Beyond The Lockout Time. Kelcy Freeman, PharmD, BCPS April 20, 2017 REMEDI Pump Collaborative Spring Conference Chicago, IL

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1 Beyond The Lockout Time Kelcy Freeman, PharmD, BCPS April 20, 2017 REMEDI Pump Collaborative Spring Conference Chicago, IL

2 Disclosure I am a full-time employee of Smiths Medical, global provider of medical devices including CADD infusion pumps. April 20, 2017 REMEDI Pump Collaborative

3 The PCA Prescription Macintyre P.E PCA bolus or demand dose Lockout interval Background or concurrent continuous infusion Dose limit A limit to the maximum amount of opioid that can be delivered over a certain period (commonly hourly or 4-hourly limit) Common limits for morphine: 10mg in 1hr or 30mg in 4hr Safety and efficacy of patient-controlled analgesia. Br J Anaesth 2001; 87: 36-46

4 How Dose Limits Work Pump library entry built with specified dose limit type (e.g. 1-hour limit, 4-hour limit) + hard/soft limits to protect programming or built with no dose limit at all Pump monitors the amount of medication delivered over the most recent specified time period (rolling). If programmed limit has been reached, pump will prevent administration of any further PCA doses and will also turn off ( to KVO) any programmed continuous infusion April 20, 2017 REMEDI Spring Conference

5 Dose Limit Evidence? Macintyre P.E There is no reliable method of determining how much opioid a patient will require for analgesia, far less how much will result in dangerous side effects there is no good evidence to show that patients have benefited from [delivery limit] inclusion in PCA prescriptions. Etches R.C To date, no evidence shows that the inclusion of these limits is of any benefit to patients. This may be anticipated because few patients reach these limits, and the sedative and respiratory effects of PCA opioids present in most patients at doses far less than the limits prescribed. Safety and efficacy of patient-controlled analgesia. Br J Anaesth 2001; 87: Patient-controlled analgesia. Surg Clin North Am 1999; 79:

6 Typical Opioid Requirements Etches R.C Negative correlation of dose versus age allows morphine needs to be estimated using: (100 age)/24 = hourly morphine dose 30-year-old 50-year-old 70-year-old 3 mg morphine per hour 2 mg morphine per hour 1.25 mg morphine per hour If PCA parameters reflect these estimates, why use a 1-hour limit of 10mg? Patient-controlled analgesia. Surg Clin North Am 1999; 79:

7 A Different Opinion Grass J Some devices allow entry to limit the patient over either 1- hr or 4-hr intervals to less total cumulative dose than were they to successfully activate the demand button at the end of each lockout interval. Use of these limits is controversial If patient uses enough demand doses to reach limit, they probably require more analgesic instead of being locked out Patient-controlled analgesia. Anesth Analg 2005; 101: S44-S61

8 Another Point Dose limits are sometimes not included in prescribers orders, but are instead calculated and added after-thefact by nursing or pharmacy Prescriber orders: Continuous infusion = 2 mg/hr PCA dose = 0.5 mg Lockout interval = 8 minutes 1-hour limit = 2mg/hr + (0.5mg x 7 doses/hr) = 5.5 mg April 20, 2017 REMEDI Spring Conference

9 And Another Counterpoint UConn Health PCA MUE, 2016 If basal rate + patient demand dose + titration dose exceeded the maximum limit of the order, it was counted as an erroneous order Department of Pharmacy, John Dempsey Hospital. PCA Safety & Order Entry. April Accessed at

10 Counterpoint Continued UConn Health PCA MUE, 2016 Department of Pharmacy, John Dempsey Hospital. PCA Safety & Order Entry. April Accessed at

11 Odds & Ends PCEA/PCRA ordered without a dose limit more frequently than IV PCA Subcutaneous PCA often used for palliative care, so dose limits are rare Intervals other than 1-hour and 4-hour are available for dose limits Max doses/hr is different type of dose limit that does not affect a continuous infusion April 20, 2017 REMEDI Spring Conference

12 What Is Your Experience? How are dose limits used at your hospital? Do you know exactly how your pump handles dose limits? Do you think prescribers know? Have new technologies or practices changed your PCA orders? Have I missed the boat completely on this topic? April 20, 2017 REMEDI Spring Conference

13 Thank you!