GUIDELINE FOR THE MANAGEMENT OF OPIOID ......GUIDELINE FOR THE MANAGEMENT OF OPIOID INFUSIONS FOR...

GUIDELINE FOR THE MANAGEMENT OF OPIOID INFUSIONS

FOR ACUTE PAIN

Version Number V2.2

Date of Issue November 2018

Reference Number MOIAP-10-2016-GOC-V2

Review Interval 3 yearly

Approved By

Name: Rachel Kenna

Title: Director of Nursing

Signature: Date: February 2017

Approver:

Name: Anne M Fitzpatrick

Title: Pharmacist

Authorised By

Name: Dr. Jacinta McGinley

Title: Consultant Paediatric Anaesthesiologist

Signature: Date: February 2017

Name: Dr. Kevin McCarthy


Name: Dr. Sinead Harte


Author/s

Name: Jill O’Callaghan

Title: Advanced Nurse Practitioner – Children’s Pain

Location of Copies On Hospital Intranet and locally in department

Document Review History

Review Date Reviewed By Signature

July 2019 J O’Callaghan

Document Change History

Change to Document Reason for Change

Minor changes to programming of Pumps Support ease and safety of programming pump

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Document Name: Guideline for the Management of Opioid Infusions for Acute Pain

Reference Number: MOIAP-10-2016-GOC-V2 Version Number: V2.2

Date of Issue: November 2018, Revised July 2019 of 29

Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019

Contents

Page No

1.0 Introduction 4

1.1 Application 4

1.2 Definitions 5

2.0 Responsibilities 5

3.0 Objective 6

4.0 Authorized Personnel Training Required 6

5.0 Procedure 6

5.1 Patient selection 5

5.1.1 Caution 5

5.1.2 Precautions 6

5.2 Prescription and Administration of PCA/NCA opioid infusions 6

5.3 PCA/NCA Bolus 7

5.4 Increasing or decreasing the rate of infusion 7

5.5 Concurrent drugs 7

5. 6 Nurse Controlled Analgesia and Patient Controlled Analgesia 8

5.6.1 Nurse Controlled Analgesia patient selection 9

5.6.2 Patient Controlled Analgesia 9

5.6.3 Criteria to meet prior to ordering PCA. 9

5.6.4 Contraindications to the use of PCA 9

5.7.0 PCA/NCA Infusion set-up 9

5.8 Parents and NCA/PCA 10

5.9 Changing PCA/NCA syringes 10

5.10 Monitoring 10

5.10.1 Physiological monitoring 10

5.10.2 Oxygen saturation monitoring 11

5.11 Pain Assessment 11

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5.11.1 Pain assessment tools 11

5.12 Managing side effects 12

5.12.1 Inadequate pain relief 12

5.12.2 Excessive sedation 12

5.12.3 Respiratory depression 13

5.12.4 Management of opioid induced respiratory depression 14

5.12.5. Nausea and Vomiting 15

5.12.6 Constipation 16

5.12.7 Pruritus 16

5.12.8 Urinary retention 17

5.12.9 Central Nervous system effects 17

5.12.10 Allergy 17

5.12.11 Cannula Tissued 17

5.12.12 Myoclonic jerks/Muscle spasm 18

5.12.13 Bladder Spasm 18

5.13 Stopping PCA/NCA 18

5.14 Ongoing opioid requirements after PCA/NCA 18

6 .0 Non- Compliance with this guideline 18

7 .0 Monitoring and Audit 18

8.0 Algorithm for Managing Pain 18

References 20

Appendix 1 - PCA/NCA Morphine prescription guideline 21

PCA / NCA Oxycodone prescription guideline

General instructions PCA and NCA Infusions

Appendix 2 - Pain Assessment tools 26

Wong Baker FACES, Numeric, FLACC

FLACC-Revised

Appendix 3 - Competency assessment for ALARIS PCAM 28

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1 INTRODUCTION

Administration of opioid analgesics by Intravenous infusion are helpful for providing a

constant analgesic effect and avoiding fluctuations in drug levels. Boluses are useful for

gaining rapid control of severe pain or for pain of short duration, e.g. dressing change, prior

to movement, physiotherapy.

When given for ongoing pain, bolus opioid doses should be given slowly using the Patient

Controlled Analgesia (PCA), Nurse Controlled Analgesia (NCA) or bolus features of infusion

devices.

Morphine is the “gold standard” for pain relief. In circumstances where morphine cannot be

used due to known or suspected allergy or where opioid rotation is deemed necessary due

to side effects of Morphine, then Oxycodone should be used as an alternative.

These guidelines are to be used alongside other IV guidelines for intravenous opioid

infusions e.g. Sickle cell Pain guideline

1.1 Application: This guideline applies to patients receiving Intravenous Opioid Infusions for

Acute Pain. Children with sickle cell pain please follow sickle cell pain guideline. Children

receiving palliative care, will usually be managed by the palliative care service.

1.2 DEFINTIONS

The 'Pain Team' referred to in the document comprises of the Anaesthesiologist on-call (bleep

8528), the Advanced Nurse Practitioner (ANP) or Advanced Nurse Practitioner candidate (ANPc,

Clinical Nurse Specialist practitioner (CNSp) Children’s Pain (Bleep 8300). Dr. Kevin McCarthy,

Consultant pain Medicine; Dr. J McGinley, Consultant Anaesthesiologist and Dr. Sinead Harte,

Consultant Anaesthesiologist.

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Patient Controlled Analgesia (PCA)

Refers to a method of pain relief in which an infusion device connected to a timing mechanism allows a child to self-administer analgesic drugs.

Nurse Controlled Analgesia (NCA)

For children who are too young or who are cognitively unable to understand the concept of PCA, Nurse Controlled Analgesia is an option. A nurse can assess the child’s pain and deliver a bolus dose of an opioid if the child is in pain or in anticipation of a painful event.

Loading Dose A loading dose can be administered to patients prior to the commencement of opiate infusions. This ensures the child’s pain is relieved to an acceptable level.

Bolus Dose Is the amount of drug the child receives when the handset or demand button is pressed to deliver the programmed bolus dose of analgesia.

Lockout Period

Lockout time can be set between 5 and 30 minutes. Longer lockout times are used for Nurse Controlled Analgesia. Shorter lockout times are suitable for Patient Controlled Analgesia. The PCA pump will not deliver a dose during the lockout time even if the button is pressed. This allows the bolus dose to reach peak effect before the patient has another bolus. It is set to avoid overdosing (bolus too frequent) or inadequate analgesia (infrequent bolus).

Demands/Good Demands/Bad

Each time the handset is activated the device will record this as a demand. When the patient presses the handset and receives a bolus this is recorded as a good demand.

