O05 Patient controlled analgesia - opiate infusions for children and young people s pain management

Transcription

1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Directorate & Speciality Patient controlled analgesia - opiate infusions for children and young people s pain management Michelle Bennett Clinical Nurse Specialist in Children s Pain Management Nottingham Children s Hospital Family Health Directorate Date of submission 24/10/12 Amended August 2015 Date on which guideline must be reviewed (this should be one to five years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Key Words Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) October 2017 Children/young people requiring continuous opiate infusions and who are able to fulfil the selection criteria, will be offered Patient Controlled Analgesia infusion (P.C.A.) to enable them to control their own pain management. This is an amendment to a current guideline in use within the Children s Hospital in response to a change in practice regarding Codeine and as noted one paragraph needed adding to be consistent with b guideline. Continuous patient controlled opiate infusion Pain management Peer reviewed by another Nurse Specialist, Consultant Paediatric Anaesthetist, Senior Paediatric Pharmacist, PDM and clinical educators group 1,2 1 NICE Guidance, Royal College Guideline, SIGN (please state whic source). 2a 2b 3a 3b meta analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasi-experimental study 4 well designed non-experimental descriptive studies (ie comparativ / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences o respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Target audience Paediatric anaesthetists Registered nurses and medical staff in the Children s Hospital This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. 1

2 NOTTINGHAM CHILDREN S HOSPITAL Nursing guideline Patient controlled analgesia - opiate infusions for children and young people s pain management Standard Statement Children/young people requiring continuous opiate infusions and who are able to fulfil the selection criteria, will be offered Patient Controlled Analgesia infusion (P.C.A.) to enable them to control their own pain management. Pre-requisites 1. All children will fulfil the selection criteria; a) Child/young person identified and assessed as competent by the anaesthetist, clinical nurse specialist, medical practitioner or child s nurse. b) Child/young person needs to be over six years of age. c) Child/young person needs the cognitive ability to understand the relationship between pushing the button and medication being delivered. d) Child/young person needs to be aware that the expected outcome is pain relief and not necessarily the complete absence of pain. e) Child/young person should have the manual dexterity to push the button of the device. f) Equipment should be available and demonstrated on the ward and parents advised not to press the button for the child. Give parents information leaflet on P.C.A. g) Staff will be knowledgeable and able to care for the child safely. h) Naloxone will be available on the wards to facilitate the reversal of the opiate should adverse effects occur. i) Non-return valves (e.g. Graseby PCA giving sets) to be used if a dedicated cannula is not available to prevent the back flow of the opiate into the maintenance infusion. j) The child/young person should be nursed in an open bay close to the nurse s station where they can be observed closely. k) Intermittent hourly spot checks of oxygen saturation level can be taken unless the anaesthetist specifies continuous monitoring due to an underlying condition or if their clinical condition requires that they need to be isolated see below 2

3 l) If the child s clinical condition requires that they be isolated then they must have continuous oxygen saturation monitoring for the duration of the infusion. As soon as isolation is no longer required, they should be moved out to an open bay if the opiate PCA infusion is still in progress. There may be other reasons for caring for child in a side room such as privacy or palliative care and in these circumstances the risks of the opiate infusion should be carefully considered against the need for nursing in a side room. m) The nursing staff involved in the care of the child with P.C.A. should be an RN who has been assessed competent to use the Alaris PCAM pump. Some staff may develop their skills further to include programming the PCA and this requires additional training and assessment of competence. Training is provided by the Children s Pain Nurse Specialists. An education pack is also available to support staff further staff should to be encouraged to complete this but it is not essential unless planning to go on to be trained to program the Alaris PCAM pump. Contraindications Previous reactions to opiates, recorded upper airway problems, or children admitted with head injuries and requiring surgery for traumatic injuries, should not be offered P.C.A.s. Equipment Alaris PCAM pump Graseby PCA non-return valve/anti siphon valve tubing Infusion stand PCA prescription, protocol and observation chart Oxygen saturation monitor Opiate Prescription sticker and opiate giving set sticker Procedure Action 1 Pumps should be sent to theatre with the child or be available on the ward. The Anaesthetist, Clinical Nurse Specialist, Medical Practitioner or nurses with signed level 2 competencies are responsible for programming the pumps. 2 The cannula should be sited in the non-dominant hand wherever possible. Rationale To ensure a pump is available prior to operation. To ensure the child receives the appropriate amount of analgesia. To preserve manual dexterity. 3 On collecting the child from theatre recovery and/or at the start of each shift change on the ward, check that : a) The PCAM pump is working To ensure continuity of the analgesia. b) i. The programme complies with the opiate prescription ii. The syringe label complies with the opiate To ensure the programme and the prescription are the same to prevent errors. 3

