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University of Colorado Hospital Policy and Procedure


Patient Controlled Analgesia (PCA): Adult and Pediatric

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
High Alert Medications

Approved by: Professional Practice Policy and Procedure Committee
Effective: 6/99
Revised: 1/11
Revised: 7/14

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.

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 EPICelectronic health record 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
Provider 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)Providers 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 [AD1]: Per Acute Pain Service and hospital policy
regarding pediatric admissions, references to pediatric PCAs and
dosing have been removed. The title needs to be updated to reflect
these changes.
Commented [AD2]: Deleted; unable to find this policy.
Commented [AD3]: Updated to reflect precise policy name
Commented [AD4]: Updated to add a related policy
Commented [AD5]: Inserted new date for policy revision
Commented [AD6]: Change per Alaris Team
Commented [AD7]: Remove references to paper order forms
Patient Controlled Analgesia (PCA): Adult and Pediatric

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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.

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:
I. Verification of Orders3
II. PCA Opioid Use, Dosage, and Safe Practice.3
A. Suitable Candidates for PCA.3
B. Demand Dosing.3
C. Basal Infusions...3
D. Opioid-Induced Respiratory Depression3
E. PCA by Proxy4
F. Initial and Ranges of PCA dosages4
G. Loading Dose.5
H. Basal Rates.5
I. Optimal Dosing..5
J. Opioid-Tolerant Dosing.5
K. Palliative Care Dosing...6
L. Nurse Setting Adjustments and Boluses6
M. Dual RN Verification.6
N. Demerol..6
O. Morphine Dosing...6
P. Subcutaneous PCA Infusions.6
Q. Changing PCA Solutions and Tubing7
R. PCA Keys..7
S. Adverse Events..7
III. Initiation of PCA Therapy.7
A. Infusion Medication and Labeling.7
B. PCA Initiation7
IV. Recommended Monitoring8
A. Recommended Monitoring and Sedation Scales...8
Commented [AD8]: Change per Alaris Team
Formatted: List Paragraph, Numbered + Level: 1 +
Numbering Style: A, B, C, + Start at: 1 + Alignment: Left +
Aligned at: 0.5" + Indent at: 0.75"
Formatted: List Paragraph, Numbered + Level: 1 +
Numbering Style: A, B, C, + Start at: 1 + Alignment: Left +
Aligned at: 0.5" + Indent at: 0.75"
Formatted: List Paragraph, Numbered + Level: 1 +
Numbering Style: A, B, C, + Start at: 1 + Alignment: Left +
Aligned at: 0.5" + Indent at: 0.75"
Patient Controlled Analgesia (PCA): Adult and Pediatric

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B. Increasing Somnolence10
C. Pain Assessment...10
D. Side Effects..10
E. Parameters for Provider Notification...10
F. Parameters for Stopping the PCA and Administering Naloxone.10
G. Increasing Monitoring..10
V. Documentation.10
VI. Education.10
References11

Policies and Procedures:
I. 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 physicians
order should contain the following:
A. Name and strength concentration of drug (mg/ml or mcg/ml)
B. Bolus or loading dose (mg or mcg)
C. Basal or continuous rate (mg/hr or mcg/hr)
D. Incremental Demand or PCA dose (mg or mcg)
E. Lockout or delay time (minutes)
F. Monitoring instructions (respiratory rate, sedation, pain intensity, etc.)

II. PCA Opioid Use, Dosage, and Safe Practice
A. 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
intellectual capacity to understand and operate the PCA.
B. Demand dose (PCA) only is the safest mode for opioid nave patients and is normally
used initially in the majority of patients with post-surgical,post-procedure or acute pain.
C. A basal infusion dose is normally only used in the opioid-tolerant patient, as needed.
Opioid-tolerant is defined as those patients who have been receiving opioids regularly for
approximately 7 days or more. A basal dose should not be increased more frequently
than every 10-12 hours, preferably 24 hours, to allow steady state to be reached and the
full effects of the dose increase to felt/observed.
D. To reduce the risk of opioid-induced respiratory depression, monitoring of oxygenation by
continuous pulse oximetry may be required by providers order. Risk factors for opioid-
induced respiratory depression have been recognized in the literature and are 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 patients 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.
Commented [AD9]: Updated formatting per new Policy &
Procedure Template
Commented [AD10]: Change per Alaris Team
Commented [AD11]: Change per Alaris Team
Commented [AD12]: Change per Alaris Team
Commented [AD13]: Change per Jeanie Youngwerth, MD
Patient Controlled Analgesia (PCA): Adult and Pediatric