Background Infusion

A continuous infusion can be added to provide a more steady blood concentration of analgesic. NCA/PCA in children can be enhanced by the addition of a background infusion which enhances sleep patterns.

Four Hourly Limit This setting is used to limit the amount of medication the patient may request in a 4-hour

period.

2.0 RESPONSIBILITY

This guideline involves all medical and nursing staff involved in the prescribing, preparation

administration and monitoring of intravenous (IV) opioid infusions for acute pain.

3.0 OBJECTIVE

This guideline details the hospitals requirements in relation to the management of Intravenous

Opioid Infusions. It is the goal of Our Lady’s Children’s Hospital to provide the safest environment

for children receiving Opioid Infusions.

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4.0 AUTHORISED PERSONNEL-TRAINING REQUIRED

It is the responsibility of relevant medical and nursing staff to familiarise themselves

and adhere to the contents of this guideline.

Members of the nursing staff authorised to manage intravenous opioid infusions

must:

Attend in-service training provided by the Department of Anesthesiology /

Pain Service Nursing staff (CNSp/ANPc)/Centre for Children’s Nurse

Education/ Clinical Nurse facilitator.

Registered nurses shall be responsible for monitoring children and notifying

medical staff of effectiveness and/or of complications of this treatment.

The Registered nurse is competent to safely administer intravenous drugs in

children.

5.0 PROCEDURE

5.1 PATIENT SELECTION

Pain due to:

Surgery

Cancer

Management of burn injury

Trauma

Other painful medical and surgical conditions e.g. mucositis, pancreatitis

Mechanical ventilation and invasive procedures in an Intensive Care Unit setting (see PICU Sedation and Analgesia Guideline).

Sickle cell disease: see sickle cell guideline

5.1.1 EXERCISE EXTREME CAUTION IN:

Non-intubated patients less than 6 months of age

Patients with airway or haemodynamic instability

Patients with evolving neurological status

Patients with apnoea or altered ventilatory status.

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5.1.2 PRECAUTIONS

N.B. If the patient is receiving other medication that may cause sedation (e.g.

antihistamines, benzodiazepines or anticonvulsants), the patient may be at increased

risk of over sedation and respiratory depression.

Prolonged administration of opioid infusions and impaired liver and/or renal function may

alter drug elimination with all opioids and possibly result in drug accumulation and

toxicity.

The morphine metabolite M3G causes CNS disturbances (including myoclonus and

tremor) and the morphine metaboliteM6G is a potent analgesic. Both these metabolites

may accumulate in patients receiving long-term morphine infusions or patients with renal

impairment.

N.B. Careful tapering of doses is important when weaning long-term opioids to

avoid iatrogenic opioid withdrawal symptoms.

5.2 PRESCRIPTION AND ADMINISTRATION OF PCA / NCA OPIOID INFUSIONS

Any Medical prescriber can order an opioid infusion according to these guidelines.

All prescribing and administration of opioid infusions should be in accordance with Our

Lady’s Children’s Hospital’s medication policy.

If the prescriber wishes the patient to be under the supervision of the pain service a referral

needs to be made by bleeping 8300 or the anaesthesiologist on call , bleep 8528 (24 hours)

and completing an inpatient blue consultation form. The referring doctor needs to ensure that

the patient's primary consultant has approved the involvement of the pain service.

Morphine is the preferred opioid in most circumstances. Oxycodone is an alternative when

pain is not controlled or children experience significant side effects such as nausea and

vomiting or itch, or for children requiring an opioid rotation.

Fentanyl infusions and hydromorphone infusions are used on a case by case basis in PICU

or for children receiving palliative care.

Pethidine is NOT used due to the concern for nor-pethidine toxicity.

NB: some patients may require different opioid concentrations than the standard opioid

concentration in this guideline. The pain service (ANP/CNSp or Anaesthesiologist can be

contacted for advice if necessary). Staff caring for children receiving opioid infusions must

make themselves familiar with the concentration of the opioid infusion.

A locked infusion pump should be used for all opioid infusions at ward level. Keys for the

PCA/NCA infusion pumps are kept together with the Controlled Drug keys on every ward.

The operating theatre recovery room and theatres also has a set of PCA/NCA keys.

Individual nurses (except for the nursing staff on the pain team) should not have their own

keys for the opioid infusion pump

A loading dose of IV opioid is only given if the patients has not already received IV,

intranasal or an oral opioid.

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The surgical team or the child's physician should be contacted for advice if the pain could be

indicative of new or escalating medical or surgical symptoms.

Pump programming must only be changed by a member of the Pain Control service or

competent nurse. Pain Service Nursing staff, bleep 8300 or Anaesthesiologist on call should

be contacted if pain relief is inadequate after more than 6 boluses in 2 consecutive hours

and adjuvant analgesic medication has been optimized.

The volume infused together with the demands made and received should be checked and

documented every hour.

5.3 PCA / NCA BOLUS / RATE CHANGES

For rapid relief of pain (or anticipated pain), the prescribed bolus dose should be

administered.

The infusion rate may be adjusted by the nurse within the dose range specified, according to

the patient's level of pain.

It takes approximately four half-lives (half-life is ~8hrs for morphine, ~1.5hrs for fentanyl) for

opioids to reach steady state plasma concentration if given as an infusion, therefore if the

rate is to be increased, a bolus should be given as well.

Bolus doses of opioid infusion should ONLY be administered using the 'bolus button' on the

syringe pump or by use of clinician access code. Once the pump is running the bolus volume

will be added to the total volume infused.

Additional boluses using the clinician override function on the pump can be used by medical

personnel, or pain team nursing staff.

Bolus doses of morphine or oxycodone must never be administered by parents or other

relatives.

5.4 INCREASING OR DECREASING RATE OF INFUSION

5.4.1 Increase the background infusion, or consider increasing the bolus size within

prescribed limits where:

An accurate pain assessment has been undertaken and

the patient has pain which has not resolved after frequent boluses (more than 3 boluses per

hour for 2 consecutive hours)

And the patient is not over sedated and other interventions have been tried and have not

been effective (regular simple analgesia, repositioning etc.).

The patient has been reviewed by the pain service or senior medical staff

5.4.2 Decrease the background infusion if the patient is:

experiencing opioid induced side effects, is pain-free and/or is requiring minimal boluses

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5.5 CONCURRENT DRUGS

When children are receiving opioid infusions, NO oral/ rectal/ intravenous or intramuscular

opioids or sedative agents should be given without prior consultation with the

Anaesthesiologist or Consultant in Charge or Pain service nursing staff on bleep 8300.

