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Patient controlled and nurse controlled analgesia

The purpose of this guideline is to provide guidance about patient controlled and nurse controlled analgesia at Great Ormond Street Hospital.

Background

The use of patient controlled analgesia (PCA) and nurse controlled analgesia (NCA) has been shown to provide a safe and effective technique for the administration of intravenous or subcutaneous opioids for the relief of pain (Anderson et al 1998; Bray 1983; Doyle et al 1993; Llewellyn 1993; Howard et al 2008; Lloyd-Thomas and Howard 1994). 

These techniques are most commonly used following surgery, but can also be effective for the management of non-surgical pain such as sickle crisis, pancreatitis and cancer related pain. With caution, PCA or NCA can also be used to manage pain prior to surgery, eg fractures and abdominal pain. 

Morphine is considered to be the gold standard for intravenous analgesia and is therefore usually the opioid of choice (Lloyd-Thomas 1994). The use of other opioids, eg fentanyl or oxycodone, may be considered when morphine is contraindicated, or as a preferred alternative. Other drugs with analgesic properties, such as ketamine, may be administered (as an adjunct) in combination with an opioid in some circumstances (Schmid 1999). In restricted circumstances, where opioids are contraindicated, ketamine alone may be used (White et al 2006). 

Throughout this document the term 'analgesic solution' will be used to refer to the specific drug or drugs prescribed in solution. 

Throughout this document the term 'patient controlled analgesia' (PCA) refers to a method of pain control that allows the patient to press a button to self-administer a pre-programmed amount of an intravenous or subcutaneous analgesic solution (the bolus dose). The pump programming will determine the time before another bolus dose can be administered, known as the 'lockout' time. The patient may also receive a small background infusion of the analgesic solution.   

The term 'nurse controlled analgesia' (NCA) refers to a technique by which the nurse (or other health professional licensed to administer medications) may press a button to give the patient a pre-programmed amount of an intravenous or subcutaneous analgesic solution (the bolus dose). The bolus dose can only be repeated after a set period of time (the lockout period). The patient may be given a larger continuous infusion of the analgesic solution. However, with the exception of intensive care areas, the pump is programmed with a longer lockout interval (20-30 minutes).   

Some patients may benefit from using a dual technique, whereby either the patient or the nurse is able to press the button on a pump with NCA settings. This must be approved by the Pain Control service and documented clearly on the Pain Management chart. For some patients, daytime PCA and night-time NCA settings may be appropriate. This can promote a restful night, while allowing the patient to maintain control throughout the day. Both these techniques are used at the discretion of the Pain Control service.

Some patients should not receive a background infusion, eg neonates or patients with renal impairment. These groups and patients with an altered level of consciousness will require particularly close monitoring for potential complications. 

The use of PCA and NCA requires a specially designed, locked pump which allows for programming of a continuous infusion rate (if required), a bolus dose and lockout interval. The pump used in the Trust (IVAC® PCAM) also requires the programming of a drug concentration and a four hourly maximum dose limit (400mcg/kg (maximum 20mg) in any four-hour period).

PCA/NCA pumps must only be initially programmed by an anaesthetist or member of the Pain Control service. Adjustments can then be made within protocol by competent nurses as defined below.

All personnel who care for patients receiving PCA or NCA must be trained and able to do so safely.

The Pain Control service can be contacted on bleep 0577, 24 hours a day. The Pain Control service nurses are available to deal with any pain-related problems from 8am to 8pm Monday to Friday and 9am to 3.30pm on Saturday. The service is provided by the duty anaesthetist and the clinical site practitioners outside of these hours. 

Abbreviations and definitions used throughout this document 

mcg = micrograms, mg = milligrams, ml = millilitres, kg = kilograms

Competent nurse - a nurse who has attended the GOSH advanced practice day and been assessed as competent in adjusting PCA/NCA programming. Some nursing staff, such as clinical site practitioners, or those practising in particular areas (recovery etc) will be authorised to undertake a wider variety of roles than others, such as clinician override bolus administration.

Pain Control service - encompasses the healthcare professionals within the Pain team, those who deputise for them and duty anaesthetists.

PCA - patient controlled analgesia, NCA - nurse controlled analgesia.

Within this document, the term child will be used to signify infants, children and young people.

Further recommendations for optimising pain control in children are included in the References section of this guideline.

Preparation: assessment

Prior to surgery/setting up the infusion the anaesthetist or Pain Control service staff will consider:

  • the suitability of PCA/NCA for each individual patient

  • the anticipated effectiveness of PCA/NCA for the type of surgery/pain (Rationale 1)

If the patient is to use PCA they must: 

  • be able to understand the technique

  • be willing to use it

  • be physically able to press the button on the handset (Rationale 2)
  • if the patient has the cognitive ability but not the physical strength to push the button on the standard handset, the Pain Control service should be contacted as an alternative handset may be available

Preparation: general

All parents should be given a copy of the leaflet entitled Pain relief for your child after surgery PCA and NCA (PDF, 91KB) (Rationale 3).   