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Risk Factors for Opioid-Induced Respiratory Depression Continuous Pulse
Oximetry
1. Use of a basal infusion dose in the non opioid-tolerant patient.
2. Obstructive Sleep Apnea (OSA), or suspected of having OSA.
3. Pulmonary disease or dysfunction (e.g., COPD).
4. Obesity, BMI 35 kg/m
2

5. Greater than 64 years old.
6. Receiving other opioid or sedative drugs in addition to PCA.
7. Impaired renal or hepatic function.
The severity of these
factor(s) and the
patients condition
should guide the
decision to use
continuous pulse
oximetry

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 and Ranges of PCA dosages for acute/postoperative pain in opioid nave adults:


Opioid
(Concentration)

Initial
Loading
Dose (repeat
PRN)

Initial
Basal Dose

Initial
DemandIncremental
(PCA) Dose

Initial
Lockout
(min.)

Morphine (15 mg/ml)
Hydromorphone (0.21
mg/ml)
Fentanyl (150 mcg/ml)

2-4 mg
0.4-0.8 mg
10-25 mcg

0-1mg/hr
0-0.2mg/hr
0-10mcg/hr

0.51-2 mg
0.12-0.4 mg
10-25 mcg

8-10 min.
86-10
min.
6-8 min.

Commented [AD14]: Changed to reflect current drug
concentrations. All dosing and lockout times are per Rob
Montgomery, Acute Pain Service.
Formatted: Tab stops: 0.5", Left + 1", Left + 1.5", Left +
5.81", Right,Leader:
Patient Controlled Analgesia (PCA): Adult and Pediatric

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G. Usual range of PCA dosages for acute/postoperative pain in opioid nave adults:


Opioid
(Concentration)

Usual
Loading Range

Usual
Basal
Range

Usual
Incremental
Range

Usual
Lockout

Morphine (15 mg/ml)
Hydromorphone (0.21
mg/ml)
Fentanyl (150 mcg/ml)

10.5-4 mg
0.4-0.80.2-1
mg
2520-50 mcg

0-1 mg/hr
0-0.2 mg/hr
0-25
mcg/hr

0.5-3 mg
0.1-0.50.6 mg
10-50 mcg

8-10 min.
8-10 min.
6-10 min.
Note: No limitation in dosing is implied by the above table.

G. A loading dose is usually not needed in patients already receiving opioids prior to starting
the PCA.
H.
H. 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
demand (PCA) dose should remain approximately 1:2. A basal rate is not routinely
recommended in opioid nave patients and should be used with caution. Demand dose only
is the safest starting mode (especially for high risk patients); start with demand only and
add basal as needed. If a basal rate is ordered for an opioid nave patient, the ratio of
continuous (basal) dose to demand (PCA) dose should remain approximately 1:2.
I.
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)

Usual
Loading
Range

Usual
Basal Range

Usual
Incremental
Range

Usual
Lockout

Morphine (1 mg/ml)
Hydromorphone (0.2 mg/ml)
Fentanyl (10 mcg/ml)

