ACUTE PAIN SERVICE GUIDELINES & PROTOCOLS
[pic] [pic]
Department of Anaesthesia and Intensive Care
The Chinese University of Hong Kong
Prince of Wales Hospital
GUIDELINES ON ACUTE PAIN SERVICE (APS)
4th edition
June 2009
CONTENTS
1. Introduction 3
1. Arranging for Acute Pain Service 4
2. Routines of the Acute Pain Service 6
1. Setting up Acute Pain Service modalities 7
1. Documentation for the Acute Pain Service 16
2. Operation guide: the Alaris PCA pump 18
3. Operation guide: the Gemstar infusion pump 26
4. Medical toolkit for patients with Acute Pain Service modalities 31
1. Nursing Guidelines – recovery room 38
1. Nursing Guidelines – general wards 42
1. Paediatric pain relief 46
2. Trauma pain relief 49
3. Rib fracture protocol 56
4. Knee and Hip replacement protocol 60
5. Duties of the pain medical officer 61
6. Duties of the pain nurse 70
7. Private patient fees 73
1. Useful telephone & pager numbers 74
First compiled January 1997 (Authors: PP Chen, M Ma, V Yeo)
Revised February 1998 (Authors: PP Chen, M Ma)
Revised August 2004 (Authors: MC Chu, J Chen)
Revised June 2009, updated March and June 2011 (Author: MC Chu)
INTRODUCTION
The Department of Anaesthesia and Intensive Care at the Prince of Wales Hospital provides a 24 hour acute pain service (APS).
At present, the modalities of pain relief available are:
1. intravenous patient controlled analgesia (PCA)
1. continuous epidural infusion analgesia (CEI)
2. continuous regional analgesia e.g. brachial plexus analgesia, para-vertebral analgesia
3. patient controlled epidural analgesia (PCEA)
This book is written to facilitate patient care by all staff at the Prince of Wales Hospital. It comprises of updated versions of guidelines produced by the acute pain team. Copies are available at the operating theatre, labour ward, the acute pain folder and also the hospital intranet. If you have any query or comment, please contact any of the team members, and we appreciate your valuable feedback.
Sr. Marlene Ma / Ms. Wendy Fung / Ms. Josephine Chen (Pain Nurses)
Dr. Simon Chan (Coordinator of Pain Services) / Dr. MC Chu / Dr. Michelle Cheung / Dr. Kristie Tsang / Dr. Peggy Li / Dr. Diane Chan
Department of Anaesthesia and Intensive Care
ARRANGING FOR ACUTE PAIN SERVICE
Peri-operative cases in the main theatre (for Anaesthesiologists)
1. All APS modalities work best when patients understand and are capable to use it. Please explain to patient about the use of the chosen APS modality during the preoperative visit. Select according to patient’s physical and cognitive state, with informed consent and documentation. The pain nurse may also assist in preoperative education upon request, if the case is not the first on the OT list.
2. Elective cases: fill in the particulars on the request form no later than 0800 on the OT day. Forms are available next to the OT lists at the 4/F Conference Room, or at the 5/F OT control desk. For emergency cases / late elective requests, inform the APS team (pager 1067 / DECT phone 6172) directly. The APS team will triage and entertain as many requests as possible.
3. The pumps shall be ready at the recovery room after 0830 (elective cases). Set the pumps up and write up the appropriate forms and keep them together with the patient in the OT, the recovery room or transfer to other areas.
4. Copies of protocols and guidelines are available at each theatre, the pain trolley and the recovery room for your reference.
5. Optimize analgesia with adequate loading doses. Ensure that the APS pump is properly connected, and all drug packages labeled before discharging patients from recovery room.
6. Please inform the APS team for any changes or cancellation of APS requests. The APS team will also liaise with the duty anaesthesiologist for any queries. Please do not start any APS modalities without discussing with the team.
Labour ward and the Intensive Care Unit (for Anaesthesiologists)
1. The Anaesthesiologist or Intensivist shall be responsible for obtaining the pump, setting it up, documentation and monitoring it during patient’s stay in these areas. The Gemstar and the Alaris pumps are available in the labour ward. The ICU does not stock any APS pumps. Copies of the relavent protocols and guidelines are available at the labour ward and the hospital intranet. Please call the APS team (pain nurse at 6172 or pain MO at pager 1067) for support.
2. As the patients might be physiologically unstable, the Anaesthesiologist or Intensivist might modify the APS regime according to the clinical needs. Different protocols for pain relief might also apply for patients within the labour ward. Upon discharge from these areas, the Anaesthesiologist or Intensivist shall ensure that the analgesic modalities follow the same protocols as per postoperative patients. Please document any alternations on the patient’s notes and the APS prescription & observation records chart.
3. The APS team shall follow the patients up regularly. Please inform the APS team upon discharge of patient, termination of service or technical trouble shooting. In case the pain relief regime is different from the standard recommendations, the APS team might switch them back to the basics before the patient is discharged to the ward.
Other areas
1. Request for APS service from other areas shall be addressed to the Department of Anaesthesia and Intensive Care by written consultation (fax: 26372422). The APS team shall made recommendations according to resources available, patient’s clinical condition and support available from the clinical area.
ROUTINES OF THE ACUTE PAIN SERVICE
1. The APS runs in shifts. Weekday day shift runs from 0800 till 1600 and includes a pain nurse (DECT phone 6172) and a pain MO (pager 1067). Evening shift runs from 1600 till 0800 the next morning. Weekend and holiday shifts are 24 hours starting from 0800 and includes a pain MO (pager 1067).
2. The APS team collects and triage the elective requests and inform the OT recovery room at around 0830. In case of pump shortage, the APS team shall liaise with the duty Anaesthesiologist, and endeavor to maximize pump allocation after the pain round at around 1030. Emergency and late elective requests will be processed after the elective requests are catered for.
2. The APS team shall educate patients on how to use the PCA devices upon special request from the anesthesiologist. It does not apply to the first case of the morning.
3. The APS team shall conduct ward rounds for all patients with an APS modality in all clinical areas. The team shall advise on clinical management in pain matters, prescribe as necessary, check for functions of the pumps, and compliance with documentations. Entries are made in the patient clinical notes and in the acute pain folder upon each visit, and upon any changes, shall communicate with the ward staff directly. This is to ensure that all parties can work together for the benefit of the patient.
4. Upon notification of patient’s discharge from the recovery room or any transfer, the APS team shall review the patient no later than 24 hours. The APS follow up form will be collected at the first visit and kept in the acute pain folder for handover.
5. Handover between shifts shall include transfer of the acute pain folder, the pain MO pager, updates on patient information in the acute pain folder, and condition and allocation of the pumps.
SETTING UP ACUTE PAIN SERVICE MODALITIES
This document refers to adult settings only. Please refer to Chapter 11 for Pediatric set up. The labour ward provides different protocols for labour pain relief and is not included in the current guideline.
Intravenous Patient Controlled Analgesia (PCA)
1. Aseptic technique applies to both the lines and the medication preparation.
2. Dedicated, ≥ 20G intravenous line is recommended, use anti-reflux valve without 3-way stopcock.
3. Use Terumo 50 ml syringes with luer lock only, as the device has been programmed for use with this syringe. Dilute 60 mg Morphine with saline up to total volume of 60 mls (final concentration: 1 mg/ml) and label the syringe with green gum labels. (For patients contraindicated for Morphine, consider Fentanyl PCA. Refer to the appendix to this chapter)
4. Use special extension lines with pre-attached anti-siphon valves.
1. Attach the syringe to the Alaris PCA pump. See page 17 for operational instructions.
1. Recommended initial program for intravenous PCA:
|Bolus dose |1-2 mg |
|Lockout period |8-15 min |
|Max. 4 hr dose limit |0.3 mg/kg |
7. In case when only one intravenous line is available, use the dedicated Y-connector to accommodate both the maintenance fluid and the PCA channel. It is available in the OT recovery room. Please be reminded that this is reserved only for the Anaesthesiologist and members of the pain management team.
Note: the 3 ends of the Y connector are labeled for fluids, patient and PCA respectively.
Appendix: Fentanyl PCA regime
Consider alternative regime of Fentanyl PCA for patients with contra-indications for Morphine:
Dilute 1200 mcg (24 mls) of Fentanyl with 36 mls of Normal Saline, up to a total of 60 mls (final Fentanyl concentration = 20 mcg/ml)
Switch the default medication from “Morphine” to “Fentanyl” upon programming the PCA pump.
Dose recommendations for adult patients only (upper limit for bigger adults)
|Medication |Fentanyl |
|Bolus dose |10-20 mcg |
|Lockout period |5-10 min |
|Max. 4 hr dose limit |200-400 mcg |
Please document the medication and regime on the PCA prescription charts accordingly. All other instructions and routines are identical to those of the conventional PCA service.
Continuous Epidural Infusion Analgesia (CEI)
1. Only trained Anaesthesiologists or trainees under supervision shall perform the epidural insertion.
2. Subjected to clinical needs of individual cases, recommended levels are:
Mid thoracic (T4-8) for upper abdominal and thoracic surgeries
Low thoracic (T8-12) for lower abdominal surgeries
Lumbar for lower limbs and pelvic surgeries
3. Patients with clotting defects or on anticoagulants shall have their coagulation profile normalized before the epidural insertion.
4. Full aseptic technique shall apply to the insertion and medication preparation.
5. Cover the epidural catheter exit site with a large transparent dressing with Micropore tape around the edges. Avoid gauze beneath the dressing. The catheter shall either run cephalad and exit at patient’s shoulder, or run laterally and then cephalad and exit at patient’s chest wall. Secure the catheter with Micropore tape along its length.
6. The filter should be cushioned with gauze at the infraclavicular fossa and tagged with an “EPIDURAL” label. Secure with a large transparent dressing. Use alternative adhesives for patients with allergies to standard adhesives.
