CLINICAL GUIDELINE FOR USE OF A PATIENT CONTROLLED ANALGESIA OR INTRAVENOUS OPIATE INFUSION IN CHILD HEALTH. 1. Aim/Purpose of this Guideline Guideline for children with a Patient Controlled Analgesia (PCA) or intravenous opioid infusion. 2. The Guidance 2.1 Patient controlled analgesia (PCA) uses a programmable infusion pump to allow patients to self administer their own analgesia. PCA has become gold standard for acute pain management and is suitable for use in children over five years of age (some children as young as four years can manage a PCA but this needs careful assessment). Continuous Morphine infusions are used for the management of pain in children where a PCA is not appropriate due to their age, medical condition, cognitive function or physical limitations. Infusion rates should be titrated against the individual child s response. Please refer to Paediatric Analgesia Guidelines for further information on prescribing and pump settings. 2.2 Any patient requiring a morphine infusion with complex medical or surgical needs requires paediatric HDU. A Registered Sick Children Nurse or RN (child) must always be available or allocated to a child receiving a PCA or intravenous infusion. They must have undergone suitable training in the management of PCA and maintained competence by regular use of skill and attending 3 yearly medical device training and clinical updates. Pre-operative explanation should be given to children/parents by anaesthetist and/or nursing staff. It should be made clear to the parents and child that the button should only be pressed by the child to prevent accidental overdose. PCA or intravenous infusion must be prescribed on the electronic prescribing and medicines administration (EPMA) chart with full instructions of lockout time and mg per bolus. Check current pump protocol matches the patient prescription. Naloxone MUST be prescribed in case of respiratory distress. Syringes must be changed by two registered nurses, one of whom must be Registered Sick Children Nurse, RN (child) or a doctor. The nurse must be competent in the administration of intravenous drugs and also undergone relevant training in the management of PCA and intravenous opioid infusions. An aseptic Page 1 of 9
non-touch technique must be used. The syringe must be labelled identifying the contents, when it was made up and by whom. Delays in renewing syringes should be avoided to achieve constant analgesia. Keys for PCA machines should be kept together with the controlled drug keys by the nurse in charge. Before attaching the infusion to the patient, the syringe must be purged by the pump to ensure that the line is fully primed and the mechanical slack has been has been removed. This should also be carried out at syringe changes. Ensure only designated syringes and lines are used i.e. BD Plastipak 50 ml luerlock and a giving set with an antisyphon valve and a non-return valve to prevent the backflow of opiate and accidental overdose. A Y connector must not be used. The child should have a pain score of five or less (mild pain) before leaving recovery. Prior to the patient leaving recovery the asset number of PCA should be recorded on the recovery sheet and paediatric pain service yellow database form. PCA giving sets should be changed every 48-72 hours or according to hospital policy. Heparin and insulin should not be infused via the PCA giving set. PCA can be infused via a central line. PCA infusion pumps should be placed at trunk height to prevent siphoning of contents due to effect of gravity. No other Opioids should be given whilst PCA or opiate infusion are running. However, Supplementary analgesia, e.g. Paracetamol and an NSAID where appropriate, should be given regularly. When alternative oral analgesia is prescribed and proven to be effective the PCA or infusion may be discontinued. Most patients self-wean off PCA analgesia, using it less as their pain decreases. Any opiate left in one syringe must be discarded into a denaturing kit. This should be witnessed by two nurses and documented in the ward's wastage book. On discontinuation, the pump should be cleaned according to decontamination policy and returned to theatres for storage. If the equipment is faulty it must be returned to Medical Physics after being cleaned according to decontamination policy. Page 2 of 9
2.3 Clinical Observations The frequency of observations is a guideline, if the child s PEWS score indicates the need for closer observation then the actions section on the PEWS chart must be followed. Observations should be recorded every 15 minutes in the recovery ward and then every 30 minutes until 2 hours post-op in the surgical ward. Close observation is required to observe for adverse reaction to the opioid. Then; Parameter Frequency Comments Sedation score Respiratory rate, heart rate and oxygen saturation Hourly until infusion/pca is discontinued Hourly until infusion/pca is discontinued See paediatric pain assessment chart Continuous pulse oximetry in children under 6 months of age Blood pressure Hourly for the first 12 hours, then this maybe reduced to four hourly Pain score Hourly See paediatric pain assessment chart Nausea/vomiting/Pruritis assessment See paediatric pain assessment Hourly for the first 12 hours then 4 hourly until the infusion/pca is discontinued If the opioid infusion rate is increased then observations should be recorded every 30 minutes for a further hour to ensure the patient is in a stable condition. If a bolus dose has been given the administrator should not leave the ward for 20 minutes so that they may respond promptly to respiratory depression or hypotension. Record infusion total and demands/good (as recorded on the pump) every hour. Assess intravenous cannula site as per policy and record on care plan. 2.4 Problems Sedation/Respiratory Depression Morphine can cause sedation and respiratory depression. Assessing level of sedation is the key to early identification and treatment of opioid-induced respiratory depression. If opioid induced respiratory depression is suspected: Stop the infusion or switch the PCA off Stimulate the patient (shake gently, call by name, ask to breathe) Administer facial oxygen Contact Paediatric Registrar to review the child Administer naloxone as prescribed, if indicated Page 3 of 9