Paracetamol, NSAIDs, Tramadol, Clonidine, Gabapentin, lignocaine, Vitamin C and

Ketamine may be used concurrently with opioid therapy and may help minimise opioid

requirements and associated side effects.

An anti-emetic should be prescribed for patients receiving opioid infusions.

Laxative medication must be prescribed for patients receiving opioids for prolonged periods.

Some children may experience side effects of opioid infusions such as rash, pruritus, nausea

and vomiting, urinary retention and may require management of these side effects. (see

section 5.12, page 14-18)

5.6. NURSE CONTROLLED ANALGESIA & PATIENT CONTROLLED ANALGESIA

Nurse Controlled Analgesia (NCA) or Patient Controlled Analgesia (PCA) involves the

intravenous infusion of opioid analgesic medication with supplemental bolus doses which are

initiated by the nurse (NCA) or patient (PCA) pressing a button, which activates a computer

controlled infusion pump to deliver a pre-determined dose of medication within set limits. To

prevent over dosage, there is a lockout period during which a second dose may not be

administered.

NCA and PCA may be administered with or without a background infusion. When a

background infusion is added children get a better night’s sleep.

Background infusions are recommended for children after surgeries such as spinal fusion,

cancer surgery, and thoracotomy.

5.6.1. NURSE CONTROLLED ANALGESIA can be prescribed for:

Children < 7 years of age in whom patient controlled analgesia may not be successful.

Children of any age who are unable to use PCA because of cognitive, developmental or

physical disability.

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5.6.2. PATIENT CONTROLLED ANALGESIA

PCA is recommended for children of 7 years and over in whom moderate to severe pain

is anticipated for 24 hours or more. Some children younger than 7 years of age may be

able to use PCA successfully if they receive instruction and are closely supervised.

The child needs to have the cognitive ability to understand the concept of pressing a

button to self-administer analgesia when required.

The child should be instructed in the use of PCA prior to coming to theatre or even in the

anaesthetic room before induction.

5.6.3. Prior to ordering a PCA opioid infusion, the following criteria must be met:

Anticipated need of at least 24 hours.

Child must demonstrate an understanding of how to use PCA device.

Child must be physically able to use PCA device.

5.6.4. CONTRAINDICATIONS TO USE OF PCA

Inability to understand the concept of PCA

Age less than 7 years

Inability to press the button.

Children not wishing to control their own analgesia.

5.8 PARENTS/GUARDIANS USE OF NCA/PCA

It is important that the child's parents understand the concept of NCA/PCA, so they can

support their child in its use. Parents should be given an information handout on PCA/NCA.

It is also important that the child's parents are aware that they are NOT to push the demand

button for their child, but rather to inform nursing staff if their child is experiencing pain or to

encourage their child to press the demand button when required.

5.9 CHANGING PCA/NCA SYRINGES

Opioid infusions can be filled and replaced by a Nurse with IV certificate, a Medical

doctor/Anaesthesiologist.

Syringes and IV lines should be changed every 24 hours. A few hours outside this limit is

permitted if infusion is to stop the same day.

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5.10 MONITORING

This has a dual role: to assess adequacy of pain relief and to ascertain that no detrimental

side effects related to pain management schedule or other ongoing pathophysiological

processes are occurring.

All documentation should be as for local hospital observations charts

The need for less frequent observations on patients with longer-term opioid infusions

should be discussed with the pain service nursing staff, bleep 8300.

5.10.5. PHYSIOLOGICAL MONITORING

Heart Rate, Respiratory Rate, and Pain Score & Sedation Score: hourly while

infusion continues.

Children <6 months of age must have continuous pulse oximetry monitoring and

recording Respiratory rate and effort: one hourly

4 hourly blood pressure and temperature or more often if clinical condition

dictates

AVPU Sedation level hourly. (See scale, Pg. 14)

Apnoea monitoring for all infants <1 Year on opioid infusions.

Pulse oximetry all children as indicated

5.10.6. Oxygen saturation monitoring MUST be implemented continuously:

In high-risk patients with any co-morbidities e.g. cardio respiratory disease,

prematurity, neurodevelopmental disability, respiratory disease, obesity.

AVPU score V or higher

Significant cardio respiratory impairment

Sleep apnoea, snoring, or airway obstruction

Spot pulse oximetry less than 94% or patient is receiving supplementary oxygen

Children receiving concurrent sedative agents.

5.10.7. Clinical indicators for ‘spot’ pulse oximetry are:

Respiratory distress, tachypnoea or slow respirations for age

Suspected cyanosis or impaired oxygenation

Confusion or agitation

Hypotension

Nurse concerned

AVPU score V or higher

Document on PEWS chart

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5.11. PAIN ASSESSMENT

At rest and on movement (performed 1 hourly x 12 hours when child is awake. If pain is

controlled pain assessment can be decreased to 2-4 hourly thereafter. Always reassess

pain after an increase in opioid infusion or administration of supplemental analgesia.

5.11.1. PAIN ASSESSMENT TOOLS ( appendix 1)

Children < 3 years use behavioural scale e.g. FLACC or FLACC revised

Children 3 to 7 years use Wong-Baker Faces Pain Rating Scale

Children > 7 years use VAS (visual or verbal analogue scale between 0 – 10, where

0 = no pain and 10 is the worst pain ever.

PICU: Comfort-B

Children with intellectual disabilities: FLACC Revised

5.12 MANAGEMENT OF SIDE EFFECTS

5.12.1 INADEQUATE PAIN RELIEF

Evaluate for:

Machine delivery problems

Failure of patient to use PCA device

Ongoing medical/surgical problem

Urinary retention

Tissue ischemia

Excessive anxiety

Remedy any of the above issues.

Provide an NCA bolus or encourage the child to self-administer a PCA bolus,

Consider supplemental analgesia i.e. NSAIDs or paracetamol, Tramadol or Clonidine. See

BNF for children for contraindications.

Bladder spasm or muscle spasm may require treatment with antispasmodic medication. See

BNF for children/hospital formulary.

The Pain service nursing staff or Anaesthesiologist on call should be contacted if pain relief

is inadequate after more than 6 boluses in 2 hours hour (PCA or NCA) and supplemental

analgesia has been optimised.

Drug Age Route Dose Frequency Maximum

Daily dose

Administer

Clonidine Child < 5kg PO or IV 0.5-1 microgram/kg Every 6 to 8

hours

5 microgram /kg/day Injection over 20 minutes

Child > 5kg PO or IV 1 microgram/kg (usual

max 60microgram)

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5.12.2. EXCESSIVE SEDATION

Respiratory rates vary a great deal, and normal has quite a wide range in children from

infancy to adolescence. Pulse oximetry is primarily useful for assessing changes in

oxygenation; it is a late indicator of ventilatory depression. SpO2 readings may remain

normal or near normal for minutes after a patient stops breathing. While it is not an early

indicator of ventilatory failure, it eventually falls as the patient stops breathing.