7. Prepare one of the following regimens with cross-check for the 5 “Rights” according to established guidelines:
• Mix 60 ml of 0.5% Levo-Bupivacaine (Chirocaine) with 16 ml (800 mcg) of Fentanyl into the 250 ml saline bag. Final concentrations: Levo-Bupivacaine 0.09%, Fentanyl 2.5 mcg/ml, total volume: 326 ml
• Mix 40 ml of 1% Ropivacaine (Naropin) with 16 ml (800 mcg) of Fentanyl into the 250 ml saline bag. Final concentrations: Ropivacaine 0.13%, Fentanyl 2.6 mcg/ml, total volume: 306 ml
• Mix 3 ml (45 mg) of preservative free Morphine into the 500 ml saline bag. Final concentration: 0.09 mg/ml, total volume: 503 ml
Label the medication bag using the green gum label, and all connections with the “EPIDURAL” tag.
5. Attach the medication bags to the Gemstar infusion pump. See page 25 for operational instructions.
6. Recommended initial program for CEI:
| |Levo-Bupivacaine & Fentanyl |Ropivacaine & Fentanyl |Morphine |
|Reservoir volume |320 ml |300 ml |495 ml |
|4 hour limit |Nil |
|Infusion rate |4 – 12 ml/hr |6 – 12 ml/hr |3 – 6 ml/hr with loading|
| | | |* |
Notes:
• Lower infusion rates are advised for elderly patients and thoracic catheter placement
• * Loading doses for epidural morphine
2 mg in 5 mls of saline (patient aged > 80 or body weight < 40 kg)
3 mg in 5 mls of saline (patient aged < 80 and body weight > 40 kg)
7. For epidural morphine infusions, please prescribe regular Ondansetron 4 mg q8H (oral or iv) for 2 days.
Continuous regional analgesia infusions
1. The precautions, prescription procedures and labeling for epidural analgesia shall apply to continuous regional analgesia. See above for details.
2. Recommended regimens for regional analgesia infusions:
• Paravertebral infusions: withdraw 100 ml from the 250 ml saline bag. Add 150 ml of 0.5% Levo-Bupivacaine (Chirocaine) into the bag. Final concentrations: Levo-Bupivacaine 0.25%, total volume: 300 ml
• Other nerve or plexus infusions: withdraw 10 ml from the 250 ml saline bag. Add 80 ml of 0.5% Levo-Bupivacaine (Chirocaine) into the bag. Final concentrations: Levo-Bupivacaine 0.125%, total volume: 320 ml
3. The Gemstar infusion pump is used for regional analgesic infusions. The set up is the same as per CEI (see page 25).
4. Recommended initial program for continuous regional analgesia infusions:
| |Paravertebral infusion |Other nerve or plexus infusion |
|Reservoir volume |300 ml |320 ml |
|4 hour limit |Nil |
|Infusion rate |4 – 12 ml/hr |4 – 12 ml/hr |
Patient Controlled Epidural Analgesia (PCEA)
1. There are 2 regimens for patient controlled epidural analgesia at the Prince of Wales Hospital. A local anaesthetic and opioid mixture is used exclusively in the labour ward for labour analgesia.
2. PCEA with Pethidine is used for postoperative analgesia. While Pethidine has both opioid and local anaesthetic actions when administered epidurally, it may be associated with other potential disadvantages such as sedation, euphoria and nor-pethidine toxicity, and is contra-indicated in elderly and patients with renal insufficiency. The Anaesthesiologist shall exercise caution when choosing this modality of analgesia.
3. The equipment and initial set up is identical to those for the epidural infusion (see above).
4. Add 60 ml of saline into a 100 ml bag. Add 18 ml of Pethidine (900 mg) into the bag. The final concentration of Pethidine is 5 mg/ml, total volume 180 ml
3. Recommended initial program for PCEA Pethidine regimen
|Reservoir volume |180 ml |
|Bolus dose |3 - 4ml (15-20mg) |
|Lockout period |8 min |
|Maximum 4 hr dose limit |0.6 ml/kg (3 mg/kg) |
Summary of Acute Pain Service Regimens
A. Regimen for Adult Patients
I. Patient Controlled Analgesia (Alaris PCA pump)
|Morphine |
|Suggested mixture: |Suggested regimen: |
|Use 50ml Terumo syringe |Morphine conc. 1mg / ml |
|Dilute 60 mg morphine with NS to a total volume of 60ml |Dose: 1 – 2 mg |
|Expel all the air bubbles |Lockout: 8 - 15 minutes |
| |4 hr dose: 0.3 mg / kg |
|Fentanyl |
|Suggested mixture: |Suggested regimen: |
|Use 50ml Terumo syringe |Fentanyl conc. 20 mcg / ml |
|Dilute 1200 mcg Fentanyl with NS to a total volume of 60ml |Dose: 10 - 20 mcg |
|Expel all the air bubbles |Lockout: 5 - 10 minutes |
| |4 hr dose: 100 - 200 mcg |
|Use extensions with anti-siphon valve |
|Use dedicated IV access of ≥ 20G IV cannula with anti-reflux valve. |
|Use Y-extension with non-return valve if patient has only one line for both maintenance fluid and PCA |
II. Epidural Continuous Infusion (Gemstar infusion pump)
|Levobupivacaine and Fentanyl |Ropivacaine and Fentanyl |Morphine |
|Suggested mixture & regimen: |Suggested mixture & regimen: |Suggested mixture & regimen: |
|Use 250ml NS bag |Use 250ml NS bag |Use a 500ml NS bag |
|Inject 0.5% Levobupivacaine 60ml (300mg) and |Inject 1% Ropivacaine 40ml (400mg) and Fentanyl|Inject 3 ampoules of 15mg preservative-free |
|Fentanyl 16ml (800µg) |16ml (800µg) |morphine (45mg) |
|3. Set pump volume 320ml |Set pump volume 300ml |3. Set pump volume 495 ml |
| | |4. Initial loading dose |
|Infusion rate 4 – 12ml / hr |Infusion rate 6 – 12ml / hr |2mg (age > 80) |
| | |3mg ( age < 80) |
| | | |
| | |Infusion rate 3-6ml /hr |
|Align catheter cephalad or laterally, site filter at infraclavicular fossae |
|Secure epidural catheters with transparent dressing, Micropore tapes along catheter |
|Label the filter, bag and catheter connections with “EPIDURAL” tags |
III. Regional Continuous Infusion (Gemstar infusion pump)
|Paravertebral Levobupivacaine |Nerve or Plexus Levobupivacaine |
|Suggested mixture & regimen: |Suggested mixture & regimen: |
|Use a 250ml NS bag |Use a 250ml NS bag |
|Aspirate 100ml NS from the bag |Aspirate 10ml NS from the bag |
|Inject 0.5% Levobupivacaine 150ml (750mg) |Inject 0.5% Levobupivacaine 80ml (400mg) |
|Set pump volume 300ml |Set pump volume 320ml |
| | |
|Infusion rate 4 – 12ml / hr |Infusion rate 4 – 12ml / hr |
|Ensure catheter is secure, labeled and connected with bacterial filter |
continue overleaf
IV. Patient Controlled Epidural Analgesia (Gemstar infusion pump)
|Epidural Pethidine |
|Suggested mixture: |Suggested regimen: |
|Use a 100ml NS bag |Pethidine conc. 5mg / ml |
|Add 60ml NS from the bag |Dose: 3 – 4 ml |
|Inject 9 ampoules of Pethidine (900 mg) |Lockout: 8 minutes |
|Set pump volume 180 ml |4 hr dose: ~ 0.6 ml / kg |
B. Regimen for Paediatric Patients
I. Paediatric IV NCA (Alaris PCA pump for aged ≤ 6 / minor)
|Morphine |
|Suggested mixture: |Suggested regimen: |
|Use 50ml Terumo syringe |Dose: 1 ml (20 μg/kg/ml) |
|Dilute morphine (B.W. in kg x 1.2) mg with NS to a total volume of 60ml |Lockout: 7 - 10 minutes |
|Expel all the air bubbles |4 hr dose: 0.3 ml / kg |
|Use extensions with anti-siphon valve |
|Use dedicated IV access with anti-reflux valve |
|Use Y-extension with non-return valve if patient has only one line for both maintenance fluid and PCA |
II. Paediatric Epidural Continuous Infusion
|Levobupivacaine & Fentanyl |
|Suggested mixture & regimen: |
|Use a 100 ml NS fluid bag |
|Aspirate 24ml NS from the fluid bag |
|Inject 0.5% Levobupivacaine 20ml (100mg) and Fentanyl 4ml (200µg) |
|Set pump volume: 90 ml |
| |
|Infusion rate: 0.1 - 0.4ml/kg/hr |
DOCUMENTATION FOR THE ACUTE PAIN SERVICE
1. All observations and clinical management by the acute pain service must be documented. It serves as a communication tool within and between the APS and other staff, and is an important part of data collection and quality control for the APS.
2. The APS shall be responsible for education, data collection and maintenance of these documents, while the user (including the Anaesthesiologist, Intensivist, APS members or ward staff) shall make intelligent use of them. Please write legibly.
Forms
1, Booking form: this is for elective postoperative bookings and is available at the 5th floor common room, or the operating theatre control area.
2. APS nursing observation form: this is for the APS user to specify the details of APS modality, and for the ward nurses to chart all pain related observations. It is available at the operating theatre, the intensive care unit and the labour ward. The completed form shall escort every patient with any APS modality, and is part of the patient record.
3. APS follow up form: this is for communication within the APS team. It is attached to the APS nursing observation form, and upon initiation of the APS, the team member shall collect the form at the ward, and put it into the acute pain folder. The APS team shall update the form upon every visit, and upon termination of service, the form will be archived and data will be audited.
Labels
1. Patient progress notes: a gum label is available for initiation of all APS modalities. Subsequent entries upon each visit shall be hand written.
[pic]
2. Prescription charts: gum labels are available for common modalities including PCA, CEI and PCEA orders. Individualized prescriptions shall be hand written. The caution note gum label shall be used on top of the prescription chart for all modalities.
OPERATION GUIDE: THE ALARIS PCA PUMP
Loading the pump
1. Open the cover with the key. 2. Lift the syringe clamp and turn left
3. Mount the syringe plunger into the plunger 4. Squeeze and slide the holder to the left
holder. Squeeze at the holder and slide to until the flanges are touching the left
the right to carry the syringe flanges to the margin of the flange holder.
flange holder
5. Bring the syringe clamp back to neutral. 6. Close the cover with a “click”
7. And don’t forget the key!
Programming the pump
1. Insert key into the key switch. Turn to SET position. [pic]
2. Press [pic] YES to clear previous patient information. Press YES again to confirm new patient.
3. The default protocol (abbreviated A on the left upper corner of the main display) will appear. Press [pic] MODIFY PROTOCOL and go through the protocol, using the [pic] & [pic] to scroll up or down the variables.