This is also available on the wards and can be obtained from the Family Resource Centre (Rationale 3). 

An anaesthetist or competent nurse will discuss the use of PCA/NCA with the child and family prior to surgery/setting up the infusion (Rationale 4).  

The child and family should be prepared for the PCA/NCA: 

  • The nursing staff and/or play specialist should explain the technique to the child and family (Rationale 5, 6).

  • Parents should be advised in a sensitive manner that they are not permitted to administer a bolus by pressing the button in either technique and that this is a safety feature of the technique (Rationale 7).

  • The family should be made aware that if the child is unable to use PCA the programming can be changed to NCA, but that this requires adjustment of the pump programming (Rationale 8).

  • NCA may be changed to PCA if the child is able and willing to press the button and understands the concept (Rationale 9).

  • If the family have any questions that ward staff are unable to answer, they should contact the Pain Control service on bleep 0577.

Nursing staff should also ensure that an age appropriate pain assessment tool and documentation is available (Rationale 10).  

Nurses should ascertain which tool is best suited to the child bearing in mind the following principles:

  • Self-report is the gold standard and should be used whenever possible (eg Wong-Baker FACES™, numerical rating scale).
  •  The tool proposed should be discussed with the child and family.
  • The child may be asked to score a previous painful experience to determine whether they are able to use the tool.

  • Words the child uses for pain and the child’s usual pain related behaviour should be recorded.

  • For infants, patients who are cognitively impaired and those unable to communicate, use an appropriate observational tool and involve carers as much as possible. 

The following baseline observations should be recorded before the child goes to theatre or uses the PCA/NCA (Rationale 11):  

  • pain assessment using a validated tool
  • heart rate
  • respiratory rate
  • blood pressure
  • oxygen saturation
  • baseline sedation score

Preparation of equipment: drugs used 

Drug: morphine sulphate

Mechanism of action: binds with opioid receptors in the brain and spinal cord to alter the transmission of impulses along the pain pathway.

Available in ampoules of: 5mg/ml, 10mg/ml, 30mg/ml (hence the need for caution that correct ampoules selected). NPSA alert restricts the use of 30mg/ml ampoules to certain clinical areas only.

Standard concentrations are:

  • Intravenous: refer to protocol on pain management chart. 

    • Patient weighs less than 50kg: 1mg/kg in 50ml of 0.9% sodium chloride or glucose 5% (1ml = 20mcg/kg).

    • Patient weighs more than 50kg: 50mg in 50ml of 0.9% sodium chloride or glucose 5% (1ml = 1mg).

  • Subcutaneous: ensure subcutaneous morphine protocol is in patient’s file. 

    • Patient weighs less than 50kg: 1mg/kg in 20ml of 0.9% sodium chloride (1ml = 50mcg/kg).

    • Patient weighs more than 50kg: 50mg in 20ml of 0.9% sodium chloride (1ml = 2.5mg).

Drug: oxycodone

Mechanism of action: binds with opioid receptors in the brain and spinal cord to alter the transmission of impulses along the pain pathway.

Available in ampoules of: 10mg/1ml in 1ml or 2ml ampoules.

Standard concentrations are:

  • Intravenous: refer to protocol on prescription.
    • Patient weighs less than 50kg: 1mg/kg in 50ml of 0.9% sodium chloride or glucose 5% (1ml = 20mcg/kg).
    • Patient weighs more than 50kg: 50mg in 50ml of 0.9% sodium chloride or glucose 5% (1ml = 1mg).

Drug: fentanyl

Mechanism of action: binds with opioid receptors in the brain and spinal cord to alter the transmission of impulses along the nerve axon.

Available in ampoules of: 50mcg/ml in 2ml or 10ml ampoules. 

Standard concentrations are:

  • Intravenous: refer to protocol on prescription. 

    • Patient weighs less than 50kg: 25mcg/kg in 50ml of 0.9% sodium chloride or glucose 5% (1ml = 0.5 mcg/kg).

    • Patient weighs more than 50kg: 1250mcg in 50ml of 0.9% sodium chloride or glucose 5% (1ml = 25mcg). 

  • Subcutaneous: ensure fentanyl subcutaneous protocol is in patient’s file. 

    • Patient weighs less than 25kg: 25mcg/kg in 20ml 0.9% sodium chloride (1ml = 1.25mcg /kg).

    • Patient weighs more than 25kg: please consult pain control service to discuss appropriate dilution and dosage.

Drug: ketamine

Action: ketamine is an NMDA receptor antagonist (not an opioid), which is thought to act within the brain and spinal cord to modify the transmission of painful messages (Schmid 1999).

