CLINICAL GUIDELINES ID TAG. PCA Guideline. Dr Aidan Cullen & Sr Jane Doyle. Anaesthetics / ATICS. Acute

Transcription

1 CLINICAL GUIDELINES ID TAG Title: Author: Speciality / Division: Directorate: PCA Guideline Dr Aidan Cullen & Sr Jane Doyle Anaesthetics / ATICS Acute Date Uploaded: May 2018 Review Date May 2021 Clinical Guideline ID CG0196[1]

2 PCA Guidelines Dr A Cullen and Jane Doyle - Acute Pain Sister 27/04/2018

3 Patient Controlled Analgesia Definition Patient controlled analgesia [PCA] is a device that enables the patient to self-administer intravenous analgesia. PCA provides flexible pain relief that is tailored to patients individual requirements, avoiding delays in administration of analgesia. Each bolus dose is predetermined and the lockout device prevents too much analgesia being delivered in too short a time. Objectives: To standardise clinical practice in the provision of PCA To ensure implementation of the recommendations in relation to NPSA alert 20 To deliver safe and effective analgesia Indications: Patients (elective and emergency) undergoing the following procedures may have a PCA system commenced for post-operative analgesia: Laparotomy Midline vertical abdominal incision Major urological procedures e.g. nephrectomy or cystectomy Thoracotomy Amputation of lower limb Trauma eg. rib fractures Following orthopaedic procedures A PCA pump may be run concurrently with an epidural pump delivering a solution of plain LEVOBUPIVACAINE to enhance the analgesia for identified patients. Contraindications Patient refusal Patient inability to use device

4 Patient inability to understand device concept Head injury or other medical/drug-induced CNS depression Establishing a PCA The patient must be aware of the options and risks involved with PCA. PCA may be commenced and run in the following areas: Theatres Recovery ICU Surgical, Gynaecology and T&O wards by anaesthetist or Pain Team on the advice of anaesthetist. Patients with PCA devices should be nursed in close proximity to the nursing station. Preparation of PCA Pump The details of the PCA must be prescribed by an anaesthetist. A PCA pump may be prepared for use by the following personnel. Acute Pain Team General Recovery trained nursing staff Trauma and Orthopaedic Recovery trained nursing staff ICU trained nursing staff Anaesthetists A PCA should have a designated IV however in patients with difficult access it is acceptable to use a Y piece with a non- return valve. PCA line should be labelled and dated e.g. - FOR PCA USE ONLY - 02/06/2014 Prefilled Bags Prefilled bags are ordered from pharmacy and stored at ward level and in theatre recovery areas in controlled drug cupboards. All prefilled bags for PCA use should be labelled and signed by those preparing the device. NB. Drugs must not be added to these pre-filled bags. Only prefilled bags of MORPHINE SULPHATE are to be used in with adult PCAs.

5 PCA Pumps (CADD SOLIS) A dedicated lockable and programmable device must be used for PCA analgesia. This pump must not be used for any other purpose. The pump is grey fronted, labelled, numbered, and when switched on has a blue display screen. The administration set has a blue line and should be clearly labelled PCA. The pump must only be programmed for PCA by an anaesthetist, a Recovery nurse or a member of the Acute Pain Team who have been trained and deemed competent in the use of the dedicated pump. Refer to manufacturer documentation for programming. PCA Prescription The pre-prepared solution available for use is: MORPHINE SULPHATE 100mgs in 100mls of 0.9% NaCl The PCA solution must be prescribed clearly on the patient s drug chart to include the following: Concentration (MORPHINE SULPHATE 1mg/ml) Total volume in the reservoir bag (100mls) Bolus dose - 1mg Lockout time - 5 minutes A patient with a PCA programmed with a bolus of 1mg and a lockout of 5 minutes has access to a total of 12mgs of MORPHINE SULPHATE IV each hour the device in operation. The prescribing anaesthetist must also prescribe the following: Regular PARACETAMOL IV/PO NSAIDS if appropriate Antiemetic medication And any other medications required e.g. NALOXONE Oxygen The prescribing anaesthetist should also discontinue or consider any other medications which could affect or increase side effects associated with IV MORPHINE.