4. Press [pic] OK to confirm, or [pic] ALTER to change the variable. The new protocol will take priority over the default protocol (still available upon pressing on [pic] NEXT PROTOCOL and the A will reappear).
5. Turn the key to RUN position. [pic]
6. Press [pic] OK to confirm the chosen protocol. Remove the key.
7. Press [pic] OK to confirm syringe type as Terumo 60 ml.
8. Connect the PCA to the patient’s IV access, unclamp the extension tubing.
9. Connect the handset to the pump by aligning the red dots. Attach the AC power cable.
10. Press Start [pic] to commence pump operation.
Checking consumption (Demand & Good) information
1. No need to stop the pump. Simply read from the main display:
Demands Drug Infused
Total # #.## μg
Good # #.## ml
Reviewing the program
1. No need to stop the pump.
2. Press [pic] Protocol to review the program. Press [pic] QUIT when done.
Changing the program
1. Insert key into the key switch. Turn to SET position. [pic]. Press [pic] NO to retain patient information.
2. Press [pic] MODIFY PROTOCOL, use the [pic] & [pic] to scroll up or down the variables. Press [pic] ALTER to change the variable.
3. Turn the key to RUN position. [pic]
4. Press [pic] OK to confirm the chosen protocol. Remove the key, and press Start [pic] to resume pump operation.
Changing the default set up (e.g. to alter the Morphine concentration for NCA or for Fentanyl PCA)
1. Insert pump key in front of Key Switch & turn to [pic] Set position.
2. Press Modify Protocol.
3. Use [pic] & [pic] button to highlight Drug Name--Morphine.
4. Press [pic] to switch to another drug name e.g. Med. 2.
5. Press Confirm to defect the pre-set protocol.
6. Highlight the options & alter the values.
7. Press Confirm & OK to save the setting.
Refilling the syringe
1. No need to stop the pump.
2. Clamp the extension tubing, then press [pic] to Stop the pump.
3. Insert the key to the left side of the pump and open the cover.
4. Prepare the new syringe according to the prescription chart. Use Terumo 50 ml syringes only. Replace with the new syringe (see above on “Loading the pump”).
5. Close the cover & remove the key.
6. Press [pic] OK to confirm the syringe type as TERUMO 60 ml.
7. Press [pic] Start to commence pump operation.
Priming the extension (pump not connected to patient)
1. The pump in [pic] RUN position.
2. Press [pic] to Stop the pump.
3. Insert the key to the left side of the pump and open the cover.
4. Press [pic] buttons together until fluid flows, and release [pic] after it is done.
5. Close the syringe cover & press [pic] Start to resume pump operation.
Bolus dosing (pump connected to patient)
1. The pump in [pic] RUN position.
2. Press [pic] Clinician over-ride button, hold for 2 seconds.
3. Use [pic] & [pic] and [pic] NEXT to enter access code 321, press [pic] OK
4. Use [pic] & [pic] buttons to select BOLUS and press [pic] OK
5. Use [pic] & [pic] buttons to specify the dose, then press [pic] OK.
6. Press [pic] OK to select delivery time as STAT
7. Press [pic] YES and begin a bolus.
Default settings of the Alaris pump
|ICONS on display |YES |
|Protocols in use |1 |
|Modify protocol |YES |
|Handset mode |C |
|Delayed call-back |NO |
|Display Sleep |YES |
|Chirp low alarms |YES |
|Continuous infusions |NO |
|Loading doses |NO |
|Max. dose limits |YES |
|Variable dose rates |NO=Stat rate |
|Comms pump identity |001 |
|Comms enabled |NO |
|Nurse call |NO |
|Nurse call inverted |NO |
|Continuous Print |NO |
|Default Syringe |TERUMO |
|Lock syringe type |YES |
|Quiet mode |NO |
|Generic Drug Enabled |YES |
|Max Dose Limit Alarm |YES |
|Mix Mass & Vol Modes |YES |
Default protocol
|Drug Name |Morphine |
|Drug Conc. |1mg/ml |
|PCA Dose |1mg (1ml) |
|Lockout Period |5mins |
|Occlusion Level |5 |
|Continuous |0 |
|Loading Dose |0 |
|Max Limit |40 |
|Limit Duration |4h |
Default drug setting
|Drug Name |Morphine |
|Dose Mode |Mass |
|Min. Drug Conc. |1mg/ml |
|Max. Drug Conc. |99.9mg/ml |
|Min. Lockout period |5mins |
|Max. Lockout period |180mins |
|Min. PCA Dose |0ug |
|Max. PCA Dose |99.9mg |
|Max. Continuous |999mg/h |
|Max. Loading dose |99.9mg |
|Max. Max Limit |999mg |
|Max. Clinician bolus |3mg |
OPERATION GUIDE: THE GEMSTAR INFUSION PUMP
Loading the cassette
1. Push down on the flow stop to close 2. Release the flow stop after inserting
the cassette the pin into the medication bag
3. Hold the cassette upright and squeeze 4. Open the case with the key
the bag to prime the tubing (see the
water level coming up). Close the
cassette again.
5. Place the medication bag into the case 6. Make sure all the 4 latches are
and load the cassette into the side of engaging the cassette
the pump
7. To unload the cassette, open the top lid,
and press the unload button.
8. Close the lid, lock the cage, and don’t
forget to remove the key.
Programming the pump
1. Press to to turn on the pump, and press [pic] to confirm the use of batteries
2. To unlock the pump, press [pic],
select 2 CONTAINER, then enter 13000.
3. Select 3 CLR PROG, SHIFT AND HISTORY
4. Select 1 CONTINUOUS as the delivery mode
5. Select 3 SELECT ml for the unit, enter the infusion rate in ml/hr, then press [pic]
6. Press [pic] to omit loading doses
7. Enter the reservoir volume in mls, then press [pic]
8. Select 1 ON for air sensitivity
9. Go through the program with the [pic] and [pic] keys, press [pic] when done.
10. Lock the pump by pressing [pic] , select 3 KEYPAD LOCK, then 2 CONTAINER, then enter 13000.
11. Press [pic] to commence pump operation. The symbols (▶▶▶▶▶▶C will roll at the bottom of the display.
12 During the programming, press [pic] will bring the display back to the previous question, while pressing [pic] will reset numerical entries to zero.
Checking consumption
The total volume infused is displayed continuously.
Reviewing the program
1. No need to stop or unlock the pump.
2. Press [pic], select 1 REVIEW PROGRAM. Use the [pic] and [pic] keys to go through the program, and press [pic] when done. The pump will continue during the procedure.
Changing the program
1. Press [pic] .
2. Unlock the pump by pressing [pic] , select 3 KEYPAD LOCK, then select 2 CONTAINER, then enter 13000.
3. Press [pic] , select 3 CHANGE PROGRAM. Enter and review the new program.
4. Lock the pump by pressing [pic] , select 3 KEYPAD LOCK, then select 2 CONTAINER, then enter 13000.
5. Press [pic]. The new program will take effect, while the total dose from the previous program will continue to accumulate into the new program.
Refilling the medication bag
1. Press [pic] .
2. Clamp the tubing. Open the case and change the medication bag according to the prescription on the medication chart.
3. Reset the volume by following the above steps for changing the program. Remember to lock the pump, lock the case, and unclamp the tubing.
4. Press [pic] and resume pump operation. The total dose will continue to accumulate into the new program.
Bolus dosing
1. Press [pic] .
2. Unlock the pump by pressing [pic] , select 3 KEYPAD LOCK, then select 2 CONTAINER, then enter 13000.
3. Press [pic] and then press 0. .Press [pic] again to program a loading dose.
4. Enter the volume in mls and press [pic]. Press [pic] again to deliver the loading dose. The message “Loading ▶▶▶▶▶▶” will roll until the end of loading.
5. Lock the pump by pressing [pic] , select 3 KEYPAD LOCK, then select 2 CONTAINER, then enter 13000.
6. Press [pic]. to resume pump operation. The loading dose will be added into the total dose delivered.
MEDICAL TOOLKIT FOR PATIENTS WITH ACUTE PAIN SERVICE MODALITIES
Respiratory depression
1. This is life threatening and must be attended immediately. Inform the pain MO (pager 1067). When the pain MO is engaged in other urgent clinical duties, the intensivist on call and the medical staff of the parent team should be consulted for resuscitation.
2. All patients difficult to arouse are at risk of developing respiratory depression and should be treated. Classical signs such as pin-point pupils or slow respiratory rate are not sensitive, and desaturation (reduced SaO2) is too late.
3. Secure patient’s airway, turn lateral if possible. Give oxygen supplement, and start manual ventilation if patient is not breathing adequately.
4. Stop the APS device immediately. Retain the device for review, including the set up, connections, program and consumption history.
5. Naloxone is usually not required for mild cases and might have significant side effect of withdrawal. Consider Naloxone if patient has significant sedation with opioid use, and is at risk of physiological deterioration (e.g.: desaturation). Dose: 0.1-0.2 mg iv/im/sc and repeat at 3 minute interval until patient recover or when a maximum of 10 mg is given. It is available in every clinical area in the emergency trolley. All patients receiving Naloxone should be reviewed by the Intensivist for consideration of ICU admission.
6. Review and exclude total spinal blocks and local anaesthetic toxicity for patients with epidurals or other head and neck regional blocks.
7. Document the event in patient’s notes and inform AIRS for significant respiratory depression with APS modalities (SaO2 < 90% on air, respiratory rate < 6, unarousable patients)
Hypotension
1. All patients with hypotension must be attended at the earliest convenience. Inform the pain MO (pager 1067). When the pain MO is engaged in other urgent clinical duties, the medical staff of the parent team should be consulted for resuscitation.
2. Exclude and treat important causes of hypotension, such as hemorrhage, sepsis, cardiogenic shock, etc. Observe the patient hourly.