Available in ampoules of: 10mg/ml (20ml ampoule), 50mcg/ml (10ml ampoule).

Intravenous or subcutaneous: refer to protocol on prescription.

    • Patient weighs less than 50kg: 1 or 2mg/kg added to an opioid PCA/NCA solution.

    • Patient weighs more than 50kg: 50mg or 100mg is added to to the opioid solution.  

It should only be prescribed after discussing the patient with a consultant anaesthetist.

Drug: naloxone

Action: a mu receptor antagonist.

  • reverses the effects of morphine or other opioid (desirable and undesirable)

  • instant reversal of opioid-induced respiratory slowing or respiratory arrest

  • has a short half-life of 30 minutes. Dose may need to be repeated.

Available in ampoules of: 20mcg/ml and 400mcg/ml.

Can also be given intra-muscularly or subcutaneously if the intravenous route is not available.

Preparation: disposables ordering

Clinical areas are expected to stock appropriate disposables for their patients (Rationale 12).

Administration sets can be ordered on a top up system through the Procurement department. For reasons of patient safety, all administrations sets used for PCA/NCA should contain an anti-siphon valve (Southern and Read 1994). 

For example: anti-siphon intravenous administration set – ORDER REF: 30862.

For patient safety reasons, all administration sets used to piggyback a PCA/NCA infusion onto maintenance fluid should contain an anti-syphon valve and an anti-reflux valve.

For example: anti-siphon intravenous administration sets with Y connector - ORDER REF: 30852.

Products with other order codes may also be suitable.

Preparation: setting up infusions

The majority of PCA and NCA pumps will be prescribed and set up in theatres after surgery. However, contact the Pain Control service on bleep 0577 if a PCA/NCA is required for a patient on the ward (Rationale 13).

The Pain Control service will request the referring clinician to write a brief summary of the child’s condition and need for analgesia in the case notes (Rationale 14). A prescription will be generated by either an anaesthetist or Pain Control service nurse prescriber.

A pain management chart and drug prescription chart should be completed by the person prescribing the PCA/NCA (Rationale 15). The prescriber should check that the patient has no other current opioids prescribed to minimise risk of accidental administration and adverse side effects. The PCA/NCA must also be recorded on EP.

Prescriptions are available in main theatre reception files or on the Pain Control service website. These should be printed on yellow paper.

Out of hours, patients requiring PCA or NCA should be listed on the Pain Control service board in main theatres.

The pain management chart outlines standard protocols for intravenous morphine only. All other regimens will have the relevant protocol printed on the back of the yellow prescription chart, also available on the website or from main theatre reception in the Variety Club Building (VCB).

It is particularly important to ensure that naloxone has been prescribed correctly before the patient leaves theatre or the infusion is commenced (Rationale 16).

Equipment for commencing PCA/NCA includes:

  • An IVAC®PCAM® PCA/NCA pump (Rationale 17). These pumps are stored in designated areas in VCB and Octav Botnar Wing theatres and should be plugged in when not in use to recharge the battery. All users must check the pump maintenance date before use. Out of date pumps must be serviced before use (Rationale 18).
  • A 50ml luerlock syringe - use a 50ml syringe for subcutaneous protocol (Rationale 19).
  • Either an anti-siphon administration set (Southern and Read 1994) eg IVAC® (Rationale 20) or an anti-siphon administration set (Southern and Read 1994) with Y connector and anti-reflux valve (Rationale 21).

The PCA/NCA pump must only be initially programmed by an anaesthetist or member of the Pain Control service. The serial number of the pump, and all of the shaded patient detail sections, must be recorded on the pain management chart (Rationale 22).

All pumps should be kept locked while in use and a dedicated line should be used wherever possible for NCA or PCA (Rationale 23). The anti-siphon line should be connected directly to the patient's intravenous access (Rationale 21).

Standard pump programming and drug concentrations should be used at all times, unless approved by a member of the Pain Control service (Rationale 24). Refer to the front of the pain management chart or drug-specific protocol for standard settings by weight and age. All out-of-protocol settings should be clearly marked as such on the pain management chart.

Standard intravenous programming

For PCA:

For NCA:

  • background: 0, 0.2, 0.5 or 1ml/hr
  • bolus dose: 0.5ml or 1ml
  • lockout: 20 or 30 minutes
  • ITU only: five minutes
Check front of pain management chart, or drug-specific protocol for further restrictions depending on age, weight and renal function.

In some circumstances, eg poor intravenous access, subcutaneous infusion may be preferred (Rationale 25). The infusion prescribed for subcutanous administration is more concentrated than the intravenous prescription (drug diluted to 20ml infusate rather than 50ml for IV), hence smaller background and bolus volumes are required to administer the same dose subcutaneously.

