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
Title: Consultant Paediatric Anaesthesiologist
Name: Dr. Sinead Harte
Title: Consultant Paediatric Anaesthesiologist
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
CHI@Crumliin
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 Page 2 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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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 Page 3 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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
CHI@Crumliin
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 Page 4 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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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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 Page 5 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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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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 Page 6 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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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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 Page 7 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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.
CHI@Crumliin
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 Page 8 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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
CHI@Crumliin
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 Page 9 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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.
CHI@Crumliin
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 Page 10 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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.
CHI@Crumliin
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 Page 11 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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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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 Page 12 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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)
CHI@Crumliin
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 Page 13 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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
CHI@Crumliin
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 Page 14 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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.
CHI@Crumliin
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 Page 15 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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
CHI@Crumliin
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 Page 16 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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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Document Name: Guideline for the Management of Opioid Infusions for Acute Pain
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Date of Issue: November 2018, Revised July 2019 Page 17 of 29
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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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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 Page 18 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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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Document Name: Guideline for the Management of Opioid Infusions for Acute Pain
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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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Document Name: Guideline for the Management of Opioid Infusions for Acute Pain
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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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Reference Number: MOIAP-10-2016-GOC-V2 Version Number: V2.2
Date of Issue: November 2018, Revised July 2019 Page 21 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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
CHI@Crumliin
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 Page 22 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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
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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 Page 23 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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.
CHI@Crumliin
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 Page 24 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
PATIENT CONTROLLED ANALGESIA OXYCODONE
Suggested NCA settings in bold and underlined. Modify according to procedure and patient.
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)
Background Infusion 0 to 1ml/hr
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
Suggested NCA settings in bold and underlined. Modify according to procedure and patient.
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)
Background Infusion 0 to 1ml/hr
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.
CHI@Crumliin
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 Page 25 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
** 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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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 Page 26 of 29
Department of Anaesthesia, Critical Care, Pain Management and Department of Nursing, July 2019
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
Individual behaviours
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
Individual behaviours
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
Individual behaviours
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
Individual behaviours
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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Document Name: Guideline for the Management of Opioid Infusions for Acute Pain
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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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Document Name: Guideline for the Management of Opioid Infusions for Acute Pain
Reference Number: MOIAP-10-2016-GOC-V2 Version Number: V2.2
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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
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