3. For patients with epidural infusions, stop the infusion, and give intravenous fluid (e.g.: 500 ml of colloid over 10 minutes for an average size adult) ± vasopressors. Check the level of sensory blockade. Re-commence the infusion at 50% of original rate after the hypotension is managed, and the level of blockade is appropriate. Titrate the infusion rate according to clinical response. Consider converting to other modes of analgesia if hypotension remained a problem.
4. Intravenous opioids are generally hemodynamically stable in healthy subjects. It might unmask other causes of shock. In case of doubt, stop the PCA, and recommence at reduced doses after stabilization.
Inadequate analgesia
1. All patients with inadequate analgesia must be attended.
2. Check that the pump is running and the drug reservoir is not empty. Exclude disconnections or occlusions.
3. Inform the APS team (DECT phone 6172 or page the pain MO at 1067) to review the set up and program of the APS device.
4. Stable patients with intravenous PCA may receive boluses of morphine 0.02 mg/kg intravenously at 5 minute intervals up to 0.1 mg/kg.
5. Stable patients with epidural / nerve blocks should have their sensory level checked. If the sensory level is inadequate, increase the basal infusion rate by 50%. If pain is distressing, give a 4 ml bolus of either the same solution or 0.125-0.25% bupivacaine and monitor the blood pressure every 5 minutes for 30 minutes.
6. All top-ups should be done by the pain MO. The pain MO also has to review the patients after the increment.
7. Give co-analgesics (see page 34).
8. Other considerations with ineffective analgesia include surgical complications, patient confusion, tolerance to analgesics, or presence of neuropathic pain. If still not effective, consult pain specialist.
Pruritus
1. Give Chlorpheniramine 5 mg iv or im. If tolerating oral intake, prescribe oral preparation 4 mg.
2. Consider Naloxone at 0.01 mg bolus iv for patients with epidural or spinal opioids.
Nausea and Vomiting
1. Exclude hypotension or hypoxia, and other causes such as ileus or raised intracranial pressure.
2. Give Metoclopramide 10 mg q4h i.v. p.r.n. Consider Ondansetron 4 mg q12h iv p.r.n. as the second line.
3. If vomiting remained severe despite symptomatic treatment, please call the APS team for re-programming or switching to other modalities of pain relief.
Leg weakness
1. Inform the APS team (DECT phone 6172 or the pain MO pager 1067). For patients on epidural infusions, check the level of neurological blockade. Stop the infusion if the blockade is adequate and review in 2 hours. If leg weakness resolves, restart infusion with reduced concentration of LA by 30%. Consider alternate mode of analgesia if weakness recur or if pain become difficult to control.
2. If leg weakness persists despite discontinuation of epidural infusion, continue hourly neuro-observation and look for signs of hematoma / abscess (such as acute back pain, lower limb acute pain or neurological impairment, fever, urinary retention or incontinence). Inform the neurosurgeon on-call if the clinical picture is compatible. Offer another mode of analgesia for rescue.
Urinary Retention
1. A trial of 30 minute is allowed. Perform up to two “in-and-out” catheterizations before inserting an indwelling catheter.
2. Observe for signs of neurological damage. Inform the pain MO if they are present and follow the leg weakness protocol (see above).
Paresthesia
1. Mild paresthesia in the area of an epidural / nerve block may be expected.
2. Follow the leg weakness protocol (see above) if the paresthesia is dense and disturbing to the patient.
Patchy Neurological Blockade (epidural only)
1. Consider withdrawing the epidural catheter by 1 cm and top-up with another bolus of epidural LA. Consider switching to epidural morphine protocol or non-regional modes of analgesia.
Difficulty in Removing the Catheter
1. Stop pulling if the catheter is starting to stretch. Try to flex the back as much as possible and pull the catheter out with a steady force. If it fails, contact the OT senior on call. Consider surgical removal under LA.
Broken or disconnected Catheter
1. Stop the infusion and inform the APS.
2. If the catheter at the patient side is still accessible, clamp the distal end with artery forceps. Do not reconnect or remove the broken catheter.
3. The APS shall attempt to remove the disconnected or broken catheter at the patient side (see above), as well as all bits at the machine side. All broken parts shall be saved.
4. If the broken catheter is embedded or not removable at the bed side, cover the site with sterile gauze followed by transparent dressing. Consult neurosurgery on call for consideration of imaging or surgical removal.
5. Review patient for analgesic plan, neurological status and offer explanation. Document in patient’s notes.
6. For broken catheters, inform AIRS, and report to the manufacturer of the catheter or part.
Please remember to document these events in the follow-up charts, patient notes and critical incidence forms (if appropriate).
SUPPLEMENT: CO-ANALGESIA
Co-analgesia can improve the quality of pain relief and might have dose sparing effect on other APS modalities.
This is a list of co-analgesics available at the time of writing (June-2009). Doses are applicable to healthy non-pregnant subjects only. Please refer to standard references for details on clinical pharmacology.
Non-opioids
| |Adult dose |Pediatric dose |
|Paracetamol |0.5 - 1.0 g q6h (oral) |15 mg/kg q6h (oral) |
|(Panadol) |1-2 gm q6h (rectal) |30 mg/kg q6h (rectal) |
|Diclofenac |100 mg slow release daily (oral) |0.5 mg/kg q12h (oral) |
|(Voltaren) |25 mg q8h (i.m.) | |
|Indomethacin |25-50 mg tds (oral) |1 mg/kg/ q12h (oral/rectal) |
|(Indocin) |100 mg bd (rectal) | |
|Naproxen |250 mg tds | |
|(Naprosyn) | | |
|Ibuprofen |200 mg q6h |4 mg/kg q6h (oral) |
|(Brufen / Nurofen) | | |
|Ketorolac |30 mg q12h for 2 days (i.v./i.m.) |0.5 mg/kg q12h for 2 days (i.v./i.m.) |
|(Toradol / Algikey) | | |
|Etoricoxib (Arcoxia) * |90 mg daily (oral) | |
|Celecoxib |200 mg q12h (oral) | |
|(Celebrex) ** | | |
* prescribed by Anaesthetists only
** prescribed by physicians only
Contra-indications
1. Personal or familial history of allergies or atopy
2. NSAID: history of dyspepsia, or peptic ulcer, renal impairment, or patients after procedures that carry high bleeding risk e.g.: brain surgery, on-going hypovolemia, bleeding tendencies
3. Paracetamol: liver impairment.
Mild opioids
Opioid co-analgesics might exacerbate sedation with APS modalities. Prescription of concurrent opioids or sedatives shall be supervised by the APS team.
| |Adult dose |Pediatric dose |
|Codeine |30 mg qid (oral) |0.5 mg/kg q4h (oral) |
|Dihydrocodeine |30 mg qid (oral) | |
|(DF118) | | |
|Tramadol (Tramol) |100 mg tds (oral/i.v./i.m.) |2 mg/kg tds (oral) |
|Tramadol + Paracetamol (Ultracet) * |2 tab. qid (oral) | |
* prescribed by Anaesthetists only
NURSING GUIDELINES – RECOVERY ROOM
The recovery room is a transition between the operating theatre and the general wards. Patients are adapting to a variety of changes including their first experience of post-operative pain. The recovery room nurses are the front line personnel in providing pain relief for these patients.
General principles
1. Inadequate pain relief after surgery increases morbidity and delays patient discharge from recovery room.
1. While the pain relief protocol is ordered and supervised by the Anesthesiologist in charge of the case, the nursing staff is trained to administered intravenous opioid for postoperative pain relief. They are competent in assessing and managing the adverse effects of these modalities.
2. The nursing staff is also trained to initiate and maintain the APS modalities. They worked together with the pain nurse to ensure smooth administration of the APS
Pain related routines of the Recovery Room nurse
1. All post-operative patients shall be assessed and document, on the Anaesthetic record, the severity of pain upon arrival and discharge from the recovery room.
2. Staff members shall administer analgesics according to the prescription on the Anaesthetic record (see below). Pain scores more than 4 shall be reported to the case Anaesthesiologist (or surgeon for LA cases).
3. After being informed of the daily APS pump allocation at 0830 the recovery room staff shall get the pumps and accessories ready, with proper labeling.
4. When patients arrived at the recovery room with their APS pumps, staff shall initiate the pumps after the following has been confirmed:
• the prescriptions at the nursing observation charts are compatible with those on the medication and the program in the pump.
• the pumps are properly set up, lines unclamped and labelled, and cases locked.
• the modality is attached to the proper port by the recovery room nurse according to existing nursing protocols. For CEI pumps, please refer to “Administration of Medication: Epidural / Intrathecal (Spinal) drugs in operating theatre 2007” (see supplement).
• PCA patients are reminded on the use of the handsets
5. Staff shall handover the pumps together with the accessories to the ward staff upon discharge from the recovery. They shall also inform the pain team (DECT phone 6172 during weekdays 0800-1600, pain pager 1067 in other times) and update the pump location board at the control desk of the recovery room.
6. Upon return of the pumps from the wards, the recovery room staff shall make sure that the pumps are intact with all the accessories, clear all previous history, perform a simple battery test and replace if necessary, and update the pump location board.
7. Recovery room staff shall maintain and updates the stock of all APS equipment & accessories and consumables, and the pain / regional block trolley
Recovery room Opioid Protocol
Adults
1. Dilute 15 mg morphine to 15 ml with normal saline. If the Anaesthesiologist bring along any opioids, make sure that they are named and the concentration specified. Other opioids might be used at the discretion of the Anaesthesiologist.
2. Default dose: 1-2 ml (1-2 mg) every 5 minutes as required, or as specified by the Anaesthesiologist
4. Total dose limit to be stated by anesthesiologist. If pain not relieved with dose limit, the nursing staff will inform the anesthesiologist to reassess the patient.
5. This protocol may precede the commencement of PCA opioid. Start PCA when patient is loaded with adequate doses of opioids, and is alert enough to use the pump. Stop the opioid protocol when PCA is started.
5. Stop when the patient is comfortable. (Patient need not to be completely pain free). Discard any leftover opioids when patient is discharged.
6. Inform the anesthesiologist of any side effects e.g. hypotension, desaturation (low SpO2), nausea or vomiting, itchiness, etc.
