Am I the only one annoyed by these PCA orders?

Flo., BSN, RN · Dec 6, 2011

Thats the basic, the doc could do a custom PCA or add in other meds.

Esme12, ASN, BSN, RN · Dec 6, 2011

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

It's pretty standard although the four hour limit is a little low but he is still getting twice the amount he was getting before. Many MD's have breakthrough pain orders (usually through additional boluses) and a slightly larger loading dose. The idea is to place control back to the patient and helping decrease pain control demands. Just keep calling....

http://mail.rainylakemedical.com/orders/PCA.pdf

http://www.ihconline.org/UserDocs/Pages/Audubon_PCAorders.pdf

wooh, BSN, RN · Dec 6, 2011

You keep calling for a breakthrough doses and eventually the doc will adjust the orders so you'll stop annoying him with phone calls. :)

fiveofpeep · Dec 6, 2011

what is the patient's background? If applicable, a pain management doc can help. I have seen them come to ICU for patients with chronic pain. They usually are less timid with dosing and more creative.

Ashley_RN · Dec 6, 2011

[0.2mg each dose/7min interval /3mg lockout in 4 hours] is our typical Dilaudid PCA orders; however, everyone is individualized. What is the pain for? Any option for bolus doses?

I second the pain specialist, if available. They are wonderful & creative as the poster above stated. If Dilaudid isnt working, what about a changing the med in the PCA? Fentanyl? Morphine? Although in my experience (which isnt saying much, Ive just passed my year :nurse: ), I'm usually switching from Fentanyl to Dilaudid for better pain control. Does his meds need to be IV? Can he be changed over to something longer acting, ex. Oxycontin with breakthrough PRN? What's his HCT & renal situation, can Toradol be of some additional help if IV is the only way?

I absolutely feel terrible for patients in pain; has your MD SEEN the patient? When I'm working with a "stingy on the pain meds" doc, I tell them to get their butts in to see the patient so THEY can be the ones to explain why they will not order anything further. Sometimes after seeing the pain on the poor patient's face, they come around :)

TriciaJ, RN · Dec 6, 2011

That does sound like a pretty homeopathic dose, even for Dilaudid. Does the rest of the hospital have standard PCA orders that you can get hold of? If DRs are not familiar with PCA dosing they can use the standard form as a guideline.

Sorry if you have to keep bugging the doctor for appropriate pain control. Sometimes that's what it takes.

morte, LPN, LVN · Dec 6, 2011

Does the doc understand that the total allowed includes the basal rate dose?

wooh, BSN, RN · Dec 6, 2011

That does sound like a pretty homeopathic dose,

:lol2:Great description!

IheartICUnursing · Dec 6, 2011

Yes, I know this patient needed a pain specialist on board. Recently at our hospital they have allowed RNs to independently put in a palliative care consult (yay!) But this was in the middle of the night. I am aware that we needed more meds on board for better pain control. After all, this was an oncology patient who has been on Dilaudid & phenergan forever but our ICU doc is just very conservative with pain meds. Yes I woke up the doc in the middle of the night several times. Yes, he saw the patient. Couldnt switch to anything else- allergic to Morphine and there is a shortage of Fentanyl so we can only use it for pts already recieving it/ allergic to everything else. I still had an order for 1mg of Dilaudid Q2hrs for breakthrough that I was using as well. However, when I went to lunch, my patient asked for it and the nurse covering just gave it through the pump instead of getting a dose from the pyxis so that REALLY screwed things up because it counted that as part of his 4mg limit.

I know the pain control is a major issue ( and I run into it all the time with our docs) but the main issue I'm addressing here is the PCA order. Wouldn't it make more sense to have the lockout interval long enough that the patient can press the button each time it is available without running out of medication before the 4 hour timeframe is up? It just seems so silly to me.

locolorenzo22, BSN, RN · Dec 7, 2011

Those orders are there because it is shown that x dose can be safely metabolized in most cases with y time. Ours are 0.2mg/q10 mins, 4mg/4hrs, and cont is usually about .4 a hour. If that's not working, then maybe we need some relaxers, something for anxiety, something else. Keep calling and do what you can. I bet the patient had some choice words for the doc the next time he saw him!

Jenni811, RN · Dec 7, 2011

i had a patient just 2 days ago was like that. Young female with a really big heart surgery d/t a birth defect. Anyway, she was in a lot of pain, more so from the chest tubes than anything.

We were running into the same issue with her PCA, and the doctor was aware the PCA would shut off and such and such a time (lockout was 20 minutes). We actually ended up getting an epidural in place that i was able to titrate 4-12 depending on patients pain level. he asked i keep it at a minimum and only titrate it if she is in pain. We were able to keep it at a 4-6, so long as she used the PCA pump which was NOT running continuous, only demand.

At first epidural seemed a little excessive to me, but she was going to need the chest tubes for a while and was so uncomfortable.

She was so scared to take anything PO, which seems a little backwards to me but whatever, pain was under control :)