Standard subcutaneous programming is:

For PCA:

  • background: 0 or 0.1ml/hr
  • bolus dose: 0.2ml or 0.4ml
  • lockout: 5 or 10 minutes

For NCA:

  • background: 0, 0.2, or 0.4ml/hr
  • bolus dose: 0.2ml or 0.4ml
  • lockout: 20 or 30 minutes
  • ITU only: five minutes

The speed at which the bolus dose is delivered will be slowed for subcutaneous delivery to minimise discomfort. Specific subcutaneous protocol should be placed in patient folder. The use of an appropriate subcutaneous administration device (such as a Thalaset®) is strongly advocated. 

When the PCA/NCA is commenced, the Pain Control service may administer an initial loading dose of (Rationale 26): 

  • morphine sulphate: 50-100 micrograms/kg or
  • fentanyl 0.25-1 micrograms/kg
This is particularly important for patients in severe pain, eg patients with sickle cell crisis or severe mucositis.

Care of patient while receiving PCA/NCA analgesia

All children receiving intravenous opioids must be supervised by a registered nurse, doctor or appropriately trained ODP.

Any child leaving a clinical area while receiving PCA/NCA analgesia must be accompanied by a registered nurse, doctor or appropriately trained ODP.

If the PCA/NCA has been set up in theatre a verbal report should be made to the recovery nurse. This should include:

  • details of intra-operative analgesia, loading dose and other drugs given

  • details of drug concentration and pump programming

  • any pain related complications that have been experienced peri-operatively
  • the pain assessment scale being used by the patient and/or carer, if known, or some indication of the child's pre-operative competence to self report if known.

All these details should be documented clearly on the patient’s pain management chart (Rationale 27).

In addition to this and at any subsequent patient handover between staff, both staff concerned should check that:

  • The PCA/NCA prescription chart has been completed correctly (Rationale 28), the analgesic solution and drugs to prevent side effects are prescribed (Rationale 29).
  • PCA/NCA recorded on the Electronic Prescribing system (EP).
  • The drug and dose being administered corresponds with the prescription chart (Rationale 30).

  • The pump programming corresponds to the most recent entry in the pain management chart (Rationale 31).

  • Pump settings are within protocol for the age and weight of the child, unless clearly indicated as out of protocol with rationale for this. Check against the pain management chart for intravenous morphine or the drug specific protocol for other regimens.

  • The patient’s pain is being managed effectively.

  • The patient is not excessively sedated.

  • Ensure appropriate dose of naloxone is prescribed (Rationale 32).

  • Prescribed anti-emetics are not duplicated on EP or the standard ward drug chart.

  • Other analgesics (such as paracetamol and NSAIDS) are prescribed and administered where appropriate (Rationale 33).

These checks are also applicable if the PCA/NCA is set up on the ward before commencing an infusion.

Record pain scores hourly on the pain assessment chart (Rationale 34).

Self-reporting should be used whenever possible.

The type and location of pain should be identified whenever possible.

Hourly pump readings should be recorded on the PCA/NCA observation chart (Rationale 35). This should include:

  • number of demands (tries)
  • number of successful demands (good tries)
  • amount infused (hourly and running totals)
  • syringe reading at least four hourly (though hourly recording is recommended) (Rationale 36)
  • presence or absence of opioid associated side effects (see below)

Never re-zero the pump (Rationale 37).

Supplementary analgesia, eg paracetamol and an NSAID (either diclofenac or ibuprofen) where appropriate, should be given regularly if either the oral or rectal route is available. Intravenous administration of paracetamol should be considered for all patients where enteral administration is not possible (Rationale 38).

No supplementary opioids (such as codeine or tramadol) should be administered while the patient is receiving PCA/NCA, unless specifically ordered by an anaesthetist or the Pain Control service.

If patient is in pain explore the cause of the pain with the patient if possible:

  • Involve parents, play specialist and teacher (ie for distraction, reassurance, comfort measures etc) particularly if the pain is anxiety related (Rationale 39).

  • Administer prescribed simple analgesics, eg paracetamol and an NSAID (either diclofenac or ibuprofen) if appropriate (Rationale 40).

  • Administer prescribed adjuncts as appropriate, eg anti-spasmodic or anti-convulsant drugs (Rationale 41).

  • For PCA: encourage the patient to give a bolus and evaluate effectiveness after 10-15 minutes (Rationale 42).

  • For NCA: administer a bolus and evaluate effectiveness after 10-15 minutes.

  • If pain score is greater than four for more than an hour and boluses have been optimised, contact the Pain Control service on bleep 0577, or competent nurse to discuss making changes within protocol limits for the technique.

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 (Rationale 43).

All patients are reviewed at least once a day by a member of the Pain Control service (Rationale 44).

Pump programming must only be changed by a member of the Pain Control service or competent nurse (Rationale 45).

