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1 DOCUMENT CONTROL PAGE Title Title: Version: 3 Reference Number: Supersedes Supersedes: All previous versions (2006) Description of Amendment(s): New hospital contact details applied. Originator or modifier Approval Originated By: Denise Jonas Designation: Lecturer/practitioner in Children s Pain Management Modified by: Denise Jonas Designation: Lecturer/practitioner in Children s Pain Management Approval by: Professional Nurse Forum Sub Committee Approval Date: [if required] Application Delete as necessary All Patients Patients Patients Children only All staff Staff Group (Nursing and medical) Other (Insert) Circulation Issue Date: September 2009 Circulated by: Children s Pain Team Issued to: Nursing and medical staff Review Review Date: September 2011 Responsibility of: Children s Pain Team D. Jonas/ Sept 2009 Page 1 of 10

2 POLICY CONTROL PAGE (2) CIRCULATION DOCUMENT Circulation List: For Information Central Manchester and Manchester University Hospitals NHS Trust is committed to promoting equality and diversity in all areas of its activities. In particular, the Trust wants to ensure that everyone has equal access to its services. Also that there are equal opportunities in its employment and its procedural documents and decision making supports the promotion of equality and diversity. Refer to section 8 for more detail on undertaking equalities impact assessment. This document must be disseminated to all relevant staff, refer to section 10: Dissemination and Implementation The Policy must be posted on the intranet: Date Posted: D. Jonas/ Sept 2009 Page 2 of 10

3 Royal Manchester Childrens Hospital NURSING PRACTICE GUIDELINES FOR PATIENT CONTROLLED ANALGESIA (PCA) Patient Controlled Analgesia (PCA) is widely used within Royal Manchester Children s Hospital for any child with moderate to severe pain who can understand and manipulate the PCA device. The concept of PCA was first developed in 1965 but more recently PCA has become a widely accepted method of postoperative pain management. Initially the use was restricted to adolescents but experience has shown that children as young as eight years, with support can use PCA effectively. However cognitive ability rather than age is usually an indicator of ability to understand the concept of PCA. Pain is always subjective and therefore difficult for others to control, PCA allows the child to have their own control over their pain relief. The child is able to use the PCA device to provide a steady level of pain relief by delivering a dose of morphine when they feel pain or prior to painful procedures. This form of analgesia eliminates the need for intra-muscular analgesia, which children dislike. The analgesia is delivered via a syringe pump with a self activation device (button). When the child presses the button, the pump delivers a bolus dose of morphine. The amount of morphine received depends on the child s weight. A lockout device prevents the child from receiving a further dose for at least five minutes although the child may still continue to press the button. Good demands are the number of doses the child actually receives whereas bad demands are the number of times the child activates the button. It is important that the child is the only person to press the button, if the child activates the button frequently then this will result in sleep and therefore the button will not be pressed. Pressing of the button by parent, doctor or nurse is prohibited as this can result in overdose and respiratory depression. Separate protocols and guidelines are in place for the use of Nurse Controlled Analgesia (NCA). For patients following major surgery a background infusion can be instigated alongside the bolus dosing, alterations to background infusion can only be undertaken by a member of the pain team or anaesthetist. All PCA infusions must be administered according to the PCA protocol (See Appendix 1). Changes may only be made to the protocol at the discretion of a consultant and this must be documented in the child s notes. Morphine is the analgesic drug of choice used in the PCA infusion, however other opiates may be used if directed and prescribed by a consultant anaesthetist. Morphine is a naturally occurring opioid which acts on specific opioid receptors in the body to reduce pain transmission. In addition to providing excellent analgesia morphine has a variety of adverse effects. The adverse effects can be reduced or reversed with the morphine antagonist Naloxone (Narcan) this acts by blocking the opioid receptors in the brain to prevent the action of the opioid. As Naloxone is short acting repeated boluses or a continuous infusion may be necessary. Use in caution with patients who have been using morphine for more than 5 days as use can result in sudden opioid withdrawal. D. Jonas/ Sept 2009 Page 3 of 10