Where over sedation or respiratory depression is suspected, stop PCA/NCA infusion,

count respiratory rate for one full minute and stimulate the child.

AVPU: Patient receiving opioids Action

Awake, arousable, alert

Responds to voice only (drowsy

and sleepy).

Child may be sedated from opioid

Obtain GCS,

Consider reducing IV opioid

Responds to pain stimulus only

(deeply asleep, arousable only

with deep or significant physical

or painful stimulus.

Stop opioid,

Obtain GCS.

If opioid related over-sedation, contact anaesthesiologist

on bleep 8528, and/or pain service nursing staff, bleep

8300

Opioid can be recommenced once child becomes more

responsive at a reduced rate

Unresponsive. Stop Opioid. Stimulate the child, administer oxygen, Call

2222, and obtain GCS.

Give naloxone to reverse opioid.

Inform pain service nursing staff.

Opioid-induced sedation Scale. Pasero-McCaffery

0 Sleeping easy to arouse

1 Awake and alert

2 slightly drowsy, easily aroused

3 frequently drowsy, arousable, drifts off to sleep during conversation

4 Somnolent, minimal of no response to physical stimulation

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5.12.3. RESPIRATORY DEPRESSION

Opioids depress all phases of respiratory activity including Rate, Minute Volume, Tidal Exchange

and Rhythm. Respiratory depression is considered clinically significant when it is severe enough to

require an intervention (i.e. stopping opioid infusion, providing physical stimulation or administering

naloxone to reverse it and prevent respiratory arrest).Because more opioid is required to produce

respiratory depression than is required to produce sedation, patients with clinically significant

respiratory depression are usually sedated. Monitoring sedation levels is as important as

monitoring respiratory status.

All documentation should be as for local hospital observations charts

Table 2. General Guide for Respiratory Depression Requiring an Intervention

Age (years) Respiratory Rate Sp02

0 – 2 years <18 ≤94

2 - 6 years <14 breaths / minute ≤94

8 - 10 years <10 breaths / minute ≤94

12+ years <8 breaths per minute ≤94

When monitoring respiration the following should be taken into account

depth of respiration

respiratory effort

level of sedation

15.12.4 MANAGEMENT OF OPIOID INDUCED RESPIRATORY DEPRESSION

If the respiratory rate and effort indicates respiratory depression AND the patient cannot be

roused AND the SpO2 is less than 90% on 6-8Litres of oxygen via face mask. STOP the

opioid infusion.

Provide Basic Life Support

If apnoeic: - administer bag & mask ventilation with 100% oxygen

If breathing: - maintain airway and administer oxygen via face mask at 8L/min

If medical emergency is indicated bleep 2222.

The treatment of opioid overdose is the opioid antagonist naloxone

Naloxone is available in the ward/unit drug cupboard and on the ward/unit resuscitation trolley.

The duration of action of naloxone is about 30 – 45 minutes. Patients who have responded

to naloxone should be carefully monitored as the duration of action of opioids may exceed

that of naloxone.

It is recommended that patients that receive naloxone be continuously observed for

a minimum of 2 hours after the last dose.

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There are two dosing regimens for naloxone:

Excess Sedation (difficulty to rouse, respiratory depression, AVPU Score P

Resuscitation (minimal respirations, AVPU score U, cardiorespiratory arrest)

Following Naloxone administration observe patient response and monitor and record

respiratory rate, hear rate, and SpO2 every minute until ventilation and alertness is achieved.

The patient should be able to open his/her eyes within 1-2 minutes. If the patient does not

respond REPEAT the dose.

Continue to monitor and record respiratory rate and effort, HR SpO2 and sedation score

every 15 minutes for 2 hours, and pain score every 30 minutes, then hourly for 4 hours.

5.12.5 NAUSEA AND VOMITING

There are multiple causes for post-operative nausea and vomiting in children (e.g. surgery,

anesthesia, prolonged fasting, opioids, antibiotics, other medication, ileus, pain, electrolyte

imbalance, renal dysfunction).

Consider all possible causes of post-operative nausea and vomiting (PONV) as this may

influence antiemetic selection.

A combination of antiemetics may be required or consider a low dose of naloxone.

Drug Indication Route Dose Caution

Naloxone Excess sedation when respiratory compromise is

present

Intravenous injection

2 - 10microgram/kg, repeated as necessary to maintain reversal

Max: 200 micrograms/dose.

Watch for rebound respiratory depression

Naloxone has a short duration of action; repeated doses or infusion may be

necessary to reverse effects of opioids with

longer duration of action.

Drug Age Route Dose Frequency Maximum dose

Preparation/ comments

Dexamethasone IV

Slow infusion

150 microgram/kg Single perioperative

dose

8mg NB this agent is commonly used intraoperatively. If this is the case it should be given as a single dose on Day 1 only

Do not use in patients at risk of tumor lysis syndrome

Slow IV infusion

Ondansetron 2-12 years IV 1mg / kg 8 to 12 hourly 4mg Ondansetron Inj: 4mg, 8mg

Slow IV infusion over at least 15minutes in 0.9% Sodium Chloride or Glucose 5%

> 12 years IV 4mgs as single dose

8mg

Naloxone IV 1 -2 microgram/kg Repeat 2 hourly if

symptoms return

200 microgram

Consider reducing opioid infusion or switching to

alternative opioid

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5.12.6 CONSTIPATION

Constipation is a common side effect of opioid administration. Prevention measures

should be started early following commencement of opioid analgesics.

Treat early with Lactulose or Movicol.

Low Dose naloxone 1 to 4 microgram/kg may be used, especially if child is Nil PO.

5.12.7 PRURITUS

This is an occasional side effect of opioids and usually settles. It can be treated with an

antihistamine e.g. Chlorphenamine or consider 5-HT3 antagonist e.g. ondansetron or a low

dose of naloxone may be considered.

If these measures fail it may be advisable to switch to alternative opioid e.g. Oxycodone,

please contact the pain service on bleep 8300 or Anaesthesiologist for advice.

5.12.10 URINARY RETENTION

Urinary retention may be due to a variety of causes (e.g. pain, bladder spasm,

constipation, dehydration, anxiety about using bed-pan, epidural blockade. Consider:

Increasing fluid intake

Conservative management e.g. close monitoring, reassurance, assess for

bladder distension.