Increase the background infusion, or consider increasing bolus size, within protocol if:

  • an accurate pain assessment is been undertaken and             
  • the patient has pain which has not resolved after frequent boluses and
  • other interventions have been tried and have not been effective (regular simple analgesia, repositioning etc)

Decrease the background infusion if the patient is:

  • experiencing opioid induced side effects, is pain-free and/or is requiring minimal boluses (Rationale 46)

Competent nurses in certain specified areas may also administer additional boluses (using the clinician override function) if required (eg clinical site practitioners, recovery staff, cardiac unit prior to chest drain removal)(Rationale 47).

All changes to pump programming should be reported to the Pain Control service on bleep 0577, and charted and signed for on the child's pain management chart.

Prevention and detection of opioid related side-effects

Sedation level

The sedation level of the child must be observed and recorded on the child’s PCA/NCA observation chart (Rationale 48).

Sedation scores should be recorded at least hourly:

The scores are as follows:

0 = awake

1 = sleepy/responds appropriately

2 = somnolent/rousable to light stimuli

3 = deep sleep/rousable (deeper physical stimuli)

4 = unrousable to stimuli

CEWS scores should be undertaken in line with Trust policy and additionally if the sedation score is greater than 2. CEWS escalation plan should be followed in all instances.


If the patient has a sedation score of four:

  • STOP the infusion (Rationale 49) and ensure the child is well supervised.

  • Contact the Pain control service on bleep 0577 and ward medical team.

  • The infusion may be recommenced once the sedation score returns to two, or on instruction from the Pain Control service.

  • These actions must be recorded in the child’s healthcare records (Rationale 50).

  • The Pain Control service or competent nurse may decide to change the pump programming.

The following patients should be monitored continually using pulse oximetry (Rationale 51): 

  • patients whose sedation score is repeatedly greater than two

  • patients with respiratory complications or obstructed airway

  • patients with a known sensitivity to morphine/opioids

  • infants under six months of age

Respiratory depression

The patient’s respiratory rate should be recorded hourly (Rationale 52):

 

  • whilst the PCA/NCA is in progress

  • for four hours after the PCA/NCA has been discontinued: during this time IV access should be available (Rationale 53)

The frequency of observation and recording should be increased if the patient is excessively sedated or their condition deteriorates.

CEWS scores should be undertaken in line with Trust policy and the Trust CEWS escalation plan should be followed in all instances.

The patient’s minimum satisfactory respiratory rate is written on the PCA/NCA prescription chart by the prescriber. This is for guidance only and the nurse should also take into account:

  • depth of respiration

  • respiratory effort

  • level of sedation (Rationale 54)

If respiratory depression occurs:

  • STOP the infusion.

  • Administer intravenous naloxone as prescribed (Rationale 55). This may need to be repeated (Rationale 56).

  • Contact the Pain Control service on bleep 0577 (Rationale 57).

  • Document actions in the child’s healthcare records (Rationale 58).

If respiratory arrest occurs:

  • STOP the infusion.
  • Contact the clinical emergency team on bleep 2222.
  • Administer basic life support (Rationale 59).

  • Administer intravenous naloxone as prescribed.

  • Contact the Pain Control service (Rationale 60).

  • Record incident according to hospital policy (Rationale 61).

Nausea and vomiting

The patient should be assessed for nausea and/or vomiting at least hourly (Rationale 62).

Any nausea or vomiting reported should be scored on the PCA/NCA observation chart. Score the highest rating in the previous hour. The scores are: 

  • 0 = nil
  • 1 = slight
  • 2 = moderate
  • 3 = severe

If the patient complains of nausea or has been vomiting:

  • Consider:
    • aspirating a nasogastric or gastrostomy tube
    • repositioning the nasogastric tube
  • Stopping oral intake.
  • Administer an anti-emetic (eg ondansetron) as prescribed - consider whether intravenous administration is required (Gan et al 2003) (Rationale 63).

  • Consider using an additional anti-emetic if the nausea/vomiting has not improved after an hour (Gan et al 2003).

  • If nausea/vomiting continues, contact the Pain Control service or competent nurse, who may reprogram the pump (Rationale 64).

Suggested changes include:

  1. Reducing or stopping the background infusion.
  2. Slowing down the speed at which a bolus is given (ie dose duration to one or two minutes).
  3. Dexamethasone may be considered if not contraindicated and nausea persists (Gan et al 2003)

Record actions in the child’s health care records (Rationale 65).

Pruritus

The patient should be observed for pruritus (itching) (Rationale 66):

  • at least four hourly

  • every one to two hours if itching becomes a problem

Record pruritis on PCA/NCA observation chart. The scores are:

  • 0 = nil
  • 1 = slight
  • 2 = moderate
  • 3 = severe

Administer an anti-histamine as prescribed, eg chlorphenamine (Rationale 67).