30 mcg/kg
5 mcg/kg
1 mcg/kg

0-30 mcg/kg/hr
0-5 mcg/kg/hr
0-1 mcg/kg/hr

10-30 mcg/kg
3-5 mcg/kg
0.2-1 mcg/kg

8-10 min.
8-10 min.
6-10 min.
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 for pager numbers) may be consulted to determine appropriate PCA
Formatted: Line spacing: single, Outline numbered + Level:
2 + Numbering Style: A, B, C, + Start at: 5 + Alignment:
Left + Aligned at: 0.25" + Tab after: 0.5" + Indent at: 0.5",
Tab stops: -0.75", Left + -0.5", Left + 0", Left
Formatted: Centered
Formatted: Font: (Default) Times New Roman, 12 pt
Commented [AD15]: Changes to sections G, H, & I made per
Rob Montgomery with Acute Pain Service.
Formatted: Font: 12 pt
Formatted: Font: (Default) Times New Roman, 12 pt
Formatted: Font color: Auto, Pattern: Clear
Commented [AD16]: Change per Alaris Team
Formatted: Font: 12 pt
Formatted: Font: (Default) Times New Roman, 12 pt
Formatted: Indent: Left: 0.25", No bullets or numbering
Commented [AD17]: Removed per Acute Pain Service and
UCH policies stating we do not admit pediatric patients.
Commented [AD18]: Removed per Alaris Team; there is
currently no pediatric entry built into the PCA pump or EPICs order
sets.
Commented [AD19]: Added Palliative Care Team per Jeanie
Youngwerth. Removed phone numbers per policy standards.
Patient Controlled Analgesia (PCA): Adult and Pediatric

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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.
N.M. Two RNs must independently verify drug, volume, concentration, and rate
including all pump settings against the orders when:
1. Initiating the PCA infusion
2. Accepting patient from another floor
3. Changing shift (with off-going RN to oncoming RN)
4. Changing any settings or changing drug
O.N. Meperidine (Demerol) is not available for PCA due to accumulation of an active
metabolite, normeperidine, which can cause seizures and tremors.
P.O. Morphine 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.
Q.P. PCA opioids may be administered via a subcutaneous (SC) infusion in special
circumstances when IV access is not possible. The pharmacy or the APS is available to
assist in determining appropriate candidates and PCA dosages in this population. A
Palliative Care Team consult is recommended when using the subcutaneous PCA order set
(this is a physician to physician consult). This team will assist in determining appropriate
candidates and PCA dosages. The following applies:
1. A single SC subcutaneous infusion site can usually accept 2-3 ml/hour.
2. Highly concentrated solutions (e.g., hydromorphone 1 or 10 mg/ml, or morphine 10-
505 mg/ml), or fentanyl (50mcg/ml) are used for SC subcutaneous infusion, and rates
are in tenths of a millimeter (0.1 ml/hour). Fentanyl is not recommended for SC
administration due to its lipophilic properties.
3. A 27-gauge butterfly subcutaneous needle is placed at a 45-degree angle according to
manufacturers instructions in the outer quadrants of the abdomen or anatomical sites
used for subcutaneous injections, bilateral subclavicular chest wall, or posterior
scapular area; the site should allow a fat fold of at least 1 to be pinched between thumb
and index finger. Avoid areas that are scarred, infected, irritated, edematous, bony,
highly vascular, or near the waistline. Cachexia is not a contraindication for
subcutaneous access, although available sites may be limited. The Ssite is prepped
similar to in the same manner as placing an IV catheter and should be covered with a
transparent dressing. Aspiration should NOT result in blood return. The site should be
monitored according to the same parameters as an IV site for erythema, induration,
leaking, bleeding, edema, infection, or tissue slough. The Ssite should be changed by
the nurse minimum every 7 daysper hospital policy, or more often if necessary
(erythema, edema, leaking).
4. A carrier line is not required with a subcutaneous PCA. The pigtail extension on the
PCA tubing where the carrier line would normally be inserted should instead be primed
with normal saline and then capped to avoid air being pulled into the subcutaneous
Commented [AD20]: Discuss existence of palliative care order
set
Commented [AD21]: See ISMP list of approved abbreviations
Commented [AD22]: Pall care consult required for
subcutaneous PCAs
Commented [AD23]: No data in the literature stating this;
where did it come from originally?
Commented [AD24]: Updated info on subcutaneous placement
based on literature; reference below
Commented [AD25]: Hospital standard under investigation.
Literature says 3-5 days, max 7.
Patient Controlled Analgesia (PCA): Adult and Pediatric

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space.
3.5.The administration set and pump should be clearly labeled subcutaneous infusion to
prevent mistaking for an intravenous line.
4.6.Dosing is the same as for IV infusion; however, a longer initial drug onset time
(approximately 20 minutes) and a longer PCA lockout interval (20 minutes) must be
allowed for due to slower absorption (peak effect) via the SC subcutaneous route.
R.Q. Change PCA bag/syringe every 24 hours for UCH mixed solutions and every 72 96
hours for pre-mixed solutions. Change the tubing every 96 hours.
S.R. The key to the PCA pump will be kept within a secured designated area, e.g., Pyxis
machine on each unit.
T.S. If 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: 1) Return the PCA pump with tag to Biomed
for inspection. The pump must not be returned 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.

