Am I the only one annoyed by these PCA orders?

[IheartICUnursing]

So, working in ICU, I never had anyone on a PCA pump w/ demand dosing since most of my patients are not with it enough to use the button so we just have them on continuous infusions. So I finally had one patient who was a&o X3 and I could not control their pain with the measly 1mg Dilaudid Q 2 hrs order I had. I finally persuaded the MD to order a PCA pump for this patient, and the order set I got was this:

Loading dose: 1mg

Continuous dose: 0.5mg/hr

Demand dose: 0.25mg

Lockout interval: 10 minutes**

4 hr limit: 4 mg. **

This order really annoys me! I don't understand why you would have a 10 min interval for the demand dose because if the patient actually uses it Q 10 min, they hit that 4 hr limit in the 1st hour, and then the pump wont deliver anything else, not even the continuous, until those 4 hours are up? Realistically, this patient could only press the button once every 30 minutes in order to not reach that 4hr limit too soon.

My patients pain was severe and he pressed it as frequently as possible and then the pump ended up locking out so he was getting NOTHING!

Am I missing something? I just want to know if this is a standard way to order PCA dosing.

The MD wouldn't change the order, so I just told the patient that if he wanted it to last he would have to press it no more than every 30 minutes

[CharmedJ7]

That's strange. Most of the patients on my floor are on PCA and the docs don't write a 4-hr lockout at all. We calculate it as a back-up to what we put in, ie, Dilaudid 0.2/0.2/10, 4-hr lockout is 5.6mg. The vast majority of patients do not zonk themselves out on PCA, for the most part I prefer my patients being on a PCA.

[DookieMeisterRN]

We've always been able to titrate pca's from 0.2-0.8 Q 10 minutes without a lockout, if they're getting too sedated we can turn down the demand dose and we rarely have a continuous rate running. For our opiate tolerant folks we have a different order set with higher rates and higher concentration.

In one hospital I worked we didn't have high concentration syringes and it was a PITA. I had one pt that I changed the pca syringe (6 ml of dilaudid) 6 times in 12 hrs.

If I had an oncology pt whose pain wasn't being managed appropriately I would probably ask my NM or house supervisor to intervene and speak with the MD, put a little pressure on him to do right by his patient....or call a rapid response.