Hypotension If systolic pressure is more than 20% below pre-op reading then give oxygen, call Paediatric Registrar to diagnose cause of hypotension. Nausea and Vomiting Morphine can sometimes cause this, if so anti-emetics should be given as prescribed. A combination of anti emetics maybe required to treat effectively or consider very low dose naloxone. Pruritus This is occasionally a side effect of morphine and usually settles within 2-3 days of commencing Opioids. Can be treated with an antihistamine, e.g. piriton, but may cause sedation. Or consider a low dose of naloxone. Inadequate Analgesia Ensure the equipment is functioning correctly and that the line is not occluded. Check that the child understands how to use the PCA. If applicable, call Paediatric Pain Team, Paediatric Registrar or on-call anaesthetist to assess analgesia. A bolus dose of opioid may be required or other non-opioid analgesics. Urinary retention Urinary retention following surgery may be due to a variety of causes and needs to be investigated fully. Consider: Increasing fluid intake Conservative management (e.g. close monitoring, reassurance and manual expression of the bladder) Encouragement strategies (e.g. increase privacy, commode by the bed, encourage male children to stand up, or running water) If the retention is likely to be opioid-induced, consider: Reducing the rate/bolus Administering very low dose of naloxone Intermittent catheterisation or indwelling catheter if all the above measures fail Any problems should be recorded in the appropriate patient records. Page 4 of 9
3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Adherence to the guideline Acute Paediatric Pain Service The child will be reviewed daily (Monday-Friday) and adherence to the guideline will be recorded on the Paediatric Acute Pain form (CHA1850) and in the medical notes. Datix reports will be investigated. The pain forms will be audited on a yearly basis in combination with the Paediatric Pain audit The audit is reported back to the Matron for Child Health and to the Children s Audit and Guidelines Group Acute Paediatric Pain Service Required changes to practice will be identified and actioned within 1 month. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 5 of 9
Appendix 1. Governance Information Document Title Date Issued/Approved: May 2015 Clinical Guideline for the use of Patient Controlled Analgesia or Morphine infusion in Child Health. Date Valid From: May 2015 Date Valid To: May 2018 Directorate / Department responsible (author/owner): Acute Paediatric Pain Service Contact details: Bleep 2283 Brief summary of contents Guidance for staff caring for a child receiving either Patient Controlled Analgesia or Morphine infusion Suggested Keywords: Target Audience Executive Director responsible for Policy: Patient Controlled Analgesia Morphine infusion Children RCHT PCT CFT Medical Director Date revised: May 2015 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Clinical Guideline for the use of Patient Controlled Analgesia or Morphine infusion in Child Health. Paediatric Practice Development Forum Paediatric Audit and Guidelines Group Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Sheena Wallace N/A {Original Copy Signed} Internet & Intranet Intranet Only Paediatrics Page 6 of 9
Related Documents: Training Need Identified? Association of Paediatric Anaesthetists of Great Britain and Ireland (2012) Good Practice in Postoperative and Procedural Pain Management, 2nd edition. Blackwell Publishing Ltd Royal Marsden Hospital. (2015) Manual of Clinical Nursing Procedures, ninth edition. On line at http://www.rmmonline.co.uk/ Twycross, A., Dowden, S.J. and Stinson, J. (2014) Managing Pain in Children: a clinical guide. West Sussex: Whiley- Blackwell. Paediatric Analgesia Guidelines Yes Registered nurse competent in administering intravenous medications. Staff Need to complete competency pack for PCA/Morphine infusions. Attendance to Child Health Pain Management study morning. 3 yearly update for medical devices. Version Control Table Date Versio n No Nov 2010 V1.0 Initial Issue Sept 2012 V2.0 May 2015 V3.0 Summary of Changes Updated and transferred to new format Updated Changes Made by (Name and Job Title) Sarah Fox Paediatric Pain Specialist Nurse Sarah Fox Paediatric Pain Specialist Nurse Sarah Fox Paediatric Pain Specialist Nurse All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 7 of 9
Appendix 2.Initial Equality Impact Assessment Screening Form Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: Clinical Guideline for the use of a Patient Controlled Analgesia or Morphine Infusion in Child Health Directorate and service area: Child Is this a new or existing Procedure? Health/ Acute Paediatric Pain Service Existing Name of individual completing Telephone: assessment: Sarah Fox Bleep 2283 1. Policy Aim* Guidelines for use of patient controlled analgesia or continuous opioid infusion with children 2. Policy Objectives* Children who have a PCA or intravenous opioid infusion are cared for safely 3. Policy intended Outcomes* 5. How will you measure the outcome? 5. Who is intended to benefit from the Policy? 6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b. If yes, have these groups been consulted? c. Please list any groups who have been consulted about this procedure. No Children with an PCA or opioid infusion are cared for safely Side effects are identified and dealt with safely Requirements for training are identified Regular review of children by pain team Monitor datix/medication errors Practitioners Paediatric patients 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age This document will have a positive impact on children by ensuring standardised care. Sex (male, female, transgender / gender reassignment) Page 8 of 9
Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment 1. 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Sarah Fox Date May 2015 Page 9 of 9