Increasing privacy, running water, use of commode

If the retention is likely to be opioid induced. Consider:

Reducing the rate/bolus.

Administering a low dose naloxone 1 to 2 microgram/kg IV Stat

Drug Age Route Dose Frequency Maximum dose

Preparation/ comments

Chlorphenamine < 6 months IV

250 microgram/kg Up to 4 times in 24

hours

2.5mg Chlorphenamine Inj 10mg/ml

Dilute in 0.9% Sodium chloride infuse over one

minute

6 months to 6 yrs

2.5mg

6 to 12 years 5mg

12-18 years 10mg

Ondansetron 2-12 years IV

1mg / kg 8 to 12 hourly

4mg Ondansetron Inj: 4mg, 8mg Slow IV infusion over at least 15minutes in 0.9% Sodium Chloride or Glucose 5%

> 12 years 4mgs as single dose

8mg

Naloxone > 1 month IV 1-2 microgram/kg Repeat after 2 hours if necessary

Max Single dose 200

microgram

400microgram/ml Consider reducing opioid

infusion or switch to alternative opioid

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Drug Age Route Dose Frequency Maximum

single dose

Preparation

comments

Naloxone > 1 month IV 1-2 microgram/kg Stat 200 microgram

400 microgram/ml

Consider reducing

opioid infusion or

switch to alternative

opioid

Intermittent catheterisation or indwelling catheter may be required if the above measures fail.

5.12.9 CENTRAL NERVOUS SYSTEM EFFECTS

The central nervous system (CNS) effects of opioids (e.g. sedation, euphoria or dysphoria)

are usually short lived and resolve within several days of commencing opioids. The effects

may be dose related; therefore a reduction in dose may resolve the symptoms.

Converting to another opioid may help. If symptoms do not resolve, other causes should be

considered, such as side effects of other medication, hepatic or renal dysfunction, infection,

electrolyte imbalance.

5.12.10 ALLERGY

True allergic or anaphylactic reactions are rare.

Urticarial, wheal formation, pruritus and sneezing are common reactions usually secondary

to opioid induced histamine release (pseudo allergic reactions).

Opioids such as morphine can cause histamine release in usual clinical doses.

Antihistamines (e.g. diphenhydramine) can alleviate symptoms.

In the case of a true allergy an opioid from a synthetic source (Oxycodone®, Fentanyl or

analogues) should be substituted.

5.12.11 CANNUALA TISSUED

Check infusion site regularly

Arrange for resiting if necessary.

Consider alternative analgesia e.g. oral morphine, paracetamol or NSAID.

5.12.12 MYOCLONIC JERKS/ MUSCLE SPASM

Myoclonic jerks can occur as a result of opioid drugs. They can be mistaken for pain.

For muscle jerks: Reduce the opioid infusion rate or switch to an alternative opioid.

Muscle spasm: a small dose of Diazepam may be administered. Monitor carefully for

excess sedation following any dose of diazepam.

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5.12.14 BLADDER SPASM

May be associated with bladder or urological surgery or a urinary catheter.

Management: Oxybutynin chloride.

5.13 STOPPING NCA/PCA

The decision to stop the opioid infusion should ideally be made in consultation with the pain

service nursing staff or Anaesthesiologist on call.

Other analgesics should be prescribed.

Most children self-wean off NCA/PCA, using it less as their pain decreases.

Oral opioid may be given an hour prior to stopping the infusion or at the time of stopping

the infusion.

To ensure no residual morphine remains in the line, flush IV cannula with 0.9% w/v Sodium

chloride and document this on IV Fluid balance sheet.

Any remaining opioid infusion must be disposed of according to OLCHC Guidelines.

Precautions: Careful tapering of doses is important when weaning long-term opioids to

avoid opioid withdrawal.

5.14. ONGOING OPIOID REQUIREMENTS AFTER PCA/NCA

If ongoing analgesic requirements are predicted to be high – a slow release oral opioid

can be started (Oxycontin® ,MS Contin®). Seek advice from the pain service.

When prescribing slow release opioid, access to breakthrough immediate release opioid

must be prescribed a required.

On the second post-operative day, the slow release morphine dose should be adjusted

by the Pain Service according to the previous day’s morphine requirement.

Other options include using transdermal opioid patch to control pain. Please seek

advice from the pain service.

6 NON-COMPLIANCE WITH THIS GUIDELINE

Inappropriate use of the PCA/NCA which will lead to opiate induced complications:

Overuse – i.e. by persons other than the patient pressing the bolus button, may

precipitate confusion, hallucinations, nausea and vomiting, convulsions, and/or

respiratory depression leading to respiratory arrest, loss of consciousness and death.

Underuse – i.e. withdrawal of, or inaccessibility to, the bolus facility or failure to address

technical problems such as machine problems or empty syringe, may lead to uncontrolled

pain and distress.

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7 MONITORING AND /OR AUDIT

Adherence to this guideline will be monitored by the Pain service.

Incident reports involving PCA or NCA opioid infusions will be monitored and reports will

be responded to when they occur.

Required changes in practice will be identified and actioned within 1 month. A lead

member of the pain service will be identified to take change forward where appropriate.

Lessons will be shared with all the relevant stakeholders.

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Incre

asi

ng P

ain

8. ALGORITHM FOR MANAGING PAIN

1. ASSESS PAIN

A. Use developmentally appropriate pain assessment tool

B. Consider changes in function/mood/activity

C. Seek child/parent/staff opinions

2. TREAT ACUTE PAIN

Pain management should be tailored to individual needs of the patient.

Use multimodal analgesia including non-drug methods.

Administer appropriate analgesia to pain score.

Treat the cause if possible.

Reduce environmental irritants (e.g. noise, lights, alarms)

Use non-drug methods (e.g. distraction, heat/cold, massage, play, education)

When converting from IV & Epidural infusions, step down analgesia must be prescribed

3. REASSESS PAIN

Regular assessment of pain and side effects of therapy is necessary to ensure effective and safe treatment.