4 prescription. iii The opiate is also prescribed on the main prescription chart. c) Naloxone, anti-emetics and concurrent regular analgesia is prescribed on the main prescription chart d) The readings are recorded and checked. (Dawson et al 2012) 4 The key to the P.C.A. pump must be attached to the ward/department drug keys and carried by a registered nurse or Medical Practitioner. 5 Respiratory rate, oxygen saturation level, pulse, pain and sedation scores must be recorded hourly on the PEWS or PICU observation chart throughout the infusion and for at least four hours after the infusion is stopped. 6 Syringes, solutions and intravenous lines must be changed every 24 hours and the giving set labelled with the date it needs changing. 7 Replacement infusions must be made up by two RN s according to the Medicines Code of Practice NUH 2011 To ensure Naloxone and anti-emetics are available immediately it is required. Use of concurrent analgesia has an opiate sparing effect which can reduce potential unwanted effects such as pruritis, nausea and vomiting. To ensure all the recordings are correct. To prevent accidental alteration of the programme. To ensure the child is receiving effective analgesia. To monitor side effects of the opiate. (Dawson et al 2012, Twycross et al 2009) To prevent infection. To preserve line integrity. To ensure efficacy and stability of drug To ensure that syringes, solutions and intravenous lines are changed on time. To ensure the correct solution is given to the child. 8 Side effects of the infusion should be noted in the child s records and the Children s Pain Team/ward doctor informed. Contact the Children s Pain Team or 3 rd on call anaesthetist out of hours if : To ensure that staff are aware of adverse reactions to the drug for future reference. a) The analgesia appears inadequate To ensure the child receives appropriate analgesia and to counteract any adverse effects promptly (Dawson et al 2012, Twycross et al 2009). b) The child is unable to use the technique successfully. c) They are experiencing unmanageable side effects 4

5 such as nausea and vomiting or pruritis. d) If the child s respiratory rate falls below the prescribed rate on the prescription chart, place the infusion on hold until respiratory rate is above the prescribed rate. 9 If nausea and vomiting occurs ensure anti-emetics are prescribed regularly and given promptly. 10 Read and record the patient history of PCA hourly on the PEWS or PICU observation chart Read and record amount infused hourly. 11 The handset should always be kept within the child s reach and the child should be encouraged to give a bolus of analgesia when they begin to feel uncomfortable, and not when they are actually in pain. 12 The child should be encouraged to give a bolus dose of analgesia before a potentially painful procedure or activity. Anaesthetic assistance is required if respiratory depression occurs. To counteract any adverse effects of the opiate. To facilitate an accurate record of the analgesia given to the child. To facilitate intervention should the child receive opiates in excess of the four hour limit. To provide effective analgesia and to prevent undue distress to the child. To reinforce the efficacy of the PCA. technique. 13 Only the child should press the PCA. The child knows the extent of the pain they are experiencing and, therefore, are the best judge of the amount of analgesia required. 14 Discontinuation of the infusion pump: -This should be a planned procedure, preferably in the morning after discussion with the Children s Pain Team (or the child s medical team out of hours). -Explain to the child and family that you are about to stop the infusion and why. -Ensure that the child has Paracetamol prescribed regularly (and regular Ibuprofen or Diclofenac if not contra-indicated). -Ensure that additional opiate analgesia is prescribed as a step down from the intravenous opiate infusion (e.g. oral Morphine or Codeine*). This can be either prescribed regularly or PRN and depends on the surgery the child has undergone and their opiate To ensure the child receives analgesia appropriate to their needs (Buvanedran and Kroin 2009, APAGBI 2008). 5

