How often do surgeons order a basal rate for PCA?

[nursenatalie, ADN, RN]

We recently had a situation in which a patient was ordered to have a basal of 3mg morphine after a lap appy! This surgeon has increasingly ordered basal rates on his surgical patients and in this situation the patient became oversedated within 24 hours. I dont only fault the surgeon for the order but believe that the oversedation resulted primarily from a lack of monitoring by the nurse. Just wondering if your surgeons often ordered basal rates or simply demand?

[canoehead, BSN, RN]

Generally 1-2mg/h basal plus demand.

[kyti]

One ENT orders basal of 2mg and demand q15min. All others use demand only. Our floor nurses flip out when there is a basal rate plus demand with no 4 hr limit set. This ENT is new and it is not what they are used to. I have no prob with it if the pts are properly monitored for sedation.

[RN-PA, RN]

I've never seen PCA ordered for lap appy or lap chole patients, let alone 3 mg basal rate The only time I've seen 3 mg/hr basal rate has been with a patient who had MAJOR pain issues. When post-ops have PCA MSO4 ordered, they generally have a basal rate of 1 mg/hr ordered and it's usually ordered to be D/C'd in the morning. Typical PCA MSO4 orders on our unit: 1 mg/injection (demand) with 6 or 10 minute lockout, and we have 1 hour maximum doses.

I'm not faulting the nurse who didn't monitor the patient for oversedation since goodness knows what his/her shift was like, but I'd certainly be monitoring more closely with that 3 mg basal rate!

[nursenatalie, ADN, RN]

I know, I dont necessarily fault the nurse as I was there the night that she became oversedated and it was hell on wheels! The problem was that the nurse said she was not told in report that there was a basal rate for the PCA and she surely didnt think there would be for a lap appy! I am not sure how she couldnt have known because we check and clear pumps at each change of shift and if there were no attempt and no injections but a shift total ~24mg then HELLO! The surgeon stated that he ordered the basal to get the patient through the first night and intended on discontinuing it the next day but he didnt round on the patient...the surgeon learned a lesson and said he would never order a basal again and all the nurses on the floor have developed a new awareness of PCA rates and monitoring. I guess that is the main thing that we can all at least learn from it. There were no longstanding effects on the patient but just scary that after 2 amps of narcan she still wouldnt respond to a sternal rub! Two more amps and she came around!

[kids]

My only input is that I have alway had a basil rate set in addition to on demand boluses when I have had a PCA (am tolerant d/t meds for chronic pain).

[zacarias, ASN, RN]

Don't you have PCA protocols that have it written the standard basal rates? I once had a resident order a PCA Dilaudid with a 12mg incremental dose!! I told him he meant .2 but what if I didn't know?!?

[Tweety, BSN, RN]

Kudos to the doc for trying to control pain. Perhaps he knew the patient and the patient didn't have a good pain threshhold and he knew the patient would be hard to control.

I've seen all kinds of basal rates in my days from .5 to 5. Depends on the doc and the patient.

[kimmicoobug]

yep, depends on the patient and what they are there for. I always start PCA's at the lowest setting on the continuous setting. However, it can be dangerous. Recently, we had a kid on a Fent continuous and PCA and he almost didn't make it...

[RNPATL, DNP, RN]

Our surgeons very rarely, if ever order a basal rate. And, if a basal rate is ordered, it is only for 1mg per hour, certainly not 3mg. Now, if there is a definite pain control issue, then we might titrate or give a bolus dose, but we very rarely run a basal.

[SharonH, RN]

I know, I dont necessarily fault the nurse as I was there the night that she became oversedated and it was hell on wheels! The problem was that the nurse said she was not told in report that there was a basal rate for the PCA and she surely didnt think there would be for a lap appy! I am not sure how she couldnt have known because we check and clear pumps at each change of shift and if there were no attempt and no injections but a shift total ~24mg then HELLO! The surgeon stated that he ordered the basal to get the patient through the first night and intended on discontinuing it the next day but he didnt round on the patient...the surgeon learned a lesson and said he would never order a basal again and all the nurses on the floor have developed a new awareness of PCA rates and monitoring. I guess that is the main thing that we can all at least learn from it. There were no longstanding effects on the patient but just scary that after 2 amps of narcan she still wouldnt respond to a sternal rub! Two more amps and she came around!

In my experience, a basal rate is always used. It is very rare to have a patient on demand only. But you are right, she should have known about the basal, she is supposed to review the RX at the beginning of the shift, check the pump at least every two hours and assess LOC with respirations every hour. That should be policy.

[sharann, BSN, RN]

I don't see 3mg basal as a problem for most adults. 3 mg/hour is all they are getting. I do see a problem if this patient was small, malnourished or a child. Also, I would want to know if there was an apnea monitor set. This is important in the case of ANY basal rate(ANY). Until you find a pt not breathing you won;t take this seriously.

Some surgeons order MS 4 mg IVP every 2 hours(that is like getting 2mg/hr). IT has to depend on the individual patient. I've seen total joints with no epidural and just PCA demand do great while I've seen a bunionectomy patient scream bloody murder until we had to sedate them with enough Valium adn morphine to kill a moose! Never know. I just know I wan't the most pain relief I can get/give.