Reassess pain 20 to 30 minutes following an intervention to treat pain

4. TREAT PAIN

If no improvement in pain, go to next step in the pain ladder

5. REFER TO SPECIALIST

Mild 2-3

Moderate

4-6

Severe

7-10

Paracetamol +

NSAID

Paracetamol+ NSAID + Opioid (oral Morphine or / Tramadol) + Clonidine

+/- Magnesium

Epidural / regional IV Morphine or OxyCodone / PCA / NCA + Paracetamol + NSAID + Clonidine + Oral or IV ketamine +/- Magnesium or

Lidocaine

Slight 1

Paracetamol Analgesic Pain Ladder

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REFERENCES

(2012) Good Practice in Postoperative and Procedural Pain 2nd Edition Pediatric Anesthesia

22:1-79

Alaris IVAC® PCAM® syringe pump directions for use. Accessed on 20/10/2016 Available at:

http://www.aquilantmedical.ie/assets/aquilantmedicalie/Products/brochures/902008/IVAN_PCAM_S

yringe_Pump_-_Directions_for_Use.pdf

Australian and New Zealand college of Anaesthesiologists and Faculty of Pain Medicine (ANZCA)

(2015) Acute Pain Management: Scientific Evidence, 4th edition. Melbourne: Australian and New

Zealand College of Anaesthesiologists. Available at www.

Baines D. (1996) Postoperative nausea and vomiting in children. Paediatric Anaesthesia. 6:7-14

Birchley. G. (2009) Opioid and benzodiazepine withdrawal syndromes in the paediatric intensive

care unit: a review of recent literature. British Journal of Critical Care Nurses, Nursing in Critical

Care; 14(1): 26-37.

Bray R, Woodhams A, Vallis C, & Kelly P (1996). Morphine consumption and respiratory depression

in children receiving postoperative analgesia from continuous morphine infusion or patient

controlled analgesia. Paediatric Anaesthesia; 6: 129-134

Bray R, Woodhams A, Vallis C, & Kelly P (1996).A double blind comparison of morphine infusion

and patient controlled analgesia in children. Paediatric Anaesthesia; 6: 121-127

BNF for Children. British National Formulary for Children (2017-2018). BMJ Group Tavistock

Square, London WC1H 9JP, UK.

Friedman D, Dello Buono FA. (2001) Opioid antagonists in the treatment of opioid-induced

constipation and pruritus. Ann Pharmacotherapy; 35:85-91

Howard RF, Lloyd-Thomas A, Thomas M, Williams DG, Saul R, Bruce E, Peters J.(2010) Nurse-

controlled analgesia (NCA) following major surgery in 10,000 patients in a children's hospital.

Paediatric Anaesthesia; 20 (2):126-34.

Malviya S, Voepal-Lewis T, Burke C, Merkel S, Tait AR. (2006) The revised FLACC observational

pain tool: Improved reliability and validity for pain assessment in children with cognitive impairment.

Paediatric Anaesthesia; 16:258-265

Merkel SL, Voepal-Lewis T, Shayevitz JR,Malyviya S(1997) The FLACC: a behavioural scale for

scoring postoperative pain in young children. Pediatric Nursing, 23 (3):292-297

http://www.aquilantmedical.ie/assets/aquilantmedicalie/Products/brochures/902008/IVAN_PCAM_Syringe_Pump_-_Directions_for_Use.pdf

http://www.aquilantmedical.ie/assets/aquilantmedicalie/Products/brochures/902008/IVAN_PCAM_Syringe_Pump_-_Directions_for_Use.pdf

http://www.ncbi.nlm.nih.gov/pubmed/20078810








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Monitto CL, Kost-Byerly S, White E, Lee CK, RudekMA, Thompson C, Yaster M (2011) The optimal

dose of prophylactic intravenous naloxone in ameliorating opioid-induced side effects in children

receiving intravenous patient-controlled analgesia morphine for moderate to severe pain: a dose

finding study. Anesthesia and Analgesia 113(4):834-842

Murphy JD, Gelfand HJ, Bicket MC, Ouanes JP, Kumar KK, Isacc GR, Wu CL. (2011) Analgesic

efficacy of intravenous naloxone for the treatment of postoperative pruritus: a meta-analysis.

Journal of Opioid Management. 7(4):321-327

Royal College of Nursing (2009) Clinical Practice Guidelines: The Recognition and Assessment of

Acute Pain in Children London. Accessed 9/10/17 https://www.rcn.org.uk/professional-

development/publications/pub-003542

Royal Children’s hospital Melbourne (2016) Pain Management clinical Practice Guidelines.

Available at: http://www.rch.org.au/anaes/pain_management/Acute_Pain_Management_CPMS/

Accessed 10/10/2016

The Association of Paediatric Anaesthesiologists of Great Britain and Ireland (2016) Guideline on

the prevention of post-operative vomiting in children. Accessed 1/11/17 . Available@

http://www.apagbi.org.uk/sites/default/files/images/2016%20APA%20POV%20Guideline-2.pdf

Voepel-Lewis, T., Wagner, D., Burke, C., Tait, A. R., Hemberg, J., Pechlivanidis, E., Malviya, S.,

Talsma, A. (2012), Early adjuvant use of non-opioids associated with reduced odds of serious

postoperative opioid adverse events and need for rescue in children. Pediatric Anesthesia.

Wong DL, Baker CM. (1988) Pain in Children: Comparison of assessment scales. Pediatric Nursing;

14 (1):9-17

https://www.rcn.org.uk/professional-development/publications/pub-003542

https://www.rcn.org.uk/professional-development/publications/pub-003542

http://www.rch.org.au/anaes/pain_management/Acute_Pain_Management_CPMS/

http://www.apagbi.org.uk/sites/default/files/images/2016%20APA%20POV%20Guideline-2.pdf

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Appendix 1

PATIENT CONTROLLED ANALGESIA MORPHINE

Suggested PCA settings in bold and underlined. Modify according to patient.

PCA STANDARD INFUSION Children aged ≥ 7 years, Weight >5kg to 50kg

Children weight ≥ 50kg

Opioid Dilution 1mg/kg Morphine made up to a total of 50 ml in Glucose 5% or Sodium Chloride 0.9%

50mg Morphine made up to a total of 50ml in Glucose 5% or Sodium

Chloride 0.9%

Concentration 20 microgram/kg/ml 1mg/ml

Loading Dose (only if no other opioid previously administered)**

50 or 100microgram/kg** (2.5 or 5ml) 50 or 100microgram/kg** (max 5mg) (2.5 or 5ml)

Background Infusion 0 to 1ml/hr

start at: 0.2, 0.5, 1ml/hr (0, 4, 10, or 20 microgram/kg/hr)

0 to 1ml/hr Start at: 0, 0.2, 0.5 or 1ml/hr (0 , 0.2mg, 0.5mg or 1mg/hr)

Bolus Dose 0.5 to 1ml

10 or 20 microgram/kg 1 or 2ml ( 1mg or 2mg)

Lockout time 5 to 10 minutes 5 to 10 minutes

Maximum 4 hourly Dose 400 microgram/kg (20ml) 20mgs (20ml)

NURSE CONTROLLED ANALGESIA MORPHINE

Suggested NCA settings in bold and underlined. Modify according to procedure and patient.