I.III. Initiation of PCA Therapy
A. Infusion medication and labeling
1. Manufacturer pre-mixed UCH pharmacy batched 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 therapies.
2. Higher concentrations of all PCA opioids are hydromorphone syringes (30ml,
10mg/ml) are only available on an as ordered basisas a patient specific medication and
must be ordered using 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. (See the Alaris tip sheet, located on the Alaris
Multidisciplinary website, for detailed instructions on setting up a high-dose infusion.)
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 Brain/Point of Care Unit (PCU)
with one Large Volume Pump (LVP) module and one PCA syringe
module
a. Alaris PCA key
b. Two replacement batteries
Commented [AD26]: Change per Jeanie Youngwerth, MD.
Commented [AD27]: Removed per policy standards.
Formatted: Outline numbered + Level: 1 + Numbering
Style: I, II, III, + Start at: 3 + Alignment: Right + Aligned
at: 0" + Tab after: 0.25" + Indent at: 0.25"
Commented [AD28]: Updated to reflect current UCH policy re:
PCA syringes & concentrations
Commented [AD29]: Updated to reflect current use of higher
PCA concentrations
Commented [AD30]: Per pharmacy
Commented [AD31]: Inserted per Alaris Team
Commented [AD32]: Changed to reflect new tubing layout
Commented [AD33]: Changed to reflect new Alaris PCA
Patient Controlled Analgesia (PCA): Adult and Pediatric

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c. PCA tubing with Y connector
d. PCA extension tubing
e.d. Syringe/bag with ordered medication
4. If the UCH Palliative Care/Oncology IV PCA order set is being used with a continuous
rate infusing via the Alaris LVP, the following additional equipment is required:
a. Alaris PCU with one LVP module (see Kaizen Bulletin: How to Administer
Controlled Substance Infusions in Non-ICU Care Areas)
b. Alaris controlled substance tubing
c. CADD lockbox
d. CADD lockbox key
4.5.Wash hands.
5.6.Verify IV or subcutaneous site patency.
7. Follow the manufacturers instructions for setting up, loading, priming the tubing, and
programming the PCA pump.
6.8.UCH Alaris pumps use Guardrails safety software 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/Oncology. (Please refer
to a UCH pharmacist or a smart pump technology team member for a list of current
Guardrails standards.) When programming the pump, the correct category of patient
must be selected in order for the appropriate Guardrails to apply.
7.9.Label tubing with date and time and sticker.
8.10. Two RNs must independently verify drug, volume, concentration, and rate
including all pump settings against the orders.
9.11. After ensuring that PCA tubing is completely primed (including Y site connection)
and attaching the maintenance IVF to the PCA tubing, Cconnect the PCA tubing to the
patient, lock the PCA pump, and then start the pump. maintenance IV line, start the
pump and lock the pump box.
10.12. Instruct the patient and family/significant other on the use of PCA.

II. Recommended Monitoring
A. Recommended patient monitoring includes assessment and documentation of vital signs,
sedation level, and pain intensity per PCA orders. Recommended monitoring parameters
are:
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 until the PCA is discontinued. For a patient with a protected
airway in the ICU, monitor respiratory rate hourly with vital signs and monitor sedation
level every 4 hours (with physical assessment) or as needed.
3. 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.
4. Assessment of the sleeping patient (non-protected airway):
a. Respiratory status should be observed without awakening the patient.
Arousal will stimulate respiration and potentially mask pending problems.
Commented [AD34]: Inserted to clarify needed items for large
volume PCA dosing
Formatted
Commented [AD35]: Inserted to discuss Alaris Guardrails and
appropriate use of patient categories of nave, tolerant, and pall care
Commented [AD36]: Inserted per Alaris Team
Commented [AD37]: Changed to reflect new tubing layout
Formatted: Indent: Left: 0.25", No bullets or numbering
Formatted: Outline numbered + Level: 2 + Numbering
Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at:
0.25" + Tab after: 0.5" + Indent at: 0.5"
Formatted: Outline numbered + Level: 3 + Numbering
Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at:
0.5" + Tab after: 0.75" + Indent at: 0.75"
Commented [AD38]: Added per Shannon Johnson-Bortolotto to
reflect ICU practices.
Patient Controlled Analgesia (PCA): Adult and Pediatric