Paediatrics
1. Morphine 20 mcg/kg q5min intravenously up to 5 doses, then review
Sedation score
1 = alert
2 = drowsy, easy to arouse
3 = difficult to rouse
4 = unconscious, not arousable
S = normally asleep, easy to rouse.
Pain score
1. Patient’s self report is preferred to subjective ratings by staff members.
2. Use the Visual Analogue Scale with the “pain ruler” or the Numerical Rating Scale.
3. 0 = no pain, 10 = worst imaginable pain
Supplement: Epidural medication administration by nurses in recovery room using pain management pump
|1) Countercheck the infusion bag regarding patient name, drug name and |2) Ensure the bag is labeled with “Epidural” warning by anaesthestist |
|concentration against the APS form | |
|[pic] |[pic] |
|3) Label the infusion tubing and epidural filter with “Epidural” warnings |4) Secure the anti-siphon valve with tegaderm |
|(Epidural tubing should be traced back carefully to the site of insertion) | |
|[pic] |[pic] |
|5) Connect the epidural filter with infusion tubing in aseptic technique |6) Cover the connection with tegaderm on patient’s chest |
|[pic] |[pic] |
|7) Ensure the tubing and its connection is secured |8) Aminister the infusion at prescribed rate |
|[pic] |[pic] |
NURSING GUIDELINES – GENERAL WARDS
General
1. Ward nurses are trained to look after patients with post-operative pain management modalities. The APS shall liaise with the various parties (ward managers and training institutions) for updates and training for both new comers and current staff.
Receiving patients with pumps from OT
1. Please check that the pump and accessories are compatible with the loan form, and the medication bag / syringes are labeled with patient’s identity. Any keys must be removed from the pump and kept at the nursing station / DDA cupboard.
2. Put the pumps below or at the same level of the patient to prevent accidental siphoning leading to an overdose.
3. All patients must have an intravenous access (either a running drip or block) apart from the dedicated line for the APS device. The exception is when intravenous access is very difficult, and an Y connector is in use (see page 8). Avoid using 3-ways for the dedicated line for PCAs
4. For epidural / regional analgesia infusions, make sure that they are labeled correctly and connected to the correct catheters. A bacterial filter 0.22 (m must always be in place.
5. Post-operative care instructions are set in the patient’s notes. All patients shall be observed using the nurse observation chart in the patient’s folder. Items include:
• Vital signs: BP, pulse, respiratory rate, SpO2
• Pain ratings: pain intensity
• Consumption of the PCA: the demand / good information (PCA only)
• Side effects: sedation, nausea, (epidurals only) lower limb power or discomfort
Please observe the patient hourly until assessed by the pain team.
N.B.: drowsiness, desaturation, hypotension and lower limb weakness could be dangerous. Inform whenever any of these occur.
6. The APS team has been informed and will review the patient at the earliest convenience. If the patient was not attended for more than 24 hours, please call the pain team (DECT phone 6172 from 0800-1600 weekdays, pain pager 1067 for other times) for review.
Maintenance phase
1. The pain team will review the patient daily (usually in the morning) and document any updates in the progress notes. You will be advised as well.
2. Only the patient could use the PCA, not even the relatives or any staff member (except NCA for minor patients. See page 42). Please separate the PCA handset from the nurse call bell.
3. Please keep the Alaris PCA pump connected to the AC power. The internal battery could support brief periods of .patient ambulation only.
4. The pump will alarm ~ 20 minutes before the medication run out.
• The prescription for refill is on the as-requested prescription chart (a gum label on the “yellow form”). Drugs are available as ward stock and at the DDA cupboard.
• Prepare the drug mix accordingly with aseptic technique, 3 checks and 5 rights
• To refill the pump, please refer to the operation manual (see page17 for Alaris pump and page 25 for Gemstar pump in this guideline). For the Gemstar pump please reprogram the reservoir volume according to the protocol (see page 7). Please remember to lock the case and don’t forget the key.
• Please confirm the correct route of administration with the nursing observation chart. Inadvertent administration of epidural medications intravenously or vice versa can be potentially life-threatening.
• Document in the prescription chart
5. When there is an alarm:
• Attend the patient, make sure he / she is stable and alert
• Read the alarm message before muting it and problem solve accordingly
• Call the pain team if you need any assistance. Do not remove, reprogram or stop the pump unless there is imminent danger of drug overdose.
Termination phase
1. The pain team shall advise on the timing of stopping the APS modality.
2. For iv PCA, simply disconnect. Please discard the residual drugs, and return the pump and the accessories to the recovery room or the labour ward.
3. Epidural catheters shall be removed at the bedside when:
• The APS is satisfied with the coagulation profile of the patient. Patients known to have clotting derangements or on anticoagulants must have their coagulation corrected before catheter removal.
• Only the APS or ward staff trained by the APS can perform the removal.
• Position the patient with flexed spine, aseptic technique, one single pull, followed by a simple occlusive dressing.
• In case of difficulty in removing the epidural catheter, stop pulling and please call the APS for review (also see page 33).
Drugs and equipment available in the ward
1. PCA keys, nursing observation charts
2. Resuscitation equipment and medications, O2 supply and delivery devices
2. Local anaesthetic solutions (Lignocaine), opioids (Morphine, Fentanyl and Pethidine), resuscitation trolley drugs (Adrenaline 1:10,000 and Naloxone 0.4 mg/ml syringes)
Supplement
APS Nursing Standing Order
Oxygen supplement as prescribed
Vital signs - Hourly BP, Pulse, SpO2, Pain Score, Sedation Level, RR
Patients on epidurals: Paraesthesia, Leg weakness
Inform Pain Team (pager 1067 / DECT phone 6172) if
1. Inadequate pain relief, Pain score > 3
2. Drowsy or over-sedated
3. Abnormal vital signs eg hypotension (< 90/40), respiratory rate < 10/min or low SpO2
4. Severe nausea & vomiting, itch
5. Leg weakness or numbness is present
1 Crisis if patient is
1. Unarousable
2. Respiratory rate < 8/min or gagging (airway obstruction)
4. Severe hypotension (80/40)
Management
1. Immediately notify any medical staff that may be on hand
2. Call the crash call (ext.2468). Then page the Pain Team (pager 1067 / DECT phone 6172).
3. Administer oxygen via a Ambu bag
4. If a patient has no respiration, administer Naloxone (Narcan) IV: 0.1 mg. Repeat within 2 minutes if there is no response up to 0.8 mg
5. If hypotension, give colloid 250 ml stat. Draw up Adrenaline.
PAEDIATRIC PAIN RELIEF
General measures
1. This is a guide on paediatric pain management for patients with APS modalities.
2. Pain relief modalities for adults, such as the PCA, CEI, use of co-analgesics, are also available to paediatric patients. The Nurse Controlled Analgesia (NCA) is a modification of the PCA for peadiatric or minor patients.
2. Pain assessment by patient’s self report (eg: verbal rating, visual analogue scale, Wong-Baker’s faces scale) are preferred to subjective rating by staff member.
3. Keep invasive procedures to a minimum. Apply topical anaesthesia with EMLA cream 60 minutes before the procedure when applicable.
4. Engage the caretaker by education on the appropriate use of pain relief modalities.
Nurse Controlled Analgesia (NCA)
1. The Alaris PCA pump is used for both PCA and NCA. The setup is similar to the adult PCA except that
• the Morphine concentration is different from the default in the pump. The Anaesthesiologist has to change the default program accordingly. See page 17 and 21 for details.
• the handset shall be kept away from the patient.
2. The APS team members, nurses at ward 7CD (pediatric surgical wards) and the ICU are trained and authorized to use the NCA. Other staff or relatives must not activate or program the NCA device.
3. Recommended initial program for intravenous NCA morphine:
• Dilute 1.2 mg/kg of Morphine into 60 mls of normal saline, use Terumo 50 ml syringes only
|Bolus dose |1 ml |
|Lockout period |7 - 10 min |
|Max. 4 hr dose limit |0.3 ml/kg |
Continuous Epidural Infusions
1. The set up is the same as per adults. The Gemstar infusion pump is used.
2. Prepare one of the following regimens:
• Aspirate 24 mls out of a 100 ml Saline bag. Add 20 ml of 0.5% Levo-Bupivacaine (Chirocaine) with 4 ml (200 mcg) of Fentanyl into the bag. Final concentrations: Levo-Bupivacaine 0.1%, Fentanyl 2 mcg/ml, total volume: 100 ml
Label the medication bag using the green gum label, and all connections with the “EPIDURAL” tag.
3. Recommended initial program for paediatric epidural infusions
|Levo-Bupivacaine & Fentanyl |
|Reservoir volume |90 ml |
|4 hour limit |Nil |
|Infusion rate |0.1 – 0.4 ml/kg/hr |
4. Pediatric epidurals might be inserted via the caudal route. Daily check for soiling of the epidural site is mandatory.
3. Other nursing observations are identical to the adult case. Hypotension with epidural is un-common for patients aged below 2, and if so, please watch out for other causes eg: hypovolemia.
Common co-analgesics and resuscitation drugs
Paracetamol
15 mg/kg q6h ie 60 mg/kg/day orally, double the dose for rectal use
Diclofenac
0.5 mg/kg q12h orally
Indomethacin
1 mg/kg q12h orally or rectally
Ketorolac
0.5 mg/kg q12h for 2 days im or iv
Tramadol
2 mg/kg tds orally or im or iv
Codeine
0.5 mg/kg in q4h orally
Naloxone
10-50 μg/kg iv, repeat at 3 minute intervals till responsive, followed by 1-5 μg/kg/hour infusion till the offending opioid is eliminated.
TRAUMA PAIN RELIEF
The following is an extract of the 2006 protocol titled “Acute Major Trauma Pain Management Guideline for PWH Accident and Emergency Department & Paediatric Surgical Trauma Service in NTEC”, jointly prepared by the Department of Accident and Emergency Services and the Department of Anaesthesia and Intensive Care.
Flowchart for A&E analgesia
[pic]
General Principles of Pain Management
Consciousness
For unconscious patients, resuscitation takes precedence over analgesia.
Assessment
All conscious patients should be assessed specifically for pain along with other vital signs2.
Document findings on the clinical notes.
Identify source of pain
Be alert for non-traumatic sources such as angina.