6 Follow Up Each day the patients with PCA device must be reviewed by the Acute Pain Team or the anaesthetist on call. Changes to a PCA prescription can only be made by an anaesthetist and facilitated by the Pain Team or anaesthetist. The Acute Pain Team liaises with the anaesthetist to facilitate prompt changes in the required treatment for each patient if required (Bleep 1710 in CAH). PATIENT MONITORING Only registered nurses must undertake monitoring of patients with PCA pumps Observations for patients with PCA pumps include: 1. AVPU (Tick and score as per Trusts NEWS chart) 2. Respiratory rate (Record value and score as per Trusts NEWS chart) 3. Pulse rate (Record and score as per Trusts NEWS chart) 4. Blood pressure (Record and score as per Trusts NEWS chart) 5. Temperature (Record and score as per Trusts NEWS chart) 6. Oxygen device e.g. Nasal specs(n/s), Rusch, Face Mask(F/M), Room Air (R/A) 7. Oxygen delivered e.g. in litres for N/S, Litres or % F/M. % for Rusch 8. Oxygen saturation e.g. % as per monitor 9. Nausea score (0-3 as per Trusts Observation chart) 10. Pain Scores on Movement and Rest (0= Mild 2= Moderate 3= Severe) 11. Total mg accessed by patient (Recorded on supplementary sheet) 12. Total mls infused bearing in mind the concentration is mg=ml 13. Volume in mg of any bolus administered by anaesthetist or Acute Pain Team or Recovery Ward staff. 14. IV Site checks. Tick when satisfactory. * - see notes. N/A- not applicable. A patient must be monitored every 15mins for at least 2 hours once device is commenced 1 hourly for 4 hours 2 hourly thereafter

7 If stable commence 4 hourly observations (or as per NEWS frequency) Following a bolus of MORPHINE: Recommence observations to 15mins for 1 hour If stable 4 hourly or as per NEWS frequency All registered nurses must have attended training in pain and pump management before undertaking responsibility for these patients. Patient transfer between wards/departments Both nurse transferring responsibility and nurse accepting responsibility for the patient must verify and record this information in the patients nursing notes or the relevant transfer documentation. This information should include: PCA is prescribed correctly Pump setting and ID no. are verified and recorded Volume of drug infused / remaining is documented Oxygen must be available. NALOXONE must be readily available. Antiemetic should be prescribed. Adjunct analgesia should be prescribed. Observations must be clearly recorded on the NEWS chart. Qualified nursing staff only must record NEWS and related observations on these patients PCA BOLUS ADMINISTRATION A bolus of MORPHINE may be needed for: Severe pain immediately post- operatively. Re-establishment of PCA analgesia following reinsertion of IV line Prior to a procedure e.g. removal of drain There are two techniques by which a bolus can be administered:

8 1. Via the PCA pump using the prescribed solution titrated up to a maximum of 10mgs. 2. Using an ampoule of MORPHINE 10mgs diluted to a concentration of 1 mg/ml, and administered appropriately. Anaesthetists, Acute Pain Sisters, Recovery staff and ICU staff are permitted to bolus via the PCA pump. Doctors at ward level may only administer IV MORPHINE via option 2. Discontinuation of PCA Any decision to discontinue a PCA must take into account the previous day MORPHINE requirement. Alternative oral analgesia should be prescribed and patient informed of the decision. Disposal of PCA MORPHINE SULPHATE When the PCA MORPHINE is being disposed of the volume remaining in the bag should be recorded and verified by two competent nurses and recorded (as per Hospital Policy for Disposal of Opioid ) in the wards Controlled Drug Record Book. Disposal should comply with hospital protocol. The pump should be cleaned with alcohol wipes 70% or less and returned to main Recovery Ward. Complications Associated with PCA Analgesia Respiratory depression: Stop PCA. Inform Anaesthetist/ DR, have NALOXONE ready. Nausea and vomiting: Give anti-emetic. Hallucinations: Consider usage and adjust dose or analgesia as per recommendation of anaesthetist or Pain Team. Pruritis: Consider use of CHLORPHENAMINE. Urinary retention: Patient is usually catheterised for duration of PCA. If no urinary catheter in place observe and record urinary output. If patient fails to pass urine a catheter may need to be inserted.

9 Procedures Associated with PCA Analgesia: ADMINISTRATION OF A BOLUS DOSE VIA THE PCA PUMP Acute Pain Nurses, Recovery Nurses, ICU Nurses and Anaesthetic staff can administer a bolus dose via the PCA delivery pump. OBJECTIVES 1. Ensure patient safety 2. Standardise the technique of administering a bolus dose via the PCA pump 3. Maintain optimal analgesia PROCEDURE 1. A top-up will only be indicated for the following situations: a. Pain score unacceptable 2. A bolus can only be administered if the patient s clinical observations state the following; a. Sedation score (AVPU A/V) b. Vital signs within acceptable range c. Intravenous fluids in progress d. Adequate urinary output 3. Inform the anaesthetist on-call of these findings 4. Refer to manufacturer instructions for administering a bolus via the dedicated PCA delivery pump 5. Titrate bolus until analgesic effect to a maximum of 10mgs 6. Check blood pressure, pulse and motor function at 5 minute intervals during the procedure 7. Monitor vital signs, including pain and sedation scores at 15 minute intervals for at least 1 hour, then resume normal observation frequency 8. If analgesia is still inadequate anaesthetist on-call must be contacted for further advice and instructions. DISCONTINUATION OF PCA This is carried out by trained staff on the advice of pain team. Amount used and amount discarded to be recorded in nursing notes and CD register. This should be verified by two trained staff. Dispose of opioid as per Hospital policy for Disposal of Opioids. IV line should be flushed with 2mls NaCl OR IV line removed