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b. Observation should include the depth and regularity of respirations and
listening for snoring.
c. Shallow respirations, periods of apnea, or snoring may be a sign of over
sedation or respiratory trouble and the patient should be awakened to further
assess.
d. If there is any question about whether the patient is sleeping normally or is
sedated, they should be awakened to further assess.
e. If respiratory rate and status are assessed as normal as noted above, it is not
required to awaken the patient to assess sedation.

Sedation scaleMoline-Roberts Pharmacologic Sedation Scale
Use for Non-ICU Patients
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


Richmond Agitation Sedation Scale (RASS)
Use for ICU Patients
+4 Combative--Overtly combative, violent, immediate danger to staff
+3 Very agitated--Pulls or removes tube(s) or catheter(s); aggressive
+2 Agitated--Frequent non-purposeful movement, fights ventilator
+1 Restless--Anxious but movements not aggressive vigorous
0 Alert and calm
-1 Drowsy--Not fully alert, but has sustained awakening (eye-opening/eye contact)
to voice (>10 seconds)
-2 Light sedation--Briefly awakens with eye contact to voice (<10 seconds)
-3 Moderate sedation Movement or eye opening to voice (but no eye contact)
-4 Deep sedation--No response to voice, but movement or eye opening to physical
stimulation
-5 Unarousable--No response to voice or physical stimulation

Formatted: Centered
Formatted Table
Formatted: Font: Bold
Commented [AD39]: Changed to reflect new sedation scale in
use on non-ICU units; reference inserted below
Formatted: Font: Bold
Commented [AD40]: Inserted to reflect sedation scale used in
ICU settings.
Patient Controlled Analgesia (PCA): Adult and Pediatric

c158411 Page 10 of 12

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. Note that sedation scales are not an appropriate measurement
of pain intensity. (Refer to the Pain Management policy for more information regarding
pain intensity monitoring and appropriate pain scale use, such as behavioral vs. self-report.)
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 (difficult to arouse)difficult to arouse (4 or more on the Moline-
Roberts scale, -3 or less on RASS), or inadequate pain relief.
F. If respiratory rate less than 8 per minute or sedation level of 1 (not able to arouse)not able
to arouse (5 or more on the Moline-Roberts scale, -4 or less on RASS), 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 per PCA orders.
G. The above monitoring parameters are minimum standards and should be increased as
warranted by patient condition and orders.

III.V. 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
b. Accepting patient from another floor
c. Changing shift (with off-going RN to oncoming RN)
d. Changing any settings or changing drug
d.e. Changing an empty syringe to a full one
4. Two RNs must witness and document wasting of controlled substances.
5. The number of PCA button demands/deliveries and the total amount of medication
(mg or mcg) used every 4 hours. After recording documenting these amounts in the
electronic health record, clear the 4 hour shift total to reset the pump for the next 4
hour total.
6. Pain intensity at least every 4 hours and within 1 hour after bolus doses or
rate/medication changes, Sside effects/complications.
7. Patient and family education on the Interdisciplinary Teaching Sheet.

IV.VI. Education
Formatted: Outline numbered + Level: 2 + Numbering
Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at:
0.25" + Tab after: 0.5" + Indent at: 0.5"
Formatted: Font: Italic
Commented [AD41]: Inserted to reference appropriate pain
scale use.
Formatted: Outline numbered + Level: 2 + Numbering
Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at:
0.25" + Tab after: 0.5" + Indent at: 0.5"
Commented [AD42]: Updated to reflect new sedation scale use
parameters for notification/stopping infusion.
Formatted: Outline numbered + Level: 1 + Numbering
Style: I, II, III, + Start at: 4 + Alignment: Right + Aligned
at: 0" + Tab after: 0.25" + Indent at: 0.25"
Formatted: Outline numbered + Level: 2 + Numbering
Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at:
0.25" + Tab after: 0.5" + Indent at: 0.5"
Formatted: Outline numbered + Level: 3 + Numbering
Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at:
0.5" + Tab after: 0.75" + Indent at: 0.75"
Formatted: Outline numbered + Level: 5 + Numbering
Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at:
1.25" + Tab after: 1.5" + Indent at: 1.5"
Formatted: Outline numbered + Level: 3 + Numbering
Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at:
0.5" + Tab after: 0.75" + Indent at: 0.75"
Formatted: Tab stops: 4.57", Left
Formatted: Outline numbered + Level: 1 + Numbering
Style: I, II, III, + Start at: 4 + Alignment: Right + Aligned
at: 0" + Tab after: 0.25" + Indent at: 0.25"
Patient Controlled Analgesia (PCA): Adult and Pediatric