Be aware for compartment syndrome when limb pain is difficult to control.
Physical methods
Simple measures such as local ice for soft tissue injuries, immobilization of fractures. Note that analgesia is often required prior to application of physical methods.
Avoid flammable sprays such as Ethyl Chloride.
1st line analgesia
NSAID or others
Relative contraindications
• Age > 70 or < 2
• Any signs of CVS instability or ongoing blood loss
• History of active GI ulcer, renal disease, asthma or allergies towards NSAID, bleeding tendency or use of anticoagulants
Doses of NSAIDs
• Ketorolac (Toradol injectable)
Adult im/iv: 15 mg q6h for 2 days
• Paracetamol (Panadol tablet)
Adult / pediatric oral: 20 mg/kg qid alone for mild pain only.
Sucrose solution (oral) up to 2 mls for infants requiring minor procedures3.
Opioids
Relative contraindications
• GCS ≤ 13
• Pending airway obstruction or respiratory failure
• Hypotension (eg: 70, chronic renal or hepatic diseases: cut all doses by 50%:
Pethidine has NO extra benefit and should NOT be used
Intramuscular or subcutaneous injections should NOT be given.
All patients receiving strong opioids should be monitored with:
• Presence of qualified medical / nursing staff
• Clinical: GCS and pain score
• Continuous pulse oximetry
• Resuscitative equipment and Naloxone should be readily available
Documentation
All patients receiving strong opioids should have the following documentation:
• Pain score every 15 minutes
• Type and dose of analgesia given.
2nd line analgesia when 1st line drugs are contra-indicated, not effective or develop side effects.
Ketamine
Contraindications
• History of head injury, mental illness or psychoactive substance abuse (including alcohol)
• GCS at or below 13
• Presence of any arrhythmias
• Pending airway obstruction or respiratory failure
Doses
• Initial loading at 50 mcg/kg (iv), followed by 20 mcg/kg (iv) boluses every 10 minutes up to total dose of 200 mcg/kg.
Monitor as per strong opioids
Nerve blocks
Contraindications:
• Expertise not available
• Patient un-cooperative, refuse intervention or GCS impaired
• Bleeding tendency
• Local sepsis or distorted anatomy
• Risk factors for local anaesthetic toxicity:
• Acidosis, electrolyte imbalances and respiratory failure
• Underlying arrhythmias
• Lignocaine > 3 mg/kg bolus (up to 7 mg/kg with adrenaline)
• Bupivacaine or Ropivacaine > 2 mg/kg
• Other specific contraindications such as contralateral pneumothorax for intercostals, etc.
Examples (please refer to standard text for technical details9)
• Field infiltration eg: scalp lacerations
• Digital blocks for finger injuries (NB: avoid Adrenaline containing LA)
• Intercostal blocks for uncomplicated fracture ribs
• Femoral blocks for thigh injuries. Technique of choice for femoral fractures. Use 10ml 1% lignocaine with 10 ml 0.5%Marcaine for routine use in adult patients.
Monitoring: patients with local anaesthetic blocks should have continuous ECG, BP and neurological monitoring till full onset of the blocks.
Methods of pain relief for paediatric trauma patients3
Systematically active drugs
Non-opioid analgesics
Paracetamol for mild pain only
• Oral loading dose at 20mg/kg
maintenance dose at 50 mg/kg/day
maximum daily dose: 90mg/kg/d (60mg/kg in neonates and infants) for up to 72 hours
• Rectal loading dose at 30mg/kg (20mg/kg in neonates and infants)
maintenance dose at 20mg/kg (15mg/kg in neonates and infants)
maximum daily dose: 90mg/kg (60mg/kg in neonates and infants) for up to 72 hours
Indomethacin
• Contraindication: Age < 2
Any signs of CVS instability or ongoing blood loss
Hx of GI ulcer, renal disease, asthma or allergies towards NSAID, bleeding tendency or use of anticoagulants
• Oral: 4-10mg/kg 6-8 hourly
• Rectal (for age: 2-15 years old): 1-3mg/kg/day in 3-4 divided doses
maximum single dose: 50mg
Opioid analgesics and sedatives
Morphine
• Contraindications: mentally confused or GCS < 13
Pending airway obstruction or respiratory failure
Hypotension with clinical evidence of shock
• IVI - 0.05mg/kg and titrate to effect
• IMI - 0.1-0.2mg/kg in 4-6 hourly
• maximum single dose : 10mg
Fentanyl (for short procedures in patients aged > 2 years old)
• 0.5 mcg/kg bolus (iv) every 5 minutes up to 3 doses
Midaziolam (for longer procedures & anxious patients)
• 0.05-0.15mg/kg (iv) and titrate to effect
Non-pharmacological interventions
Environmental factors
Supportive and distractive techniques
Music and art therapy
Local ice therapy for soft tissue injury
Immobilisation of fractures
Review
Effect and side effects must be reviewed after the anticipated onset time, and doses have to be titrated (or switched to other modalities).
Decision to stop should also be documented in clinical notes.
Handover
Type and dose of analgesics should be handed over to the receiving parent team when patients are transferred
Special Cases
Spinal injuries, abdominal injuries
Concerns that analgesics may mask the symptoms and interfere with clinical judgment are largely anecdotal, and are proven not true repeatedly4.
Airway obstruction and burns
These patients are prone to further obstruction when sedatives are given. Judicious use of opioids with close monitoring is needed. In case of doubt one should consider securing the airway first before further doses of opioids.
Transfer
This is a high risk period when patients may develop ongoing sedation while support is limited. For patients breathing spontaneously, avoid transferals for 10 minutes after the last dose of strong opioid / ketamine. Discharge to another parent team should be accompanied by documentation of current analgesic plan.
Opioid tolerance
Opioid tolerance may develop in chronic pain patients receiving long term opioids, or with opioid abusers. Strong opioids are indicated for both pain management and for preventing withdrawal. They are not contraindicated for strong opioids provided that they understand and comply with the treatment protocols. For pain control, consider supplements such as NSAID or regional nerve blocks.
References
1. Inadequate analgesia in emergency medicine. Rupp T. et al. Annals of Emergency Medicine 2004 43(4): 494-503
2. The ‘fifth vital sign’. Yuen TST et al. Hong Kong Medical Journal 2005 11(3): 145-6
3. Clinical Practice Guidelines. Royal Children’s Hospital, Melbourne. .au/clinicalguide/cpg.cfm?doc_id=5144
4. Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Chapter 37. Agency for Healthcare Research and Quality, US Department of Health and Human Services. clinic/ptsafety/chap37a.htm
5. Acute pain guidelines 3rd Edition. Department of Anaesthesia and Intensive Care, PWH. PWH intranet:
6. Acute Pain: a guide for RMOs. Westmead Hospital, Sydney. pain/Acute%20_RMOs.html
7. Local Practice Guidelines. Edinburgh Orthopaedic Trauma Unit. trauma.co.uk/local.htm
8. Acute Pain Management: Scientific Evidence 2nd Edition 2004. Australian and New Zealand College of Anaesthetists. anzca.edu.au/publications/acutepain.pdf
9. Interventional Pain Management 2nd Edition 2001 WB Saunders. Editor: SD Waldman
RIB FRACTURE PROTOCOL
The following is an extract of the protocol “Protocol for pain management of multiple rib fracture (fracture >=3 ribs)”, developed by the Department of Anaesthesia and Intensive Care
Flowchart for selection of analgesia in multiple rib fracture
Principle
1. Inadequate pain control in multiple rib fracture limit ability to cough and breath deeply, resulting in sputum retention, atelectasis, reduction in FRC, compromised lung compliance, ventilation-perfusion mismatch, hypoxemia and respiratory distress.
2. Resuscitation precedes pain relief
3. Frequent review of patients is required: pain score, respiratory function (RR, SaO2, triflow spirometry), SE
4. Multimodal analgesia is recommended
Regional analgesia:
**For epidural analgesia and thoracic paravertebral analgesia, please check availability of pain procedure session with the pain nurses.
Epidural analgesia
1. The preferred technique after severe blunt thoracic trauma
2. Patients with >=4 rib fractures who are >=65 years of age should be provided with epidural analgesia unless contraindicatedYounger patients w/ >=4 rib fracture or patients aged >=65 with lesser injuries should be considered for epidural analgesia
3. Advantages:
• superior analgesia with increase in FRC, dynamic lung compliance, VC and PaO2, reduction in airway resistance
• change shallow breathing to near normal and reduce paradoxical chest wall movement
• modify immune response
4. Disadvantages:
• technically demanding, esp. distressed in pain
• may mask intraabdominal injury
• cause hypotension
5. side effect (nausea, vomiting, urinary retention, respiratory depression, pruritis)
6. complication (dural puncture, epidural haematoma, spinal cord trauma)
Thoracic paravertebral infusion
1. Also an effective analgesia, resulting in improved respiratory parameters and ABG
2. Advantages:
• unilateral segmental blockade sparing the central nervous system, and allows continuous neurologic assessment (especially in patents with head injury or concomitant lumbar spinal injury)
• technically simple, does not require palpation of rib, feasible for fractures of upper ribs
• lower incidence of complication like urinary retention and hypotension
3. Complications: hypotension, vascular puncture, pleural puncture, pneumothorax, inadvertent epidural anaesthesia
Intercostal nerve block
1. Improve peak expiratory flow rate and volume
2. Disadvantages:
• Technically difficult for upper ribs Require multiple injection-painful
• Time consuming
• Predispose to local anaesthetic toxicity
3. Complication: pneumothroax
Intrapleural
1. Less complications like hypotension, urinary retention, lower extremity paresthesia and weakness
2. Disadvantages:
• Significant amount of anaesthetic may be lost in presence of chest drain (may require temporary clamping which may cause tension pneumothorax)
• Theoretically impair diffusion of anaesthetic in presence of haemothorax
• Posture-dependent
3. Complication: pneumothorax
Medications
Paracetamol (oral/PR) 1g qid
• Contraindication: hepatic derangement
NSAID:
• Provide effective analgesia.
