Menu Search Donate
Child Health Guideline Identifier

Pain - PCA and NCA

This document is only valid for the day on which it is accessed. Please read our disclaimer.

Introduction

If a patient is in moderate to serve pain and oral analgesia or IV morphine as per protocol (APP) is insufficient in treating it an opioid PCA or NCA may be commenced.

Patient controlled analgesia (PCA) and nursing controlled analgesia (NCA) are techniques of intravenous opioid administration via programmable infusion pumps. They allow for administration of opioid bolus doses at the push of a button as well as a background infusion rate if required.

Common indications for the use of a PCA or NCA are;

  • Postoperative pain
  • Pain related to trauma
  • Cancer related pain

Patient controlled analgesia

PCA allows a patient to self-administer analgesia and allows the child to have some control over the amount of drug they receive. To use the PCA the child must be cognitively able to associate pressing the PCA button with receiving pain relief as well as be physically able and willing to push the button.

Nursing controlled analgesia

NCA is used when the child is too young, physically unable or cognitively impaired and unable to use a PCA. The bolus button is pushed by the nursing or medical staff when required. A second staff member does not need to be present when pushing the button and administering a bolus.

Responsibility

PCA and NCA modalities must only be charted by Anaesthetists or the Acute Pain Service. Patients on a PCA and NCA will be managed by the Acute Pain Service (APS) and will be reviewed daily by the service. The APS is to be contacted if analgesia is inadequate or side effects are occurring.

Medications

In the majority of cases morphine will be the drug of choice. However, there are occasions when morphine causes unacceptable side effects or the patients' medical condition contraindicates its use. Oxycodone is an acceptable alternative in these situations. Fentanyl is another alternative if morphine or oxycodone are either ineffective or contraindicated.

Dosage

Prescription guidelines for each medication can be found on the Intravenous Analgesia Preparation and Prescription form (CR9003).

Parent involvement

The child's parents must not under any circumstances push the PCA or NCA bolus button, however, they can encourage the child to use it or request the medical staff to.

Additional Analgesia

Non-opiate analgesics such as Paracetamol and non-steroidal anti-inflammatory drugs (if not contraindicated) should be administered to a child on a NCA/PCA. This has the potential to decrease the amount of opiate required and in return limit opioid induced side effects.
With the exception of tramadol, no other opioid analgesia should be administered unless discussed with the anaesthetist or pain service.

Set up & Management

Prescription

Ensure PCA/NCA is prescribed correctly by an anaesthetist on the prescription paperwork (CR9003). It must include appropriate charting of NCA or PCA and correct parameters for the age of the child.

A patient name label must be attached to the medication bag with the time, date and initials of the two registered nurses completing the check. Made up opioid bags must also have a medication additive label attached with details of the opioid medication added.

Ensure drug and patient checking procedures are completed as per medication administration policy.

Equipment

  • CADD solis pump (sourced from Equipment pool)
  • CADD solis lockbox key (kept with the controlled drug keys)
  • CADD Administration set

Tubing (CADD administration set)

The single line CADD tubing should be attached to a bifurcated Y extension set. One lumen of the Y-extension set will have the CADD tubing attached and the other lumen will have intravenous fluid running as charted by the primary medical team (at least a minimum of TKVO rate).

Pain PCA

Programming

A Registered nurse, who has attended the Pain Study Day and had their CADD Pump competency signed off, can set up and programme a PCA/NCA pump. This must be done with a second registered nurse both of whom must sign the PCA Prescription.

Ensure the pump is programmed as per the prescription (CR9003);

  • Select new patient
  • PCA or NCA Paediatric programme
  • Continuous dose and PCA dose correct
  • Correct reservoir volume
  • Correct lockout time

The programme should be re-checked when taking over a new patient or after a bag or line change. This can be done by a single registered nurse. Before commencing a PCA/NCA and after any programme changes two registered nurses are required to complete the programme checks.

Alterations to the programme can be made post commencement if needed. A code (supplied to all registered nurses) will be required to make any changes. All changes must be checked by two registered nurses and fall within the prescribing limits charted.

Priming the line

Once the CADD pump is programmed and the settings have been reviewed it will prompt you to prime the CADD administration set line. Ensure all clamps are unlocked and the line is not attached to the patient before commencing the prime. When you are confident the line is completely primed click the button below the words 'stop priming'

Commencement

Once pump settings have been reviewed against the prescription and tubing line primed and connected to the patient via the appropriate peripheral or central access point the PCA/NCA may be commenced.

Changing medication bag and tubing

The medication bag if made up must be changed every 24hrs.