4 Adverse Effects of morphine The incidence of respiratory depression and sedation is generally considered to be reduced with use of PCA. As the patient is the only person to activate the device, when the child becomes drowsy they will fall asleep and no further demands will be made. Drowsiness and sedation close monitoring of child s sedation score can minimise this effect. Use of sedatives, anti-emetics or anti-histamines can increase the risk of sedation and therefore should be used with caution. Background infusions added to the PCA also increase the incidence of sedation and therefore should be used minimally. Respiratory depression morphine causes a reduction in the sensitivity of the respiratory centre to CO 2 leading to shallow and slow respirations. Close monitoring of sedation score, respiratory rate, and dose appropriate to the weight of the child can minimise this adverse effect. A close indication of impending respiratory depression is increased sedation and reduced respiratory rate. Nausea & vomiting due to stimulation of the chemoreceptor trigger zone in the brain. Anti-emetics such as Ondansetron and Cyclizine may reduce the effects (See nausea and vomiting protocol) Itching due to increased histamine release from mast cells, IV anti-histamine such as Chlorpheniramine (Piriton) is usually effective in reducing the discomfort causes by itching. Pupillary constriction due to stimulation of the parasympathetic third cranial nerve muscle. Constipation - due to reduction in gastric motility in small and large bowel. Patients on long term PCA should be given prophylactic laxative. Urine retention due to constriction of smooth muscle of ureters. Urinary catheterisation may be necessary. Nightmares, hallucination and euphoria consider reduction in rate of morphine or other analgesia. Accumulation of morphine metabolites increases the incidence of sedation and respiratory depression in renal impaired patients. Equipment required to commence a PCA Alaris PCAM PCA infusion pump Alaris Luer lock infusion giving set incorporating an Anti-reflux valve and Antisyphon valve 50ml Luer lock syringe Infusion prescribed according to protocol on child s prescription sheet (protocol in red pain manual) Blue Morphine label and hospital drug additive label Morphine ampoules - 1mg/ml, 10mg/ml, 30mg/ml, 60mg/ml concentrations are available. (Be aware that the boxes look very similar). 0.9% sodium chloride to dilute morphine as per protocol Blue PCA infusion observation chart Pulse oximeter and age appropriate size probe Ward/unit area must have resuscitation equipment IV Naloxone, Piriton and Ondansetron must be available in the ward/unit medicine cupboard. D. Jonas/ Sept 2009 Page 4 of 10

5 Assessment of child The assessment of the child is important to ensure that the child will be capable to use the PCA before it is commenced. Intravenous analgesia will be required for period of more than 12 hours for moderate to severe pain. The child should be physically capable of pressing the button The child can understand the concept of cause and effect, e.g. if they have pain they have to press the button for the pain to go away. Cognitive age of the child. Desire to use PCA. The nurse/doctor should value and respect a child s decision not to use PCA. Parents may need additional information to help them support their child with the use of PCA. Details must be given to child and parents of any adverse effects, details of observations carried out hourly and safety measures undertaken to minimise adverse effects. The child should able to understand the pain assessment tool used to assess their pain. The child also has to understand that the PCA will not remove all pain and render them completely pain free. The child may be shown the pump beforehand to explore its workings and ask questions. The child should be reassured that the nurse is there to help the child manage their pain using the PCA device. Information leaflets PCA Information for Children and PCA information for parents and carers are available to reinforce any verbal information given. Nursing staff monitoring a child and supervising the delivery of PCA must be IV competent and trained in the use of the PCA device. Hourly observations must be documented and signed for by an IV competent member of staff. The PCA device must always infuse in conjunction with IV maintenance fluid. PCA devices are available from theatre recovery. The PCA machine must only be programmed by a member of the pain team, a member of theatre/recovery staff assessed as competent or an anaesthetist. The PCA key must be kept on the ward controlled drug key ring and not left in the machine. Nursing staff assessed as competent, may change syringes but must not make alterations to the pump program. Action 1 The doctor/anaesthetist will inform the child s nurse or member of the pain team of their intention to use PCA to control the child s pain. The concept of PCA will have been discussed with the child and parents by the doctor/anaesthetist and nurse. 2 The parents and child will be given a PCA infusion information leaflet. Rationale To obtain the child and parents cooperation and ensure they are adequately informed. To ensure that an assessment has been made of the child s ability and cognitive level to use the PCA device. To check availability of a PCA pump. To reinforce verbal information given by nurse/doctor. D. Jonas/ Sept 2009 Page 5 of 10

