hours , then every 2 hours x 12 hours, then every 4 hours 3. Two RNs must independently verify drug, volume, concentration, lock-out interval and rate including all pump settings against the orders when: a. Initiating the PCA infusion b. Accepting patient from another floor

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Patient Controlled Analgesia @CA): Adult and Pediatric

Changing shift (with off-going RN to oncoming RN) Changing any settings or changing drug Two RN:s must witness and document wasting of controlled substances The number of PCA button demands/deliveries and the total amount of medication (mg or mcg) used every 4 hours. After recording these amounts, clear the 4 hour shift total to reset the pump for the next 4 hour total Pain intensity at least every 4 hours and within t hour after bolus doses or rate/medication changes Side effects/complications Patient and family education on the Interdisciplinary Teaching Sheet.

4. 5. 6. 7.
6.
A.

c. d,

Education
Where appropriate, provide patient education sheet "Patient Controlled Analgesia (PCA)" (DOD# P8D00105-0902 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:
. "*I*=&"!Je!Cstqn,"5,.t?Q19).411-erra.tilrpJnlu.ilm.Asgs.r".r*y"iss.:.=ls.!I"Als.I"Qrr.4ss (Eds.J. Ifit..Vof..,\:rJr.sirgn ,{lr" Er:iqlqrc.c;_ Basedr,lplroacfi (np. 516-521). St. l,ouis" lV10: Saunders Elsevier. (l,OE"l) *'f,* 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 VD l3,-Lehmann, K. (2005). Recent developments in Patient-Controlled Analgesia. Journal of Pain and Symptom Management. 29(55) S72-S89. (LOE I) &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 VD 6. McCaffery, M. g Pasero, C., (2010). Pain Assessment and Pharmacologic Management. St.

l.--Fer

A. Corrigan. t.. Gorski. .1. Hankins. & R. Perucca

&7, Moli

Loui,s:

Mosby. (LOE VD

B, & Reberti. [4,"(201,?),,,=\,,didiFi,i]I Ilharmacologic Sedation Scale. Clinical Nurse Specialist. 26(3):140-148. (LOE ?) &8-*Pasero, C. & McCaffery M., (2005). Authorized and unauthorized use of PCA pumps. American Joumal of Nursing, 105(7), 30-32. (LOE VD &!. *Pasero, C. (2009). Assessment of sedation during opioid administration for pain management. Journal of Perianesthesia Nursing. 24(3):186-190. (LOE VI) &1fi*Patient controlled analgesia by proxy. Sentinel Event Alert, Dec 20,2004. Available at http://www jointcommission.org/SentinelEvents/SentinelEventAlerUsea_33.htm. Accessed 918t200s. (LoE v)
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