Patient Controlled Analgesia (PCA) - Paediatric Guideline - NHS Borders

1. Nursing staff in ward 15 will make up a paediatric PCA.
   
   
2. IV access will be required, and a small background of IV fluid of 5mls/hr enables line to remain patent, and opioid delivery beyond the cannula into the vein.
3. IV loading with opioid may be required until pain is reasonably well controlled (PCA will not be so effective if pain is poorly controlled when handset given to patient).
   
   
4. PCA devices can be obtained from Theatre Recovery, and are signed out on collection for traceability. Patient’s details and location also need to be provided.
   
   
5. A request will be put on the portering system by ward 15 staff to collect paediatric PCA equipment from the Recovery Room. Ward 15 staff will contact theatre staff (bleep 6595) to let them know that a PCA is required. Staff in theatres will gather together the PCA equipment required (dedicated IV PCA infusion line, (includes a “Y” connector) and a PCA cartridge (for filling with opioid).
   
   
6. Staff need to be familiar with PCA devices and have completed PCA training (online and practical aspects of training), and to have competency signed off (on CARS). The IV Therapy course needs to be completed and signed off (yearly updates).
   
   
7. After making up or refilling cassettes with opioid, check correct patient, correct prescription, countersign prescription & pump chart:
   
   
   • Set up PCA pump and connect to patient.
     
     
   • Explain to patient how to use.
     
     
   • Lock PCA pump, key attached to ward master key.
     
     
   • Ongoing patient and pump monitoring by ward staff as on monitoring chart
     
     
8. One to one nursing supervision must be used when the PCA is started to ensure the child is using the pump correctly.
   
   
9. A change of drug (morphine) is needed every 24 hours for PCAs. Dispose of cassette into sharps box, and if there is any unused opioid, state the volume discarded on the monitoring chart and sign this off. Plan ahead for refills.
   
   
10. A change of IV infusion line is needed every 24 hours.
    
    

PCA should only be instituted after discussion with the anaesthetist managing the patient or duty anaesthetist (bleep 3933)

For children > 50kg: apply the maximum weight of 50kg to the calculation in box below

For children up to 50kg:

Concomitant opioids should NOT be prescribed for children on PCA.

• The PCA prescription must be correctly completed on the drug Kardex (stipulate precise amount of morphine in mgs to be added to PCA cassette) AND on separate Paediatric PCA Prescription Chart.
  
  
• The PCA cassette must be prepared and set up in accordance with IV infusions policy.
  
  
• The calculated dose of naloxone for the individual child should be prescribed as required on the PCA prescription chart. Naloxone must be available in the ward drug cupboard.
  
  
• An antiemetic should accompany the PCA prescription – see paediatric antiemetic protocol.

The following minimum observations must be made

PATIENT MONITORING (on PEWS chart)

• Hourly pulse and respiratory rate.
• Hourly sedation score (eg. AVPU) and nausea score.
• Hourly pain (using a paediatric pain assessment scale). Occasionally more frequent pain assessment may be required. All complaints of pain must be taken seriously.
• Continuous pulse oximetry should be carried out and recorded.

There must be hourly recordings of pulse, respiratory rate, pain sedation, nausea and vomiting. Respiratory rate alone is not an adequate monitor of respiratory depression and it is imperative that sedation scores are recorded as these provide an earlier indicator of increased risk of respiratory depression. Continuous pulse oximetry should be carried out and recorded. Unlike for adults, supplemental oxygen is not routinely used for PCAs in children for this reason.                                                                                                                                                                                                                                  

PCA PUMP MONITORING (to be documented on PCA prescription chart)

• Hourly recording of volume infused & volume remaining in the PCA syringe
• Number of patient demands
• Total dose of drug used
• Visual check for issues with giving set or cannula, e.g. Leaks, cracks, obstruction of giving set or tissued cannula
• Check correct equipment is being used in correct format ie. PCA giving set used with anti-syphon and anti-reflux valve, not being used in combination with other drug infusions via the same cannula.

Daily review of the requirement for a PCA is required, to be carried out by the clinical team in combination with, ICU or Anaesthetics teams.

If the PCA is to be discontinued, prior explanation to patient and family/carers is needed. Satisfactory alternative analgesia must be available when PCA is discontinued prescription of step-down analgesia opioids may be required. Discontinue PCA prescription on drug Kardex AND Paediatric PCA Prescription Chart. Discard the cassette containing any opioid into the ward sharps box. Return PCA device to the Recovery Room within Operating Theatres, remembering to sign this back in.

Contact details for help

• Advanced Practitioner in ward 15
  
  
• Theatre Recovery ext 26593, Operating Department bleep 6595
  
  
• Duty Anaesthetist bleep 3933

Along with yearly infusions training, PCA training should take place on an annual basis for trained nursing staff. Infusions training will incorporate PCA training. There needs to be familiarity with the PCA devices themselves (via PCA device training organised by educational department) as well as familiarity with PCA prescription charts, PCA monitoring charts, how to make up PCAs, ensuring correct device is used for PCAs.

Paediatric PCA Pathway v7 Checklist

Separate doc – link to this.

Paediatric PCA Prescription Chart V8

Separate doc – link to this.