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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 Evidence-Based
Approach (pp. 516-521). St. Louis, MO: Saunders Elsevier. (LOE 8)
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. : American Pain Society
(LOE VI6)
2.3.Lehmann, K. (2005). Recent developments in Patient-Controlled Analgesia. Journal of Pain
and Symptom Management. 29(5S) S72-S89. (LOE I15)
4. Institute for Safe Medication Practice Newsletter (2009). Beware of basal opioid infusions with
PCA therapy. March 12 issueRetrieved from http://search.ismp.org/cgi-
bin/hits.pl?in=517791&fh=80&ph=1&tk=mIWJ-%3AW%20IWJ-
%3AWnQ%20LK%20LKnQ%20I-Q-e%20I-Q-
enQ%20LpqLq%26%20LpqLq%26nQ%20qwK_QqLwQ%20qwK_QqLwnQ%20qwK_QqL
w&su=pPJJQATTXXX.e_pQ.%3AFkTbEX_LEJJEF_T%26KvJEK%26FET%26FJeKLE_T
20090312.%26_Q&qy=ywbUufb%20X%3A%20wujuJ%20XxFXFp%20FC%3AMjFXCj&p
d=1 . (LOE V8)
3.5.Jarzyna, D., Jungquist, C.R., Pasero, C., Willens, J.S., Nisbet, A., Oakes, L., Dempsey, S.J.,
Santangelo, D., & Polomano, R.C. (2011). American Society for Pain Management Nursing
Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression. Pain
Management Nursing, 12(3), 118-145. (LOE 8)
4.6.Macintyre P. (2005). Intravenous patient-controlled analgesia: One size does not fit all.
Anesthesiology Clinics of North America. 23, 109-123. (LOE VI8)
7. McCaffery, M. & Pasero, C., (2010). Pain Assessment and Pharmacologic Management. St.
Louis: Mosby. (LOE VI8)
5.8.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)
6.9.Pasero, C. & McCaffery M., (2005). Authorized and unauthorized use of PCA pumps.
American Journal of Nursing, 105(7), 30-32. (LOE VI8)
7.10. Pasero, C. (2009). Assessment of sedation during opioid administration for pain
management. Journal of Perianesthesia Nursing. 24(3):186-190. (LOE VI8)
8.11.
Patient controlled analgesia by proxy. Sentinel Event Alert Issue 33. Dec 20, 2004. Available
aRetrieved from \t
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm
. Accessed 9/8/2005. Retrieved from
http://www.jointcommission.org/assets/1/18/SEA_33.PDF. (LOE V8)
9.12. Safe use of opioids in hospitals. Sentinel Event Alert Issue 49. August 8, 2012. Retrieved
from http://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf. (LOE
8)

Formatted: Outline numbered + Level: 2 + Numbering
Style: A, B, C, + Start at: 1 + Alignment: Left + Aligned at:
0.25" + Tab after: 0.5" + Indent at: 0.5"
Commented [AD43]: Reference for subcutaneous infusions.
Formatted: Font: Italic
Formatted: Font: Italic
Formatted: Font: Italic
Commented [AD44]: Updated reference for sedation
monitoring.
Formatted: Font: Italic
Commented [AD45]: Reference for new sedation scale.
Formatted: Font: Italic
Formatted: Font: Italic
Formatted: Font: Italic
Commented [AD46]: New Sentinel Event reference from the
Joint Commission.
Patient Controlled Analgesia (PCA): Adult and Pediatric

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