• Contraindicated for patients with GI upset, renal dysfunction, CVS instability, bleeding tendency, head injury, allergy
Voltaren SR (oral) 100mg daily
Ketorolac (iv) 15mg BD for 2/7
Weak opioids
Dologesic tab 2 qid
• Contraindications: hepatic derangement, allergy
Tramadol (oral/ iv/ PR) 50-100mg tds
• Side effects: nausea, vomiting, dizziness
• Contraindications: concomitant MAOI
Strong opioids:
Advantages:
• Improve pain score and vital capacity
• Ease of administration by nurse without risk of invasive procedure
Morphine: iv PCA- loading dose required or iv morphine prn (only in ICU)
• Side effects: respiratory depression, sedation, cough suppression
Reference:
Manoj K. Karmakar and Anthony M.H. Ho: Acute pain management of patients with multiple fractured ribs. The Journal of trauma injury, infection and critical care: vol 54, no. 3, 2003
Eastern Association for the Surgery of Trauma: Pain Management in blunt thoracic trauma. An evidence-based outcome evaluation 2nd review-2003
KNEE AND HIP REPLACEMENT PROTOCOL
The following is an extract from the protocol “Protocol for Post-operative Pain Management in Patients After Joint Replacement Surgery”, promulgated by the Department of Anaesthesia and Intensive Care
1. All patients will have the pain management intervention, such as epidural analgesia, IV PCA or femoral catheter local anaesthetic infusion for 48 hours.
2. Unless instructed otherwise by orthopaedic team, anaesthesiologist-in-charge or pain specialist, all pain management intervention will be discontinued and epidural/femoral catheter removed on day 2 post-op.
3. All patients will be prescribed intravenous ondansetron 4 mg tds for 2 days.
4. All patients will be adequately hydrated from fasting and intravascular volume replaced in accordance to the drain output as per orthopaedic team.
5. All patients would be reviewed by pain team members in the ward approximately 6 hours after surgery and prescribe oral co-analgesia, except when patient:
• Can not tolerate oral diet/fluid
• Haemodynamic instability
• Excess bleeding – additional drain output > 500ml since discharged from recovery room
6. Oral co- analgesia will be prescribed for 72 hours and include – Diclofenate (Voltaren SR) 100 mg daily AND tramadol 50 mg tds, if no contraindication to NSAIDs.
7. If NSAID is contraindicated (history of GI bleeding or ulcer, allergy, renal impairment with serum creatinine > 120 µmol/L), oral co-analgesia should be changed to – paracetamol 1 gm Qid AND tramadol 50 mg tds.
DUTIES OF THE PAIN MEDICAL OFFICER
General
1. The pain medical officer (MO) is an integral part of the APS team. He / she is a medical officer from the Department of Anaesthesia and Intensive Care, working the under the supervision of the co-ordinator of pain services.
2. The pain MO provide 24 hour coverage on medical issues related to all aspects of pain services. Shifts of the pain MO are:
• Weekdays: 0800-1600
• Afterhours: 1600-0800 next day
• Weekends and public holidays: 0800-0800 next day.
Afterhous and weekend duties are covered by the Anaesthesiologist on Obstetrics call.
3. The pain MO shall carry the pager 1067 at all times.
4. The pain MO shall be familiar with the daily routines and all guidelines of the pain service.
5. The pain MO shall advise other parties, including ward staff and pain nurses, in medical matters in pain management. He/she shall be responsible for teaching medical students
Acute pain services
1. The pain MO attends the hand-over at the 5/F common room of the Department of Anaesthesia and Intensive Care. This includes:
• briefing of all APS patients from the previous shift
• any patients who developed complications or difficulty in pain management
• handing over of the acute pain folder and
• the pain MO pager (1067)
If the pain MO is engaged in other clinical duties (see below), he shall communicate with the upcoming pain MO. All parties shall wait until a handover is feasible, or, if prolonged delays are inevitable, he / she might authorize the pain nurse to conduct the handover of patient information. The upcoming pain MO shall approach the late pain MO for the pager.
2. At the daytime the pain MO shall conduct the acute pain round with the nurse. All patients under the care of the APS team must be assessed for:
1. Pain severity (using appropriate scoring system)
2. Patient stability (blood pressure, SpO2, sedation score) or neurological function with nerve blocks or epidurals (sensory, motor and urinary function)
3. Side-effects (sedation, pruritis, nausea and vomiting)
4. System set-up (venous / epidural site, dressings, connections, pump programme and history, power)
3. During afterhours or holidays, the pain MO shall attend every new APS patients upon notification by the recovery room or the labour ward.
4. The pain MO should resolve to continue, modify, stop the APS modality, or close the case by crossing out the prescription order for the APS device. Make sure that patients receive adequate analgesia upon cessation of APS device. Please document patient’s satisfaction score on the follow up chart.
5. The pain MO shall manage the side effects, prescribe co-analgesics, reprogram and provide trouble-shooting if necessary.
6. The pain MO shall liaise with the ward staff, parent team doctors or other colleagues on patient conditions or any clinical decisions.
7. Please consult the senior pain MO or the coordinator of pain service for any queries or difficulties.
8. All relevant information and decisions should be documented in patient’s notes and APS follow-up sheets.
9. The pain MO shall attend urgent acute pain consultations if he / she is not engaged in other clinical duties. A written reminder from the consulting ward shall be sent to the Department of Anaesthesia and Intensive Care for archiving.
10. The pain MO might be consulted for allocation of pumps, and in the event of the absence of pain nurses, will be responsible for these matters.
Chronic pain services
1. The secretaries of the Department of Anaesthesia & Intensive Care will inform the pain MO upon reception of in-patient chronic pain consultations (from 0800-1400 weekdays). The pain MO during that shift shall attend to the consultation within 1 working day. When the DPM trainee is available he/she will have the priority to review the patient.
2. All in-patient chronic pain consultations must be discussed with the senior pain doctor rostered on that day (either the DPM trainee or the specialist). It may be more appropriate to discuss the case before the pain MO document anything on the medical record.
3. The pain MO shall join the chronic pain rounds on Mondays and Fridays mornings.
4. There are 2 chronic pain clinics at the Prince of Wales Hospital: the Oncology pain clinic on Monday afternoons, and the Neurosurgical pain clinic on Friday afternoons. The pain MO shall attend both clinics unless other clinical duties prevail (see below).
5. The pain MO might be consulted for editing the pain OT list before 1400 the afternoon before the OT session. He/she shall consult the pain specialist who book the procedure in case of any queries.
6. The pain MO is responsible for admission and discharge matters for patients undergoing pain procedures. The pain MO is encouraged to attend the pain OT sessions. If he/she is rostered for the session, he/she should attend the OT session first, before joining the pain nurse for the acute pain round. The pain MO will be given the opportunity to assist and perform pain management procedures under the supervision of the pain specialist.
7. The pain MO may be required to attend pain management sessions at different hospitals in the NTE cluster.
Other clinical duties
1. The pain MO may be required to attend in-patient Anaesthesia consultations and to provide Anaesthesia at peripheral locations.
2. The pain MO is one of the essential staff of the department when the Black Rainstorm signal or the Tropical Cyclone signal (no. 8 or above) is hoisted. He/she shall remain on duty according to the department guidelines.
Education and training for Anaesthesia trainees
1. The Prince of Wales Hospital is an accredited training centre for both the Hong Kong College of Anaesthesiologists, and the Australian and New Zealand College of Anaesthetists. Training in pain management is conducted by the module coordinator for pain according to guidelines of both colleges (see supplement 1 and 2).
2. The trainee is expected to self-study on pain management under the tutorship of the module coordinator for pain. The list of core topics is in the supplement 2.
2. The trainee will be required to complete a presentation on a topic on pain management, either in the departmental CME meetings or the NTE pain CME meetings
3. The trainee will be required to log all acute and chronic pain cases that have been under his/her care during the pain rotation. At the end of the module he/she shall present the statistics to be endorsed by the module coordinator.
SUPPLEMENT 1
Fellowship in Anaesthesia training requirements
The Hong Kong College of Anaesthesiologists (HKCA)
(Extracted from the HKCA policy document “Vocational Training Guide for Anaesthesiology 2005”, downloaded from the college website on 18th June 2009.)
1.8 The Clinical Anaesthesia experience [referred to under section 1.6.2 and 1.6.4] must include an adequate exposure to all of the following CORE areas in anaesthesia. To ensure adequate exposure, a trainee is expected to have managed a minimum number of cases in each core subspecialty (as defined in the brackets ) over the 6 years of training.
1.8.9 Acute pain management (300 patient-days)
1.9 Apart from the CORE areas, some experience in each of the following NON-CORE subspecialties would be required, particularly for future subspecialty development. Trainees will be required to complete two modules from category 1 and a minimum of 20 cases from category 2.
1.9.1 Category 1 NON-CORE modules
1.9.1.4 Pain medicine (50 chronic / cancer pain cases)
1.10 Elective options [referred to under Section 1.6.4]
1.10.1 Trainees may undertake the following or a combination of the following as part of their elective training:-
1.10.1.3 Pain medicine
1.10.1.5 Research related to anaesthesia and/or intensive / critical care medicine and/or pain medicine
SUPPLEMENT 2
Fellowship in Anaesthesia training requirements
The Australian and New Zealand College of Anaesthetists (ANZCA)
(Extracted from the ANZCA policy documents (TE10: Recommendations for Vocational Training Programs 2003) and the college website on Anaesthesia Training Program, Module 10: Pain Medicine, downloaded from
, and on 18th June 2009)
Recommendations for Vocational Training Programs (TE10)
2.7 The Training Modules outline a series of required learning experiences within the overall Training Program, including but not limited to:
2.7.5 Pain Medicine
Trainees require 50 sessions (1/2 days) of pain medicine experience. While it will be acceptable for the majority of this experience to be in acute pain management, trainees must obtain experience in the management of chronic and cancer pain.
MODULE 10 - Pain Medicine - Advanced Module
The aim of Module 10 is for Trainees to acquire clinical abilities and skills in managing peri-operative post-traumatic, acute medical and persistent pain as an anaesthetist (but not to the level of a FFPMANZCA specialist). This includes learning to integrate and apply knowledge and skills in clinical management, such as in:
• Assessing pain.