6 requirements. *N.B. Codeine should not be used in children under 12 years of age or in anyone under the age of 18 with a history of sleep apnoea or having adenotonsillectomy - Stop the pump, leave infusion connected and ensure Paracetamol and Ibuprofen or Diclofenac has been administered as prescribed if due at that time. - If the child does not have intravenous fluids infusing through the cannula, flush and then clamp the cannula. - Continue hourly observations for four hours after the infusion is discontinued. If after four hours the child appears comfortable, dispose of the infusion and record the volume wasted on the PEWS chart. 15 If the child is assessed as having a score of moderate to severe pain using the Nottingham Pain Assessment Tools after the PCA infusion is stopped: - Check the source of pain (e.g. operation site, blocked urinary catheter, bladder spasms, blocked cannula, colicky pain, muscle spasms, muscle stiffness, referred shoulder tip pain) and take appropriate actions. * Medicines and Healthcare Products Regulatory Agency (2013) Association of Paediatric Anaesthetists of Great Britain and Ireland (2013) To ensure that an unwanted bolus of Morphine or Fentanyl is not administered accidentally at a later time. Opiate half life is between 2-4 hours so the child needs to be monitored during this time and assessed to ensure that they do not experience increasing pain (Twycross et al 2009). The source of pain will indicate what actions to take. - Administer the first prescribed dose of oral Morphine or Codeine if it has not already been given. - Re-assess minutes after the oral Morphine or Codeine has been administered and if the child s pain score continues to be moderate to severe restart the PCA infusion and contact Troubleshooting Personnel as detailed on the opiate prescription. Peak effect of oral Morphine and Codeine is minutes (Twycross et al 2009). Outcomes 1. The child s pain will be effectively managed or steps taken to achieve this goal. 2. The child will be assessed regularly (as per protocol) for pain, sedation and adverse effects. 3. Any adverse effects from the technique will be identified promptly and appropriate action taken to remedy this. 6

7 References and Further Reading Association of Paediatric Anaesthetists of Great Britain and Ireland (2008) Good Practice on postoperative and procedural pain Association of Paediatric Anaesthetists of Great Britain and Ireland (2009) Guidelines on the prevention of post-operative vomiting in children Association of Paediatric Anaesthetists of Great Britain and Ireland (2013); Codeine and Paracetamol in Paediatric Use: etamol%20final%20v2.pdf. Buvanedran. A. Kroin. J. (2009) Multimodal analgesia for managing acute postoperative pain. Current Opinion in Anaesthesiology, 22: Dawson. P. Cook. L. Holliday. L. Reddy. H. (Editors) (2012) Oxford Handbook of Clinical Skills for Children s and Young People s Nursing. Oxford University Press, Oxford. Medicines and Healthcare Products Regulatory Agency (2013); Codeine for analgesia: restricted use in children because of reports of morphine toxicity: Morton. N. (2010) Association of Paediatric Anaesthetists national audit of pediatric opioid infusions. Pediatric Anaesthesia, 20(2): Nelson, K.L., Yaster, M., Kost-Byerly, S., Monitto, C.L. (2010) A national survey of American Pediatric Anaesthesiologists: Pain Controlled Analgesia and other intravenous opioid therapies in Pediatric Acute Pain Management. Anaesthesia and Analgesia, 110(3): NUH (2011) Medicines Code of Practice Nottingham University Hospitals Trust. Twycross. A. Dowden. S. Bruce. E. (2009) Managing Pain in Children. Wiley Blackwell, Oxford. Authors: Michelle Bennett and Sharon Douglass Date: October 2012 Review date: October 2017 Consultation: Dr Hannah King, Sharon Douglass Updated by: Michelle Bennett July 2015 to include change in practice regarding the use of Codeine Phosphate Ratified by: Clinical Educator s Group, Nottingham Children s Hospital Signed off by: Dorothy Bean 08/09/2015 7