6 3 The child s bed will be prepared with a pulse oximeter. Suction and oxygen at the bedside will be checked. Naloxone will be available on the ward/unit area. 4 The PCA pump must be programmed by and checked by two IV competent members of staff from theatre recovery or a member of the pain team or an anaesthetist. Both programmers will be identified on the PCA observation form. The prescription will be written according to protocol. Any changes in protocol can only be made by a consultant and must be documented in the child s notes. 5 The syringe will be made up using aseptic non-touch technique principles and according to the child s prescription or using a pre prepared syringe made up from pharmacy. The syringe will be correctly labelled using a blue morphine sticker and hospital drug label. The preparation will be made according to the hospital drug policy and management of controlled drugs policy. 6 The syringe and pump must not be placed more than 80cm above the chest level of the child 7 Ensure an anti-reflux valve and antisyphon valve infusion set is used and connected to the appropriate maintenance infusion line. 8 The blue PCA observation chart must be commenced as soon as the PCA is connected to the child. Observations must be recorded at a minimum hourly and recorded in conjunction with the EWS system. The starting volume in the syringe must be recorded. 9 The ward nurse and recovery nurse must check the prescription, syringe labelling and programming of the pump before the child leaves recovery. This ensures that the child is nursed in a safe environment, where appropriate monitoring is available and safety measures are undertaken. To reverse the effects of the morphine should respiratory depression occur. To ensure safe programming of the pump and to exclude mistakes made by human error. To ensure that the IV preparation is as aseptic as possible. (Syringes and giving sets need to be changed according to IV policy). To indicate what concentration is in the syringe and to enable the nurse to check the concentration against the prescription at the start of the shift. To prevent syphonage occurring To prevent back flow of morphine into the maintenance fluid line. To ensure that the child s safety is maintained and the protocol adhered to. To ensure that the prescription is written according to protocol. To accept accountability for the PCA program and pump. Any errors made can be rectified before the child leaves theatre. At each shift change two registered nurses, one of whom is IV competent must undertake the same checking of the pump, syringe and prescription. D. Jonas/ Sept 2009 Page 6 of 10

7 10 If the PCA is commenced post surgery then the nurse must ensure that the child s pain is controlled before they leave theatre. The recovery nurse must document a least one set of PCA observations before the child leaves theatre. 11 If further analgesia is required or alteration to program then the child must remain in recovery for at least a further 20 minutes. 12 All sections of the PCA observation chart must be completed 13 The child s respiratory rate and sedation score will be recorded at minimum hourly. 14 The child will be monitored continually using a saturation monitor and the readings recorded hourly. 15 The child s heart rate will be recorded hourly 16 The child s pain will be assessed and documented hourly using a pain assessment tool. Encourage the child to press the button prior to painful procedure such as turning or physiotherapy. To ensure maximum comfort for the child. Anaesthetists are readily available in theatre should additional analgesia need to be given. To assess the effectiveness of any additional analgesia before the child leaves theatre. To detect early signs of the adverse effects of the morphine. To detect early signs of increased sedation or impending respiratory depression. If respiratory rate below level for child s age or sedation score of 4 stop infusion and contact on-call anaesthetist. If respiratory depression occurs then follow Event Protocol (see red pain manual) To detect late signs of respiratory depression and in accordance with the protocol. To indicate possible increases in levels of pain due to increased heart rate. To ensure that the PCA is effective and the child s pain is controlled. To provide optimum pain relief prior to a painful procedure. 17 The child will be observed hourly for signs of nausea & vomiting. Prophylactic antiemetics should be used 18 The child will be observed for signs of itching, urine retention or hallucinations 19 The total number of demands the child has made and the number of demands the child has received will be recorded hourly. The total volume of morphine infused and volume left in the syringe will be recorded hourly In order to take prompt action to reduce the discomfort of nausea and vomiting by use of anti-emetics. To detect early sings of adverse effects of morphine and take appropriate action by administering anti-histamines, performing urinary catheterisation or instigating another form of analgesia. To ensure accurate recording of amount child has received. (Use in conjunction with child s IV fluid chart) To detect early errors with pump failure. To establish the effectiveness of pain relief and ascertain if the child is using PCA appropriately. D. Jonas/ Sept 2009 Page 7 of 10