• Taking a "pain history" and examination
• Providing peri-operative and other acute pain relief
• Identifying and managing patients with persistent pain, including referral when appropriate, to pain medicine specialists
• Working in an interdisciplinary management paradigm
Knowledge on (please refer to original document for details)
• Neurobiology of Pain
• Pharmacology of Analgesic Agents
• History, Philosophy and Medicolegal Aspects
• Psychological and Sociocultural Issues
• Substance Abuse
• Professional Practice
• Pain Assessment and Measurement
• Acute Pain
• Cancer Pain
• Neuropathic Pain
• Pain in Children
• Pain in the Elderly
Clinical skills, attitudes and behaviours in (please refer to original document for details)
• Clinical Evaluation
• Technical Skills
• Communication Skills
• Educational Skills
• Attitudes and Behaviours
• Specialist Practice
• Professionalism and Ethics
• Patient Considerations
• Research Considerations
Relevant ANZCA Professional Documents for Module 10
|PS3 |Guidelines for the Management of Major Regional Analgesia |
|PS9 |Guidelines on Conscious Sedation for Diagnostic, Interventional Medical and Surgical Procedures |
|PS15 |Recommendations for the Perioperative Care of Patients Selected for Day Care Surgery |
|PS19 |Recommendations for Monitored Care by an Anaesthetist |
|PS20 |Recommendations for Responsibilities of the Anaesthetist in the Post-Operative Period |
|PS37 |Statement on Local Anaesthesia and Allied Health Practitioners |
|PS38 |Statement Relating to the Relief of Pain and Suffering and End of Life Decisions |
|PS41 |Guidelines on Acute Pain Management |
Relevant FPM Professional Documents for Module 10
|PM2 |Guidelines for Units Offering Training in Multidisciplinary Pain Medicine |
SUPPLEMENT 3: ACUTE PAIN SERVICE FOR THE OBSTETRIC / PAIN MO
The following flowchart has been designed to assist the Obstetric / Pain Medical Officer to handle acute pain consultations on top of other clinical duties.
[pic]
The surgical team should be able to assess the patient, give iv fluid challenge and prescribe supplementary analgesia (e.g.: single injection NSAID or opioid) under the supervision of the Obs /Pain MO. In all circumstances, the Obs/Pain MO MUST review the patient as soon as he/she is available.
DUTIES OF THE PAIN NURSE
General
1. The pain nurse is the nursing representative from the Department of Anaesthesia and Intensive Care, working the under the supervision of the co-ordinator of pain services and the Advanced Practising Nurse of the NTEC pain services.
2. At PWH the pain nurse are available on:
• Weekdays: 0800-1600
Afterhous and weekend duties are covered by the pain MO (Anaesthesiologist on Obstetrics call).
3. The pain nurse shall carry the DECT phone 6172 at all times.
4. The pain nurse shall be familiar with the daily routines and all guidelines of the pain service.
Acute pain service
1. The pain nurse participates in the handovers. In case the pain MO is engaged in clinical duties, the pain nurse, at the discretion of the pain MO, may conduct the handover
2. The pain nurse collect all APS requests from the OT control and the 5/F common room by 0800 on weekdays, and confirm existing pump locations. He/she will triage the requests, allocate available pumps, and inform the recovery room accordingly. In case of unmet requests, the pain nurse will liaise with the list Anaesthesiologist and the pain MO for alternative planning.
3. The pain nurse participates in the acute pain rounds for all patients with APS modalities. Pain nurse would give boluses under medical supervision, assess & adjust pain control devices, and give pain-related management orders e.g. O2 therapy, pain observation frequency, and termination of pain service. While the pain nurse would not prescribe nor alter any prescriptions from any medical staff, they may cancel the APS prescriptions upon termination of pain services.
4. Patients with indwelling epidural or regional block catheters will be reviewed daily and for 1 more day after catheter removal.
5. In case of complications, standing orders as prescribed on observation record should be applied. Hospital resuscitation protocols should be followed during emergencies.
6. Parent team will be notified of patient’s condition as appropriate.
7. The pain nurse offer patient education on PCA use upon request of the Anaesthesiologist, if the patients are not the first on the morning list.
8. The pain nurse attends all new pain patients upon notification by the recovery room during their working hours.
9. The pain nurse maintains the acute pain folder and updates the contents periodically. Data on closed cases shall be archived for auditing later.
10. The pain nurse maintains and updates the stock of all APS equipment, accessories, forms and consumables.
Chronic pain services
1. The pain nurse shall attend the chronic pain rounds on Monday and Friday mornings. He/she shall assist the pain MO and the pain specialist in clinical management, and update the patient logistics in the chronic pain folder periodically.
2. The pain nurse shall attend the Neurosurgical pain clinic on Friday afternoons. He/she shall participate in patient assessment, screening, patient education, and assist the pain MO in the running of the clinic. He/she shall update patient statistics from all pain clinics after each session. The pain nurse might be asked to attend and participate in the private consultations at the Prince of Wales Medical Centre.
3. The pain nurse shall maintain the pain procedure booking registry. On the afternoon before each procedure day, the pain nurse shall upload the bookings onto the OTMS system. He/she shall keep record of all the procedures.
4. The pain nurse shall assist in arranging for patient admissions for pain procedures. At the Prince of Wales Hospital they are performed in the main operating theatre with theatre nursing support. The pain nurse shall participate in advanced procedures such as implantations, including the nursing care peri-operatively.
Administration
1. The pain nurse provides managerial support for APS, inpatient & outpatient chronic pain service. He/she shall keep record of all pain related activities, maintain the corresponding databases, prepare and send monthly services data to department heads. At the approval of the coordinator of pain services, the data shall be made available to relevant parties out of the pain team.
2. The pain nurse plans and conducts quality assurance or other audits on the pain services.
3. The pain nurse shall liaise with the operating theatre, EMSD and various ward staff for maintenance of pain equipment & fixtures, consumables and related stationary.
4. The pain nurse supervises and provides education for patients, ward nurses, or other staff members on pain services. He/she shall orientate any new member of the pain services on the routines.
5. The pain nurse supervises clerical staff of the Department of Anaesthesia and Intensive Care, and of other clinical areas, for pain related clerical matters.
6. The pain team, including the pain nurses, acknowledges & respects fully the standards & practices of parent teams, and shall actively liaise with ward staff on matters related to pain services
Research
1. The pain nurse shall assist in pain research projects from the pain team. He/she shall endeavor to collaborate with other staff on pain related research projects.
PRIVATE PATIENT FEES
Please note that private charges have been revised and will be charged according to the S.S No. 4 to Gazette No. 13/2003:
Section 1 Private Charges
1. Inpatient Charges
1.2 Doctor Fee: Daily Medical Attendance / Consultation $500
This will cover all fees related to in-patient pain-related consultations and follow ups, including acute pain round, chronic pain round and other follow-up visits whenever a medical doctor is present.
Please fill in the appropriate charge form PWH 101 when acute pain service is terminated. Thank you.
USEFUL TELEPHONE AND PAGER NUMBERS
Useful telephone extension numbers:
Resuscitation 2468
Department Anaesthesia & Intensive Care Main Office 2735
fax: 26372422
ICU 3026/3027
Operating Theatre Control 2527/2534
Recovery room 2532/2533
Useful hospital pager numbers
Duty Pain MO 1067 (24 hr)
Pain Nurse (DECT phone) 6172 (Mon-Fri: 0800-1600)
Duty Obstetric Anaesthesia MO 1068 (24 hr)
ICU MO 1050
ICU senior 1065
OT MO 1054
OT senior 1040
-----------------------
CONTACT
Surgical team for assistance
REVIEW case when able
WAIT
See patient when able
Attend Patient
Cannot wait > 1 hour
Can wait > 1 hour
Unable to attend
Able to attend
MO Triage
Paged by ward staff
IV PCA MORPHINE
Add 60mg MORPHINE
to a total of 60 ml
with Normal Saline
ON IV PCA / EPIDURAL INFUSION
NO OTHER OPIOID & SEDATIVE
UNLESS PRESCRIBED
BY PAIN TEAM
EPIDURAL INFUSION
Mix 5mg/ml Levobupivacaine 60 ml
& Fentanyl 800mðg
into 250ml Normal Saline bag
Tota0μg
into 250ml Normal Saline bag
Total vol 326ml
EPIDURAL INFUSION
Mix 10mg/ml Ropivacaine 40 ml
& Fentanyl 800μg
into 250ml Normal Saline bag
Total vol 306ml
EPIDURAL MORPHINE INFUSION
Add 45mg PRESERVATIVE-FREE MORPHINE
into 500ml Normal Saline bag
Total vol 503 ml
PCEA PETHIDINE
Add 900mg PETHIDINE
to a total of 180 ml
with Normal Saline
APS Post Operative Care
For patient on PCA / Continuous Infusion, please
1. Do not prescribe other opioid analgesic & sedative.
2. Give O2 supplement □ No □ Yes___ L/min O2.
3. Do hourly pain observation until review by Pain Team.
4. Any query, please contact Pain Team:
Pain Medical Officer Pager: 1067 (24-hour) or
Pain Nurse DECT Phone: 6172 (Mon-Fri 0800 to 1600)
Key switch
Start
Main Display
1. Document severity of pain
2. Identify source
3. Consider physical methods
Stop
Assess vital signs
Conscious?
Resuscitate
ψ
1st line analgesia
Give NSAID or Opioids if not contraindicated.
If 1st line contraindicated or inadequate, consider 2nd line analgesia
1. Nerve blocks
2. Ketamine
3. Physical methods
Reassess
Stable?
Reassess
Effective?
Side effects?
Monitor
Document
Handover
N
Y
N
Y
Y
N
High risk group:
1. Age>65?
2. >=4 rib fracture?
3. Cardiopulmonary disease?
4. DM?
Yes
Regional analgesia
No
Contraindications for regional analgesia?
No
Expertise available? **
Yes
Yes
No
Contraindication for iv PCA morphine?
1. Confused?
2. CVS stable?
3. Airway obstruction?
Head injury, intraabdominal injury, CVS instability?
No
No
Yes
Yes
Epidural analgesia
Thoracic paravertebral block
For iv PCA morphine+ oral/iv/PR medication
Oral/iv/PR medication
________________ INFUSION
Mix 5mg/ml Levobupivacaine ____ ml
into _____ml Normal Saline bag
Total vol _____ml
................
................
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