Premixed medication bags require changing every 72hrs.

The tubing line must be changed every 72hrs. A sticker with the date and time the line was changed should be applied to the tubing.

Documentation

Commencement and cessation of the PCA/NCA should be documented on the back of the Intravenous analgesia preparation and prescription (CR9003) form.

The following should also be documented on this form:

  • Rate changes
  • Bolus changes
  • Bag changes (and bag volume discards)
  • Checks when taking over patient care

The modality continuation forms (CR8986) can be attached to the CR9003 if additional space is needed for documenting these details.

Observations required should be documented on the paediatric early warning signs (PEWS) chart where sections allow for it. All other details should be documented in the patient's clinical notes.

Line changes should be documented in the clinical notes by the nursing staff. If the patient has a central access line the line change should be documented on their CLAB form (CR4032).

Volume administered should be read and documented hourly in the fluid balance chart. This balance can be found via reports and then given and PCA dose encounters on the CADD pump. The given volume is then documented. This volume should be cleared every 24hours at 0700.

NCA bolus doses do not need to be documented or signed for when given by the nurse or medical staff. The CADD pump will automatically record these bolus doses.

Safety

Patients with a PCA/NCA should not leave the ward environment without a registered nurse in attendance.

Where possible the patient should be educated around the PCA/NCA. Patients using a PCA should be aware of the green light showing a bolus dose is available and the lockout times with the PCA.

Observations

Details are outlined on the Intravenous Analgesia Preparation and Prescription form (CR9003). They are as follows:

Hourly 4 Hourly Observe and document every shift
HR, RR, SP02 - Any observations >1 on Paediatric Early Warning Score (PEWS) chart, a full set of PEWS is required.
BP - hourly for 1st 4 hours
Level of consciousness
Pain Assessment
PEWS - as per Starship Children's Health Observation and Monitoring Guidelines.
Nausea/Vomiting
Urinary retention,
Itching
• Continuous oximetry for patients 'at risk' or requiring oxygen
• If asleep and PEWS are stable for over 6hrs: document level of consciousness and pain assessment 4 hourly.
• Continue observations for 4hrs after stopping intravenous analgesia infusion.

Essential Requirements

All patients on a PCA or NCA:

  • No prescription change except by Pain Service
  • With the exception of tramadol, no other opioids to be charted except by order of the pain service

Adverse Events

Occurrence Action
Unarousable • Stimulate patient
• Stop PCA/NCA
• Call Code Pink
• Or if necessary call code blue and commence paediatric advanced life support
• Inform pain service
Decreased Respirations • Stop PCA /NCA
• Contact Pain Service
• Consider oxygen if saturations <94%
• Call code pink or blue if necessary
Nausea/Vomiting • Administer antiemetic's
• Contact pain service if not effective
Urine Retention • Determine if the bladder is full.
• Considering indwelling catheter insertion
• Consider decreasing the opioid dose
• Contact pain service
Pruritus • Consider Phenergan or loratidine
• Contact pain service
Constipation • Consider laxatives

Naloxone

Naloxone is an opioid antagonist that is used to treat opioid overdose. It is indicated for use in:

  • Narcotic induced respiratory and CNS depression
  • Over sedation

Dosage (can be found on the back of the CR9003 form)

  • Reversal of sedation 1-2mcg/kg then 0.5-1 mcg/kg/hr if further needed
  • Resuscitation 10mcg/kg to max dose of 0.4mg

If required naloxone will be charted on the stat side of the medication chart.

Transitioning to orals

PCA/NCA are generally discontinued when oral intake is being tolerated and oral analgesia is expected to keep the child comfortable.
Some children may require oral opiates for a short period of time post stopping a PCA/NCA.

The APS will decide when the PCA/NCA is to be discontinued and will document in the notes and sign the authorised discontinuation section of the CR9003 form. The patient will be discharged from the APS once transitioned onto oral analgesics.

References

  • McGrath, J, P., Stevens, B, J., Walker, M, S., & Zempsky, T, W. (2014) Oxford Textbook of Paediatric Pain. Oxford, United Kingdom : Oxford University Press.
  • Twycross, A., Dowden, S., & Stinson, J. (2014) Managing Pain in Children. A Clinical Guide for Nurses and Healthcare Professionals (2nd ed). United Kingdom: Wiley Blackwell

Did you find this information helpful?

Document Control

  • Date last published: 02 August 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Pain Service
  • Author(s): Andrew Liley, Taryn Mannix
  • Owner: Paediatric Pain Service
  • Editor: Greg Williams
  • Review frequency: 2 years

More From Starship