8 20 There should be adequate supervision of the child with the PCA especially when they move out of bed or to other ward areas. 21 Check IV cannula site, PCA pump, syringe position and volume infused after moving a child 22 Ensure that the handset is always available to the child. 23 Ensure that only the child presses the button 24 Replacement syringes of morphine will be made up by pharmacy or by IV competent members of staff according to hospital policy. Infusion lines will be changed according to IV policy using the dedicated PCA infusion line. All PCA syringes will be changed every 24 hours. 25 When changing or discontinuing syringes of morphine two IV competent staff will witness and document on the blue PCA observation form the discarding of any surplus morphine into a sharps bin (not the sink). 26 Nursing staff should actively encourage the use of other regular analgesia such as Paracetamol whilst the child is receiving the morphine infusion. NSAIDs such as Ibuprofen or Diclofenac may also be given, however other opiates such as Codeine or oral morphine should not be used. 27 The PCA will be discontinued when the child s pain is controlled with other analgesia and demands have reduced. 28 The pump must be cleaned and returned to theatre recovery Change of position promotes healing but the safety of the child must be always considered. Any child attached to a PCA must be accompanied by an IV competent nurse when transferring from the ward area to another ward or using toilet/bathroom facilities. To ensure that the IV cannula or syringe has not been dislodged and the pump is working. To prevent undue distress to the child if the handset is mislaid in the bed. Prevent additional and unnecessary doses being given and increasing the risk of respiratory depression. If parents are seen to press the button then full explanation must be given as to why only the child must press the button. If the parent subsequently continues to press the button then the PCA must be removed. To prevent infection and preserve line integrity. To prevent misuse of discarded morphine and to ensure correct disposal of unused morphine. Paracetamol used in addition to morphine provides an enhanced effect thus enabling a reduction in the overall amount of morphine. By ensuring optimum plasma levels of other analgesia reduction in demands without breakthrough pain is more successful. Additional opiates will not improve pain relief but will increase the incidence of adverse effects. To ensure that the PCA is not discontinued inappropriately and the child pain is continued to be managed effectively. To reduce the incidence of cross infection and ensure that the pump is available should it be required by another patient. D. Jonas/ Sept 2009 Page 8 of 10

9 References Dawson, Taylor, Reide (2002) Pharmacology (2 nd Edition) Elsevier Science Ltd. Omoigui (1995) The Pain Drugs Handbook. Mosby Year Book, Missouri USA Yaster &Maxwell (1993) Opioid agonist and antagonist in Schechter, Berde & Yaster. Pain in Infants, Children and Adolescents. Williams & Wilkins, USA. Royal College of Paediatrics and Child Health (1997) Prevention and Control of Pain in children. A manual for all health care professionals.bmj Publishing, London. McKenzie, Gaukroger, Ragg, Brown (1997) Manual of Acute Pain Management in Children. Churchill Livingstone, New York. Alder Hey Royal Liverpool Children s NHS Trust (1998) Guidelines on the Management of Pain in Children. 1 st Edition. Arroweline Print & Design, Wirral. D. Jonas/ Sept 2009 Page 9 of 10

10 APPENDIX 1 Royal Manchester Childrens Hospital Children s Pain Team PATIENT CONTROLLED ANALGESIA PROTOCOL (PCA) (All drug doses to be prescribed on patient s medication prescription sheet.) PATIENT SELECTION; Used in children over the age of 8 years who have the ability to understand the concept of PCA. Some children may have difficulty pressing the demand button so the technique may not be appropriate. DRUG DILUTION: DOSE: MORPHINE ONLY 1 milligram per kilogram mixed to make a total of 50ml with Normal Saline. Maximum Dose in any syringe = 50 milligrams Bolus Dose = 1ml (20 micrograms per kilogram) Lockout Interval = 5 minutes Background Infusion = 4 to 8 micrograms/kg/hr. Changes to the above protocol can only be made at the discretion of a Consultant Anaesthetist. If the pain relief is insufficient then on-call anaesthetist or consultant on call must be informed to instigate changes EQUIPMENT IVAC PCAM Infusion pump An anti-syphon valve must be used to prevent uncontrolled emptying of the syringe the PCA set also incorporates an anti-reflux valve, this must be used to prevent back flow of morphine. PCA key kept on ward controlled drugs keys MONITORING All children must in addition to the normal ward observations be managed with the PCA OBSERVATION CHART and continuous PULSE OXIMETRY. ACTIONS Inform the on-call anaesthetist if: PAIN SCORE more than 6 on a scale of 0-10 SEDATION SCORE = 4, RESPIRATORY RATE below the level for the child s age (see observation form) OXYGEN SATURATION below level set by anaesthetist Ensure regular anti-emetic for prevention of NAUSEA & VOMITTING Whilst PCA is infusing regular administration of Paracetamol should be encouraged. D. Jonas/ Sept 2009 Page 10 of 10