PCA dosing

[MdBrndPhrmcst]

Hi guys.. i'm not asking advice for a real patient..cause that seems to be a hot button around these parts. I have to write a careplan for a hypothetical pateint . Its like a practice case and I'm stuggling with the analgesia I was wondering if you guys could help me.

I got a pateint who is on IV PCA morphine for pain...

-basal dose 1.2mg/hr
-demand dose 1.0 mg lockout interval 8 minutes
-1 hour limit 8.7mg/hr

Pateint's pain is uncontrolled 4 out of 10...
should i just increase the dose by 25% and reasses in an hour? and what do i increase? the demand dose? basal? max? all by 25%?

I cant find any defintive guidlines on how to do this.. any help would be appreciated..

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[sdn1977]

Hi guys.. i'm not asking advice for a real patient..cause that seems to be a hot button around these parts. I have to write a careplan for a hypothetical pateint . Its like a practice case and I'm stuggling with the analgesia I was wondering if you guys could help me.

I got a pateint who is on IV PCA morphine for pain...

-basal dose 1.2mg/hr
-demand dose 1.0 mg lockout interval 8 minutes
-1 hour limit 8.7mg/hr

Pateint's pain is uncontrolled 4 out of 10...
should i just increase the dose by 25% and reasses in an hour? and what do i increase? the demand dose? basal? max? all by 25%?

I cant find any defintive guidlines on how to do this.. any help would be appreciated..

I'm not a fan of basal rates unless you have an opiod tolerant pt..then the basal should cover that need alone. What dose what that opiod before surgery?

I'd also like to know your pts wt & type of surgery (I'm assuming this is post op - you didn't say). I thinking keeping your pt under "4" is good - so you're very close. Now..if you need to dose for PT or something like that - it may be different, but that's transient & not required all day.

Also...give some hx - how many days post op. Is the pain improving or not changiing. What does the pump hx show - if more pushes at night when the pt has no visitors & no distractions, that tells you something different than during the day.

 

[MdBrndPhrmcst]

Pateint had surgery 24 hours ago.. spinal fusion.. pateint weighs 63.5 kg.. patient wasnt on any opiods before the surgery. I'm not sure if the demand doses were in the night or day sorry..

 

[sdn1977]

First...its hard for me to believe someone who had a spinal fusion did not have an opioid exposure beforehand. Most folks with back pain have been on Vicodin or something prior.

However...we'll go with what you've got.

This is a guideline - every facility I've ever worked in has had specific standing orders with ways to change them.....but here is what I'd recommend:

You've loaded your pt (the initial loading dose should have been about 0.04mg/kg = 3mg, but it took about 30 minutes to do it. You've already set up some anticipatory pain....however, you don't know what happened in PACU or with anesthesia - they may have helped you out here! But...once the pt anticipates pain...they want relief before they know they can't tolerate it.

Your PCA dose should be about 0.02 mg/kg = about 1.3mg with a lockout of 6-10 minutes. Your 4 hour lock out could be 0.3mg/kg (about 20mg) which translates to a 1 hour lock out of 5 mg - lower than what you have, but you can go to a maximum of 40mg/4hr which you're close to. I definitely wouldn't the 4 hour max.

I have real doubts about a spinal fusion which has not had prior narcotics, so I would try to get a clearer picture of preop - what did this pt use for their pain which required a spinal fusion? So I wouldn't change the lock out - keep it at 8 minutes....& up the PCA dose while decreasing the basal infusion. You'd need to check with MD & nursing...if the pt is at all comfortable at any time....the basal is taking care of the previous narcotic load. However...you want to ultimately change that to an as needed narcotic demand...so by decreasing the basal & upping the pca dose...you accomplish what you need. Particularly when physical therapy begins to move pt & start their therapies. One of the things about pcas & pharmacists...they just like to look at the pump settings & not the history or talk with nursing or read nursing notes.

If you are going to develop a plan for a patient - or more importantly, a standardized order, you must learn to develop a way of looking at your patient not just by pump settings. How does your patient respond during all the 24 hours of the day? How frequent & when are the pca doses given? Your care plan should include all of these assessments & a clear understanding of the physicians goals & the nursing assessments. The pca pump settings is ony one aspect of the whole picture.

I hope this helps some..

 

[WVUPharm2007]

Give them propofol and put them under. Then they can't complain.

 

[MdBrndPhrmcst]

Thanks sdn111 that was very educational... are you a student? please tell me your a pharmacist with several years of expereince in a clinical setting..

 

[ApothRM]

Give them propofol and put them under. Then they can't complain.

I AGREE

 

[sdn1977]

propofol! Well...you could do that, except pt gets really hard to get involved & your dop will get pissed off you blew off so much money.......


that aside...yes - I'm a pharmacist with many (maybe waaaaay too many years of experience - 29+ in many clinical settings). So...I've not only seen many pca orders, I've written standardized orders & altered them as the therapy has evolved.

Its a great use of pain medication & a much better use of nursing staff. You just can't take the pump settings & their printout readings outside of what is really happening with the patient.

Remember - it is the patient who is the important part of the therapy - not the pump settings!

 

[WVUPharm2007]

Just make sure they go get a look at him every few minutes so he doesn't have enough time to figure out the code to the pump and pushes 35mg of Dilaudid into his body all at once.