Actions must be recorded in the child’s health care records (Rationale 68).

Contact Pain Control service or competent nurse to review if pruritis persists.

If pain control is good, reduction or discontinuation of any background infusion may be beneficial.

Pain Control service may consider the substitution of another opioid (such as fentanyl) for morphine as the analgesic solution (Rationale 69). 

Urinary retention

The database of patients at GOSH who have undergone PCA/NCA therapy indicates there is no evidence that intravenous opioid administration causes urinary retention in children. For this reason, retention in children on PCA/NCA should be treated as for any other child in hospital.

Output:

  • Record the patient’s urine output on their fluid balance chart (Rationale 70).

  • If the patient has not passed urine twelve hours after surgery/commencing PCA/NCA check fluid intake and consider abdominal ultrasound of bladder (Rationale 71).

  • If no palpable bladder/empty bladder on ultrasound, consider dehydration as a possible cause of anuria.

  • If the patient has a palpable bladder or urinary discomfort, try adjusting positioning, providing privacy, water-play to promote voiding (Rationale 72).

  • Ensure that the patient is pain-free (Rationale 73).

  • Contact the relevant medical team/surgeons to determine whether the patient needs to be catheterised (Rationale 74).

If the patient is catheterised:

  • The amount of urine drained should be recorded (Rationale 75).

Drug administration: technical issues

Intravenous morphine syringes and administration sets must be changed every 24 hours (Rationale 76).

These may be changed by any healthcare professional who is competent in the administration of intravenous drugs and authorised by the Trust to do so (Rationale 77).

The PCA/NCA pump should be put on hold (using the call-back facility initiated by maintaining pressure on the stop button), rather than switched off, during the syringe change or any other occasion when the programme is interrupted (Rationale 78).

Drug administration: technical problems

In line with the manufacturers instructions, all staff caring for children using NCA or PCA should have undergone pump specific training and be able to recognise the significance of alarm messages.

If the pump alarms:

  • Stop the infusion.

  • Check the display panel to identify cause of alarm (Rationale 79).

  • If the line has occluded:

    1. De-clutch the PCA drive mechanism before investigating the cause of occulsion or releasing any clamps to avoid delivery of excessive dosage when obstruction released.
    2. Check the cannula site.
    3. Check for kinks or closed clamps.
    4. Flush the cannula.
    5. Restart the infusion.
  • If the syringe is empty a new syringe (as per prescription) should be made up by a nurse who is competent in the administration of intravenous drugs.

  • If alarm is due to a flat battery, plug the pump into the mains.

  • If the pump is faulty, it will need to be replaced and returned to Biomedical Engineering with a label describing the fault (Rationale 80). Contact the Pain Control service on bleep 0577.

  • If the patient has reached their four hourly maximum infusion limit, or the cause of the alarm is unknown, put the device on hold and isolate the infusion from the patient by clamping the administration line. Contact the Pain Control service on bleep 0577.

If pain persists after the four hourly maximum dose has been reached, the Pain Control service may, after reviewing the patient, alter the prescription and increase the four hourly limit to 25ml. This must be clearly documented and reviewed within 24 hours.

Staff must ensure that faulty pumps are returned to Biomedical Engineering with the problem accurately described (Rationale 81).

Any pump which has been dropped or damaged must be taken out of service until checked by Biomedical Engineering (Rationale 82).

All PCA/NCA pumps are fitted with a Biomedical Engineering tracking device.

Discontinuing PCA/NCA

The PCA/NCA may be discontinued by any member of staff who is competent and prepared to accept responsibility for the change (Rationale 83). Consideration should be given to the clinical condition of the patient and the possibility of withdrawal (see weaning and withdrawal guidelines).

Criteria for stopping PCA/NCA include:

  • the patient is able to take analgesia via an alternative route and this is prescribed

  • the background infusion has been reduced or stopped

  • the patient is requiring minimal bolus doses

Background infusions of 0.5ml/hr and 1ml/hr are usually reduced before the NCA is stopped.

The PCA/NCA must be stopped by any nurse in the following situations (Rationale 84):

  • excessive sedation

  • respiratory depression or respiratory arrest

  • pump malfunction

The Pain Control service must be informed that the infusion has been stopped. Discontinuation must be recorded in the child’s health care records (Rationale 85).

Maintain IV access and record pain scores for at least four hours (Rationale 86).

Clean the pump with damp cloth and detergent solution (Rationale 87).

Pumps are routinely deep cleaned by HSDU prior to annual service.

Return cleaned PCA/NCA pump to theatre when not required (Rationale 88).