NCA STANDARD INFUSION

Neonates & Infants <5KG* Children> 5kg to 49kg Children >50kg

Opioid Dilution

0.5mg/kg Morphine made up to total of 50 ml in Glucose 5% or

Sodium chloride 0.9%

1mg/kg Morphine made up to total 50 ml in Glucose 5% or Sodium

chloride 0.9%

50mg Morphine made up to total 50ml in Glucose 5% or Sodium

chloride 0.9%

Concentration 10microgram/kg/ml 20microgram/kg/ml 1mg/ml

Loading Dose** 20-100microgram/kg**

Max dose 100microgram/kg 50 or 100microgram/kg**

(2.5 to 5ml) 50 or 100microgram/kg** (max 5mg) (2.5 or 5ml)

Background Infusion

0 to1ml/hr Start at: 0, 0.5 or 1ml/hr

(0, 5 or 10 microgram/kg/hr)

0 to1ml/hr Start at: 0, 0.2, 0.5, 1ml/hr

(0, 4, 10, or 20 microgram/kg/hr)

0 to1ml/hr Start at:0, 0.5 or 1ml/hr

(0, 0.5mg or 1mg/hr)

Bolus Dose

0.5 to 1ml

(5 to 10microgram/kg) 0.5 to 1ml

(10 or 20 microgram/kg ) 1 or 2ml

( 1 or 2mg)

Lockout time 15 or 20 minutes 15 or 20 minutes 15 or 20 minutes

Maximum 4 hour dose

200 microgram/kg (20ml) 400 microgram/kg (20ml) 20mg (20ml)

*Babies (birth-12 weeks) undergoing multiple surgeries may require more morphine than their age suggests

** Administered over 5mins with Respiratory & SaO2 monitoring only if no other opioid received.

NB: This guide is intended for use in children who are opioid naïve. Children who have been on oral or IV opioids including opioid transdermal patch or children with conditions associated with severe pain, (major surgery, sickle cell disease, cancer, and severe burn injury) may have higher opioid requirements.

Infusion rates higher than this guideline is at the discretion of the Pain service, Consultant in charge, Consultant anaesthesiologist, Consultant PICU. If in doubt contact the pain service.

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PATIENT CONTROLLED ANALGESIA OXYCODONE


PCA STANDARD INFUSION Children aged ≥ 7 , Weight >5kg and < 50kg Children ≥ 50kg

Opioid Dilution 1mg/kg Oxycodone made up to a total of 50 ml in Glucose 5% or Sodium Chloride 0.9%

50mg Oxycodone made up to a total of 50ml in Glucose 5% or Sod Chloride 0.9%

Concentration 20 microgram/kg/ml 1mg/ml

Loading Dose**

50 or 100microgram/kg

(2.5 or 5ml)

50 or 100microgram/kg (max 5mg)

(2.5 or 5ml)


Start at: 0, 0200.2, 0.5, 1ml/hr 0, 4, 10, or 20 microgram/kg/hr

0 to1ml/hr Start at: 0, 0.2, 0.5 or 1ml/hr

(0 , 0.2mg, 0.5mg or 1mg/hr)

Bolus Dose 10 or 20 microgram/kg

0.5 or 1ml 1 or 2ml ( 1mg or 2mg)

Lockout time 5 or 10 minutes 5 or 10 minutes

Maximum 4 hourly Dose 400 microgram/kg (20ml) 20mgs (20ml)

NURSE CONTROLLED ANALGESIA OXYCODONE


NCA STANDARD INFUSION Neonates & Infants <5Kg

*Oxycodone is not recommended for routine use

in neonates*

Children

Weight greater than or equal to 5kg and less than 50kg

Children

Weight greater than or equal to 50kg

Opioid Dilution

0.5mg/kg Oxycodone made up to total of 50 ml in Glucose 5% or

Sodium chloride 0.9%

1mg/kg Oxycodone made up to total 50 ml in Glucose 5% or

Sodium Chloride

50mg oxycodone made up to total 50ml in Glucose 5%

or Sodium chloride 0.9%

Concentration 10 microgram/kg/ml 20 microgram/kg/ml 1mg/ml

Loading Dose**

20-50microgram/kg(2 to 5ml) Max dose 100microgram/kg

50 or 100microgram/kg (2.5 or 5ml)

50 or 100microgram/kg (max 5mg) (2.5 or 5ml)


Start at: 0, 0.5 or 1ml/hr

(0, 5 or 10 microgram/kg/hr)

0 to 1ml/hr Start at: 0, 0.2, 0.5, 1ml/hr

( 0, 4, 10, or 20 microgram/kg/hr)

0 to1ml/hr Start at: 0, 0.5 or 1ml/hr (0 , 0.5.mg or 1mg/hr)

Bolus Dose**

0.5 to 1ml (5 to 10microgram/kg)

0.5 to 1ml (10 or 20 microgram/kg )

1 or 2ml ( 1 or 2mg)

Lockout time 20 or 30 minutes 15 or 20 minutes 15 or 20 minutes

Maximum 4 hour dose 200 microgram/kg (20ml) 400 microgram/kg (20ml) 20mg (20ml)

Oxycodone infusion is not recommended as first line therapy. It can be used at the discretion of Consultant

anaesthesiologist/Intensivist/ Haematologist

NB: This guide is intended for use in children who are opioid naïve. Children who have been on oral or IV

opioids including opioid transdermal patch or children with conditions associated with severe pain, (major

surgery, sickle cell disease, cancer, and severe burn injury) may have higher opioid requirements.

Infusion rates higher than this guideline is at the discretion of the Pain service, Consultant in charge, Consultant

anaesthesiologist, Consultant PICU. If in doubt contact the pain service.

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** Administered over 5mins with Respiratory & SaO2 monitoring only if no other opioid received.

Sample Prescription

Child weight 35kg. Age 11yrs

PCA Morphine 35mgs made up to total of 50mls in Glucose 5%

Concentration: 1ml=700microgram (20microgram/kg/ml)

PCA Bolus: 1ml (20microgram/kg)

Lockout time: 6 to 12 minutes

Continuous infusion: 0 to 1ml/hr. Start at: 0.2ml/hr (4microgram/kg/hr)

Maximum 4 hourly dose: 400microgram/kg 20mls

SEDATION – AVPU

A - Awake, arousable, alert

V - Responds to voice only (drowsy and sleepy). Child may be sedated from opioid. Obtain GCS. Action:

Consider reducing IV opioid

P - Responds to pain stimulus only (deeply asleep, arousable only with deep or significant physical or painful

stimulus. Action: Stop opioid, Obtain GCS. If opioid related over-sedation, contact anaesthesiologist on bleep

8528, and/or CNS Acute Pain, bleep 8300. Opioid can be recommenced once child becomes more responsive.

