GGC Paediatric Guidelines
For all pain enquires, APRS team are available Monday to Friday 0800-1600 on Ex 84319. Outwith these hours please contact the resident on call anaesthetist on Ex 84342.
Fentanyl NCA / PCA, RHCG
Warning
Objectives
This guideline aims to provide clear guidance for the safe use of Fentanyl by Patient Controlled Analgesia (PCA) or by Nurse Controlled Analgesia (NCA) in patients at the Royal Hospital for Children, Glasgow.
Scope
Following a successful pilot programme on ward 3C with strict inclusion and exclusion criteria, Fentanyl PCA/NCA will now be rolled out across the wider hospital.
Examples of clinical scenarios where Fentanyl PCA/NCA may be used include, but are not limited to:
- children with significant renal impairment
- children who are post renal transplant who require acute or post-operative pain management
- children who are sensitive to or have had inadequate analgesia with other opioids
Audience
This protocol is intended for use by medical, nursing and allied health professionals involved in the care of patients who require analgesia as part of their post-operative care or acute painful condition. Programming of the analgesic devices should only be undertaken by pain nurses, anaesthetists or appropriately trained staff.
Fentanyl PCA/NCA is used extensively in tertiary paediatric centres around the world. The RHC Fentanyl prescription and PCA/NCA pump settings are comparable with protocols from other paediatric centres, and have been agreed upon by a collaborative multi-disciplinary steering group. This group includes paediatric nephrology, palliative care, pharmacy and pain management. There has been revision of some aspects of the initial protocol based on clinical review of the patients who received Fentanyl in the pilot and feedback from relevant parties.
The use of Fentanyl as a primary agent in specific patient groups (for example patients with renal impairment) is recommended as best practice given its pharmacokinetics and pharmacodynamics properties.
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Patients suitable for Fentanyl PCA/NCA |
Patients not suitable for Fentanyl PCA/NCA |
Caveat |
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All patients admitted requiring PCA/NCA as part of analgesic management who do not meet exclusion criteria |
Patients <5kg |
Patients with eGFR<10* – can be included with reduced dose, see below |
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Examples include patients with reduced or fluctuating renal function, post renal transplant and post complex urological procedures |
Patients <13 weeks postnatal age |
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Anti-emetics |
All patients requiring PCA/NCA should have at least one anti-emetic prescribed PRN First line Ondansetron 0.15 milligrams/kg 8 hourly |
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Oxygen |
As required |
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Naloxone |
If a child on an opioid infusion is excessively sleepy or has a respiratory rate below 10 (20 for infants), the infusion should be stopped and parent/ward team called to review and ABC assessment undertaken |
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Indication |
Dose |
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Severe/life threatening respiratory depression |
400 micrograms IV Can be repeated at 5 minute intervals for 5 doses, maximum dose 2mg Can also be given by IM and SC route if IV not available at same dose and frequency |
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Sedation/mild respiratory depression/itch |
1 microgram/kg |
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PCA |
Dose Range |
Suggested Initial Dose |
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Background |
0-1 ml/hour (0-0.5 micrograms/kg/hour) |
0.5-1 ml/hour (0.25-0.5 micrograms/kg/hour) |
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Bolus |
0.5-2 ml (0.25-1 micrograms/kg) |
1 ml (0.5micrograms/kg) |
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Lockout |
5-10 minutes |
5 minutes |
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NCA |
Dose Range |
Suggested Initial Dose |
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Background |
0-1 ml/hour (0-0.5 micrograms/kg/hour) |
1 ml/hour (0.5 micrograms/kg/hour) |
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Bolus |
0.5-2ml (0.25-1 micrograms/kg) |
1ml (0.5 micrograms/kg) |
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Lockout |
20-30 minutes |
20 minutes |
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eGFR<10* |
Dose Range |
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Background |
0-1 ml/hour (0-0.5 micrograms/kg/hour) |
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Bolus |
0-1 ml (0-0.5 micrograms/kg) |
Following the experience of the local Fentanyl PCA/NCA pilot, all patients should receive a fentanyl loading dose prior to starting a fentanyl PCA/NCA and should be fully monitored throughout this process.
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Dose Guidance |
Factors to Consider |
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Minimum 1 microgram/kg before initiating PCA/NCA, up to 50microgram/dose (>50kg) For renal transplant or major urological surgery, consider up to 5 microgram/kg, titrated to effect Maximum dose at the discretion of the anaesthetist All patients should be fully monitored throughout loading |
Operation type / indication Age Weight Renal function |
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Clinician or APRS Only – Loading Dose |
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Consider use of prepared PCA/NCA syringe (concentration 0.5 micrograms/kg/ml) Decant 5ml into a syringe Administer 0.5-2ml (0.25-1 micrograms/kg) aliquots |
This dose should be given in aliquots with continuous monitoring and assessment for response |
In addition to increasing continuous (background) rate, patients with pain or escalating analgesic requirements should be routinely reloaded with up to 2microgram/kg in divided doses, titrated to effect. If reloading through the pump, this would equate to 4ml, in 1ml aliquots (1ml=0.5microgram/kg). As above, patients should have continuous monitoring during reloading.
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Clinician or APRS Only – Reloading or Extra Bolus |
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1-4ml (0.5-2 micrograms/kg)
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This dose should be given in aliquots with continuous monitoring and assessment for response |
Patients on NCA/PCA Fentanyl should:
- Be attached with an anti-siphon (non-return) valve
- Be nursed in a central location within their assigned ward
- Be centrally monitored, or as a minimum hourly observations with continuous saturations
- Be reviewed at least daily by the APRS
- Have syringe changed by APRS or Anaesthetics on call (84342) only
- There will be a package of training aimed at nursing staff, facilitated by the Acute Pain Service and local nurse educators on each ward.
- This will include targeted training through learnpro modules, and refresher training on PCA safety, common side effects and trouble shooting.
- The use of fentanyl PCA/NCA will be included as part of the Acute Pain induction material, delivered to new nursing staff and rotating anaesthetic trainees.
- Designation of pain link nurses for each ward. These nurses will be :
- Empowered to take an active role in each patient’s pain management, learning about the pharmacodynamics and pharmacokinetics of each drug, effects, side effects and trouble shooting
- Supported by the acute pain team to be more involved in escalating and de-escalating of pain management techniques including weaning to oral opiates.