Rationale

Rationale 1: To ensure that the benefits are balanced against potential risks.
Rationale 2: To ensure that the most appropriate technique is used for the patient.
Rationale 3: To provide information.
Rationale 4: To provide information.
Rationale 5: To meet information needs.
Rationale 6: To reduce anxiety.
Rationale 7: In order to ensure patient safety, only staff trained in the use of the NCA technique (and aware of the potential side effects of opioids) may administer boluses.
Rationale 8: In PCA excessive opioid demands, initiate sedation: the child falls asleep and allows the opioid level to decrease. NCA requires the nurse to take responsibility for assessment of the child's sedation level and respiratory rate.
Rationale 9: PCA and NCA programming differs substantially in the lockout set.
Rationale 10: To ensure the child understands and can use the tool prior to the painful experience, and to record accurately the effectiveness of the technique.
Rationale 11: To establish normal parameters with which to compare future observations.
Rationale 12: To ensure that there is an adequate supply within the hospital and that equipment can be changed in a timely manner.
Rationale 13: To provide effective analgesia with minimal complications.
Rationale 14: To ensure effective communication between clinical teams.
Rationale 15: To provide information and adhere to hospital drug administration policy.
Rationale 16: To allow for immediate treatment of opioid induced respiratory depression.
Rationale 17: To administer PCA/NCA.
Rationale 18: All PCAM® pumps should be deep cleaned and serviced at least once a year. Orange stickers indicate when this service is due.
Rationale 18: All subcutaneous prescriptions are diluted to 20ml, however the PCAM® pumps are designed to recognise 50ml syringes.
Rationale 20: To prevent siphonage (Southern and Read 1994).
Rationale 21: To prevent siphonage and reflux.
Rationale 22: Patient safety and audit trail of equipment used.
Rationale 23: Patient safety.
Rationale 24: To provide effective analgesia with minimal complications.
Rationale 25: To provide effective analgesia with minimal complications.
Rationale 26: To establish initial pain relief.
Rationale 27: To provide adequate information.
Rationale 28: To adhere to hospital drug policy.
Rationale 29: To ensure effective analgesia with minimal side effects.
Rationale 30: To prevent drug errors.
Rationale 31: To adhere to hospital policy.
Rationale 32: To allow for immediate treatment of opiate induced respiratory depression.
Rationale 33: To ensure a strategy of multi-modal analgesia is being undertaken.
Rationale 34: To determine effectiveness of analgesia.
Rationale 35: To monitor hourly morphine consumption and provide information.
Rationale 36: To ensure the syringe pump is infusing correctly.
Rationale 37: An accumulative total is recorded.
Rationale 38: Regular administration of simple analgesics can reduce the amount of opiate the child requires.
Rationale 39: To manage the emotional component of pain.
Rationale 40: To ensure optimal analgesia is provided.
Rationale 41: To treat cause of pain.
Rationale 42: To ensure swift action is taken if analgesia is unsatisfactory.
Rationale 43: Increasing analgesia could potentially mask surgical complications or other problems that may need further intervention.
Rationale 44: To provide effective analgesia with minimal complications/side effects.
Rationale 45: To minimise the risk of complications.
Rationale 46: To provide effective analgesia with minimal complications/side effects.
Rationale 47: To provide effective analgesia either when the infusion rate is inadequate or prior to procedures likely to be painful eg chest drain removal.
Rationale 48: To ensure early detection and treatment of opioid induced sedation.
Rationale 49: To prevent further sedation which may potentially result in respiratory depression.
Rationale 50: To maintain an accurate record.
Rationale 51: To ensure early detection and treatment of opiate induced sedation and respiratory depression (Southern et al 1994).
Rationale 52: To ensure prompt detection and treatment of respiratory depression.
Rationale 53: The half-life of morphine is about two hours.
Rationale 54: Respiratory rate and pattern can vary and the child’s normal respiratory rate must be taken into consideration.
Rationale 55: To ensure prompt treatment.
Rationale 56: Naloxone has a half-life of 30 minutes.
Rationale 57: To review the patient’s analgesia.
Rationale 58: To maintain an accurate record.
Rationale 59: To ensure prompt treatment.
Rationale 60: To review the patient’s analgesia.
Rationale 61: To maintain an accurate record.
Rationale 62: To ensure early detection and treatment of nausea and vomiting.
Rationale 63: Ondansetron has been shown to be efficacious in the management of post operative nausea and vomiting (Gan et al 2003).
Rationale 64: Alteration to the pump programming may reduce opiate induced nausea/vomiting.
Rationale 65: To maintain an accurate record.
Rationale 66: To ensure early detection and treatment of opioid induced pruritus.
Rationale 67: Histamine release may cause pruritus.
Rationale 68: To maintain an accurate record.
Rationale 69: Opioids have different side effect profiles in different individuals.
Rationale 70: To ensure early detection and treatment of urinary retention.
Rationale 71: To determine whether the patient is dehydrated.
Rationale 72: To encourage voiding.
Rationale 73: If the patient is tense due to pain, they will be less likely to pass urine spontaneously.
Rationale 74: To allow for drainage of the bladder.
Rationale 75: To ensure an accurate recording of output.
Rationale 76: To comply with Trust policy and reduce the risk of infection.
Rationale 77: To maintain patient safety.
Rationale 78: To maintain patient safety by reducing the risk of accidentally reprogramming the pump.
Rationale 79: To determine and correct the cause of the problem.
Rationale 80: To prevent administration errors due to faulty equipment.
Rationale 81: To ensure timely maintenance and to maintain patient safety.
Rationale 82: Patient safety.
Rationale 83: To ensure effective analgesia is maintained once the PCA/NCA is stopped.
Rationale 84: To allow for the problem to be corrected.
Rationale 85: To maintain an accurate record.
Rationale 86: To ensure IV access remains to allow treatment of side effects and re-commencement of PCA/NCA if pain increases.
Rationale 87: To prevent cross-infection.
Rationale 88: To ensure equipment is available for patients requiring them.