10 Inadequate Analgesia with PCA If analgesia is ineffective the following MUST be done: 1. Check PCA infusion pump, IV site and patient observations and how frequently they have been accessing the PCA. 2. If PCA can be accessed more appropriately advise the patient of this. 3. If PCA has been accessed to maximum or near maximum 12mgs per hour, check observations, try to ascertain the cause of the increased pain, ensure adjunct medications have been administered. 4. Continue to monitor observations including pain assessment every 15 minutes. 5. If analgesia does not improve within 30 minutes, inform the Acute Pain Team or anaesthetist on call. If Acute Pain Team or anaesthetist cannot attend the nurse should ask the surgical doctor on call to prescribe and administer MORPHINE up to 10mgs IV or an amount that is necessary to ensure the patients comfort and safety. If any member of staff is concerned that the above guidelines are not being followed they should contact the Acute Pain Team. Confusion in Patients with PCA Analgesia Acute confusion may follow any operative procedure, especially in the elderly. It may be the accumulative effect of MORPHINE. Every attempt should be made to identify and rectify the cause. If no serious cause found then if possible, management should be conservative. Reassurance, leaving room lights on and using cot sides may be sufficient. Management should NOT involve any additional sedative drugs. Sedatives are likely to add to confusion. In all cases of confusion GIVE OXYGEN AS THE FIRST LINE OF TREATMENT Common causes of confusion:

11 Excess opiate: Suspect the diagnosis if the respiratory rate is below 8 breaths per minute and patient appears drowsy with pin-point pupils. Having excluded the analgesic infusion as the cause of confusion, the Medical or Surgical team should be contacted and they should consider other common causes: Blood Glucose: Hypoxia: Hypoglycaemia or hyperglycaemia may cause confusion. If SaO 2 less than 93% give O 2 immediately. Continue O 2 therapy until confusion resolved. Hypoventilation: Hypercapnia: Hypovolaemia/ Hypotension: Sodium: Uraemia: CVA: Check respiratory rate. If low, give Naloxone and check arterial blood gas. Often a consequence of hypoventilation. Check arterial blood gas to confirm diagnosis. Likeliest cause is opiates. Check fluid balance, drains and other losses. Give fluid challenge. If BP fails to respond to fluid consider myocardial insufficiency (eg MI) Check electrolytes. High or low sodium may cause confusion. Check U&E. Neurological examination Step-down from PCA PCA devices are usually discontinued after 2-3 days and earlier if appropriate. The transition from PCA to oral/other analgesia should be planned in advance with consultation with the patient. Some patients will require opiate analgesia following the discontinuation of PCA. If possible, the step-down analgesia should be planned to avoid problems. The following are recommended: A. Patients able to take oral analgesia: Regular oral PARACETAMOL 1g QID Regular oral NSAID provided this is not contraindicated B. Patients unable to take oral analgesia: Regular IV PARACETAMOL 1g QID Regular IV PARECOXIB 40mgs BD (only if specified by anaesthetist)

12 Plus As required Oral Opiate: Mild to moderate pain: Oral CODEINE up to 60mgs 6hourly (use with caution following bowel surgery). Consider use of mild laxative and advice of constipating effects of regular CODEINE. Moderate to severe pain: IM MORPHINE 5-10mgs 4 hourly. Provide adequate anti-emetic cover with same Use of oral oxycontin will be at the discretion of the Acute Pain Team. Care should be taken on discharge. These patients will require review by GP. References National Patient Safety Agency (2007) Safer Practice Notice 20): Promoting safer use of injectable medicines. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2005) Acute Pain Management: Scientific Evidence. The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7 th edition (2008) Wiley-Blackwell NMC The Code- Standards of conduct, performance and ethics for nurses and midwives. Saving Lives: Peripheral intravenous cannula care bundle DOH (2007) Standards for infusion therapy: RCN (2007) SHSCT PGD for Naloxone