U - Unresponsive. Stop Opioid. Stimulate the child. Administer oxygen. Call 2222. Obtain GCS.

Give naloxone to reverse opioid.

Analgesic Interventions with PCA/NCA

0 No Pain

1 - 3 Mild Pain NCA: Give bolus 10 minutes before activity.

PCA: encourage bolus 10 minutes before activity

4 - 6 Moderate

Pain

NCA: Give Bolus. PCA: encourage bolus

7 - 10 Severe

Pain

NCA or PCA: Pain uncontrolled with 3 boluses/hr & adjunctive analgesia. Contact Pain

Service

Nausea and Vomiting ITCH

0 - No vomit 0 - No Itch

1 - Nausea 1 - Slight

2 - Vomit 2 - Moderate

3 - Vomit more than 3 in last hour 3 - Severe

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APPENDIX 2: PAIN ASSESSMENT TOOLS For pain assessment tools in other languages see hospital intranet

Wong-Baker Faces Pain Rating Scale©

Category FLACC SCALE -REVISED Adapted from Merkel et al, 1997, 2006, Used with permission

0 1 2

Face No particular expression or smile

Occasional grimace or frown, withdrawn, disinterested. Appears sad or worried.

Frequent to constant quivering chin, clenched jaw. Distressed looking

Individual behaviours

Legs Normal position or relaxed. Usual tone and motion to limbs

Uneasy, restless, tense. Occasional tremors

Kicking or legs drawn up. Marked increase in spasticity. Constant tremors or Jerking


Activity Lying quietly, normal position moves easily. Regular, rhythmic respirations

Squirming, shifting back and forth, tense. Tense or guarded movements. Mildly agitated (e.g. moving head back and forth, aggression). Shallow, splinted respirations, intermittent sighs

Arched, rigid or jerking. Severe agitation. Head banging. Shivering (not rigors). Breath-holding, gasping or sharp intake of breaths. Severe splinting of respirations


Cry No cry or verbalisation (awake or asleep)

Moans or whimpers; occasional complaint. Occasional verbal outburst or grunt

Crying steadily, screams or sobs, frequent complaints. Repeated outbursts. Constant grunting


Consolability Content, relaxed Reassured by occasional touching, hugging or being talked to, distractible

Difficult to console or comfort. Pushing away caregiver. Resisting care or comfort measures


Instructions for Use:

Individualize the tool. The nurse should review the descriptors with each category with the child’s parents or carers. Ask them if

there are any additional behaviours that are better indicators of pain in their child. Add these behaviours to the tool in the appropriate

category.

Score Each of the 5 categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2.

Patients who are awake: Observe for at least 2-5 minutes. Observe legs and body uncovered. Reposition patient or observe activity,

assess body for tenseness and tone. Initiate consoling interventions if needed.

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Patients who are asleep: Observe for at least 5 minutes or longer. Observe body and legs uncovered. If possible reposition the

patient. Touch the body and assess for tenseness and tone.

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APPENDIX 3

Competency Statement

ALARIS 3300 PCA Pump Self-Assessment High Risk Device - STOP Do not use this item unless you are competent to do so

Surname:

Forename(s):

Title (Mr. / Mrs. / Miss / Dr. etc):

Job Title / Designation

Dept / Directorate & Ward / Unit:

Extension No:

Self-verification of competence is undertaken by assessment against the following statements:

These statements are designed to indicate competence to use this device. Responsibility for

use remains with the user, so if you are in any doubt regarding your competence to use the

device, you should seek education to bring about improvement. Various methods including,

self

directed learning, coaching & formal training may be initiated.(Consider local resources,

product operating manual, IV study day, Pain study days & discussion with Clinical facilitator,

colleagues or the CNS Acute Pain)

Carry out an initial assessment. You must be able to answer “yes” to all the questions before

considering yourself to be competent.

If you are not competent, instigate learning & then repeat self-verification.

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Questions to ask yourself:

Initial assessment

date:

Final assessment

date:

Are you safe using this device? Do You Know:

1. What is the purpose of the self-test when the pump is first switched on? 1. Yes / No 1. Yes / No

2. How to load the syringe into the pump? 2. Yes / No 2. Yes / No

3. Do you know how to programme the pump? 3. Yes / No 3. Yes / No

4. Do you know how to alter the name of the drug to be infused? 4. Yes / No 4. Yes / No

5. Why should you purge the pump before connecting the infusion to the patient? 5. Yes / No 5. Yes / No

6. Do you know the code for a clinician (Medical doctor) bolus? 6. Yes / No 6. Yes / No

7. Do you know how the hand set operates? 7. Yes / No 7. Yes / No

8. Do you Know how long it will take for a bolus dose (NCA/PCA) to be effective? 8. Yes / No 8. Yes / No

9. What should you do if a child makes excessive PCA demands? 9. Yes / No 9. Yes / No

10. Do you know why what to do if the 4 hourly maximum dose is reached early? 10. Yes / No 10. Yes / No

11. What you should do first if an occlusion occurs? 11. Yes / No 11. Yes / No

12. How to alter pump settings to wean patients off opioid? 12. Yes / No 12. Yes / No

13. What potentially dangerous event might occur if the syringe plunger or barrel were not secure and the pump was above the level of the patient’s heart?

13. Yes / No

13. Yes / No

14. Do you know under what circumstances you might increase a background infusion? 14. Yes / No 14. Yes / No

15. Do you know how to calculate and check the drug concentration display? 15. Yes / No 15. Yes / No

16. How to obtain the patient history of bolus demands? 16. Yes / No 16. Yes / No

17. Do you know where to access the hospital guidelines for PCA/NCA? 17. Yes / No 17. Yes / No

18. How you would clean and store the pump after use? 18. Yes / No 18. Yes / No

Statement: Having answered “yes” to all the questions above & taken into account my personal assessment of my

competence with the product, I declare that: I am competent to use this product without further training

Signature: ……………………………………………………………………………………….. Date: ……………………………………….

I require further training to before I can use this product in a competent manner

Signature:……………………………………………………………Date: ……………………………….NMBI:……………………………………

Indicate how you plan to meet your learning needs:

Keep this form in your personal portfolio or training record. Send a copy of this form to CNF/CNSp pain ANPc Children’s Pain

Copyright©2018, Our Lady’s Children’s Hospital Crumlin, Dublin 12. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright holder. Every effort has been made to ensure that the information provided is accurate and in accord with standards accepted at the time of printing.

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