References

Reference 1:
Anderson BJ, McKenzie R, Persson MA, Garden AL (1998) Safety of postoperative paediatric analgesia. Acute Pain 3(1): 14-20.

Reference 2:
Bray RJ (1983) Postoperative analgesia provided by morphine infusion in children. Anaesthesia 38: 1075-78.

Reference 3:
Doyle E, Harper I, Morton NS (1993) Patient controlled analgesia with low dose background infusions after lower abdominal surgery in children. British Journal of Anaesthesia 6: 121-7.

Reference 4:
Lloyd-Thomas AR (1994) Management of postoperative analgesia. Current Opinion in Anaesthesiology 7: 262-6.

Reference 5:
Schmid RL, Sandler AN, Katz J (1999) Use and efficacy of low-dose ketamine in the management of acute post-operative pain: a review of current techniques and outcomes . Pain 82: 111-23.

Reference 6:
Southern DA, Read MS (1994) Overdosage of opiate from patient controlled analgesia devices. British Medical Journal  309: 1002.

Reference 7:
Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philip BK, Sessler DI, Temo J, Tramer MR, Mehernoor W (2003) Consensus guidelines for managing postoperative nausea and vomiting. Anesth. Analg 97: 62-71.

Reference 8:
Llewelly N (1993) The use of PCA for paediatric post-operative pain management. Paediatric Nursing 5:5: 12-5.

Reference 9:
Howard R, Carter B, Curry J, Morton N, Rivett K, Rose M, Tyrrell J, Walker S, Williams G. Association of Paediatric Anaesthetists of Great Britain and Ireland (2008) Good practice in post operative and procedural pain. Paediatr Anaesth 18: Suppl 1:1-3.

Reference 10:
Doyle E, Mottart KJ, Marshall C, Morton NS (1994) Comparison of different bolus doses of morphine for patient controlled analgesia in children. British Journal of Anaesthesia 72: 160-3.

Reference 11:
Lloyd-Thomas AR (1990) Pain Management in Paediatric Patients. British Journal of Anaesthesia 64: 85-104.

Reference 12:
McNeely J, Trentadue N (1997) Comparison of PCA with and without night-time morphine infusion following lower extremity surgery in children. Journal of Pain and Symptom Management 13(5): 268-73.

Reference 13:
Morton N (1997) Paediatric patient controlled analgesia. Paediatric and Perinatal Drug Therapy 9: 14.

Reference 14:
Morton N (1998) Prevention and control of pain in children. British Journal of Anaesthesia 83(1): 118-29.

Reference 15:
Morton N (1998) Acute Paediatric Pain Management. London, WB Saunders

Reference 16:
Rose JB, Watcha MF (1999) Postoperative nausea and vomiting in paediatric patients. British Journal of Anaesthesia 83(1): 104-17.

Reference 17:
Royal College of Paediatrics and Child Health (1997) Prevention and Control of Pain in Children: A Manual for Health Care Professionals. BMJ Publishing, London

Reference 18:
Twycross A, Moriaty A, Betts T, editors (1998) Paediatric Pain Management. Oxon, Radcliffe Medical Press

Reference 19:
Lloyd-Thomas A, Howard R (1994) A pain service for children. Paediatric Anaesthesia 4: 3-15.

Reference 20:
White M, Shah N, Lindley K, Lloyd-Thomas A and Thomas M (2006) Pain management in fulminating ulcerative colitis. Pediatric Anaesthesia 16: 1148 - 1152.

Document control information

Lead author(s) 
Judy Peters, Clinical Nurse Specialist, Pain Control Team

Approved by
Clinical Practice Committee

First introduced: 22 September 2008
Date approved:
10 January 2013
Review schedule: Two Years
Next review: 10 January 2015
Document version: 5.0
Replaces version:
1.0