CPOT scale medication orders??

calivianya, BSN, RN · Aug 7, 2015

We do exactly what you're looking for. :)

The physician orders the pain/analgesia/delirium protocol, and then we can do everything below based on that order without ever calling anyone again.

We can start off with acetaminophen for low pain scores but most of us just jump straight to the good stuff. We use fentanyl exclusively on the protocol as far as narcs go. Per the scores, the dosing looks like this:

CPOT 1-3: 25mcgs q15min PRN

CPOT 4-6: 50mcgs q15min PRN

CPOT 7-10: 100mcgs q15min PRN

And if we give three or more doses in a two hour period, we can start a fentanyl drip per protocol. We're supposed initially give a 50mcg bolus off the bag and start at the current pain level, i.e. 25mcgs/hr for CPOT 1-3, and then bolus 50mcgs before any rate increase, but in reality, no one follows the titration rules. We are supposed to d/c the q15min IVP orders when we order the fentanyl drip.

The range for the drip is 25mcgs-200mcgs/hr. If we hit 200mcgs/hr and the patient is still thrashing around in the bed, and the patient is vented, we can start propofol per protocol. This way, we ensure pain is managed first before resorting to propofol/benzos, so there is less risk of ICU delirium in general since the patients are more with it, just sedated from the narcs. The propofol has limits of 20-80mcgs/kg/min. If we hit the point that we're on 200mcgs of fentanyl and 80mcgs of propofol, then we have to call for something else because we've officially hit the limit of what the protocol can do for us. If the patient is not vented and still freaking out at 200mcg/hr of fentanyl, we don't have anything we can give per protocol and have to call for more orders.

I almost never have to call for additional pain medicine/sedation. Even the most hardcore drug seekers/narc abusers are usually reporting no pain on high level fentanyl drips. With the really bad drug abusers we will usually touch base with the physician early and say something like, "This patient has a known history of abusing narcs, would you like to go ahead and put in a higher limit for the fentanyl?" and they usually do. 500mcgs/hr is the highest I have ever run it.

The protocol holds us over very well. It just gets tricky when someone is intubated in the ED and only has propofol running when sent to us and then the pain protocol is ordered, because technically speaking, the ED skipped to the end of the protocol without starting at the beginning and screwed it all up. Per protocol, we should have to d/c the propofol and start the q15min IVP fentanyl, then graduate to the fentanyl drip, and then max out the fentanyl drip before we could get the propofol back. Most people just leave the propofol running to avoid the chaos and gradually add in the fentanyl, but it technically violates the protocol when we do that. We are not supposed to have any additional sedation/pain meds outside of the protocol or the protocol is supposed to be d/ced altogether.

...Considering the massive amounts of fentanyl we can give, and that non-vented patients can be on the protocol, the protocol also has built-in narcan orders. We have narcan already ordered per the protocol when it is ordered so we can just pull it out of the Pyxis without overriding because it is already on the patient's MAR. We are supposed to call any time we give a PRN narcan but it is nice having it readily available just in case.

beleanor · Sep 3, 2015

Thank you so much Calivianya!!! This is exactly what I was looking for. May I ask what hospital you work for? I'm at Mercy St. Louis is the BURN ICU, so we also give massive amounts of fent/versed (though most of us nurses prefer propofol). The most I've ever had on a gtt was 1200mcg fent and 18mg versed, so it can get crazy. I really like the CPOT, but I think there are some practical things to consider. My shared governance committee is meeting with our head physician and pharmacist in a day or so. Again, thanks, this is great!

calivianya, BSN, RN · Sep 3, 2015

Thank you so much Calivianya!!! This is exactly what I was looking for. May I ask what hospital you work for? I'm at Mercy St. Louis is the BURN ICU, so we also give massive amounts of fent/versed (though most of us nurses prefer propofol). The most I've ever had on a gtt was 1200mcg fent and 18mg versed, so it can get crazy. I really like the CPOT, but I think there are some practical things to consider. My shared governance committee is meeting with our head physician and pharmacist in a day or so. Again, thanks, this is great!

I post my opinions too bluntly to be very specific about my workplace here. I think I've bashed it more than a few times on this forum. I work in NC. I imagine you do have problems managing pain in a Burn ICU. I've always been very curious about those. Would love to stick my toe in one someday. :)