Department of Anaesthesia & Intensive Care
The Chinese University of Hong Kong
Prince of Wales Hospital, Shatin
ACUTE PAIN SERVICE
GUIDELINES & PROTOCOLS
3rd edition
2004
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INDEX
Page
1.
Introduction
3
2.
Arranging APS service for OT patients
4
3.
Arranging APS service for ICU patients
7
4.
Requesting for APS service for patients in the general ward
9
5.
Recovery room pain relief protocol
10
6.
Setting up intravenous patient-controlled analgesia
12
7.
Setting up patient-controlled epidural analgesia
15
8.
Setting up for continuous epidural infusion analgesia
16
9.
Duties of the daytime pain MO
18
10.
Duties of the pain nurse
27
11.
Acute pain service for the night Obstetric / Pain MO
30
12.
Pain MO Guidelines for managing patients with APS devices
31
13.
Guidelines on Co-analgesia
37
14.
Paediatric pain relief
40
15.
Forms and stamps for the acute pain service
43
16.
Graseby 3300 pump
46
17.
Graseby 9300 pump
54
18.
Abbott Pain Manager APM-II pump
60
19.
Non-axial regional analgesia
65
20.
Private patients’ fee
67
21.
Nursing Guidelines – Recovery room pain relief
68
22.
Nursing Guidelines – Care of patients on Patient-Controlled Analgesia (PCA)
71
23.
Nursing Guidelines – Care of patients on epidural infusion analgesia
74
24.
Nursing Guidelines – Monitoring & side effects
77
25.
Nursing Standing Orders
79
26.
Useful telephone & pager numbers
81
First compiled January 1997 (Authors: PP Chen, M Ma, V Yeo)
Revised February 1998 (Authors: PP Chen, M Ma)
Revised August 2004 (Authors: MC Chu, J Chen)
Acute Pain Service, Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong
Prince of Wales Hospital, Shatin, Hong Kong
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INTRODUCTION
The Department of Anaesthesia and Intensive Care at the Prince of Wales Hospital provides a 24
hour acute pain service.
At present, the modalities of pain relief available are:
1. intravenous patient-controlled analgesia (PCA)
2. patient-controlled epidural analgesia (PCEA)
3. continuous epidural infusion analgesia (CEI)
4. continuous regional analgesia e.g. brachial plexus analgesia, para-vertebral analgesia
This book compiles the series of guidelines and protocols produced by the acute pain team which
aimed to facilitate the smooth and safe operation of this service. This series will be regularly
updated as appropriate, and new guidelines and protocols added as necessary. If you have any
query or comment, please contact any of us for further discussion. We shall appreciate your
valuable feedback.
Acute pain services (APS) team
Ms. Marlene Ma / Ms. Wendy Fung / Ms. Josephine Chen (Pain Nurse, DECT phone 6172)
Dr. Simon Chan
Dr. MC Chu
Pain MO (Pager 1067)
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ARRANGING APS SERVICE FOR OT PATIENTS
What the anesthesiologist should do
Pre-operative
1.
All analgesics work best when patients understand and are capable to use it. Please select
according to patient’s physical and cognitive state.
2.
Explain to patient about the use of PCA pump or epidural analgesia method during your
preoperative visit. Informed consent, documentation and communication with parent team
doctors and ward staff are recommended. The pain nurse may also assist in preoperative
education if the case is not the first on the OT list. Please tick the appropriate box in the
request form.
3.
Elective cases: fill in the particulars on the request form no later than 0800 on the OT day.
Forms are available next to the OT lists at the 5th floor Conference Room, or at the OT
control desk.
Emergency cases / late elective requests: Inform APS team (pager 1067 / DECT phone 6172)
directly. The APS team will try to entertain all requests. Please do not start any APS
modalities without discussing with the team.
Intra-operative
1.
Confirm pump availability with the recovery room after 0830. The APS team will approach
you directly in case of problems.
2.
Set the pumps and write up the appropriate forms (see below) and keep them with the patient
in the OT and the recovery room.
Post-operative
1.
Optimize analgesia with adequate loading doses before discharging patients from recovery
room.
2.
Make sure that patient is stable and the APS modality is working before discharging patients
from the recovery room.
3.
These recommendations are designed to suit the local caseload and the general ward setting.
Please inform the APS team in case the anesthesiologist requests for any special analgesic
regimes outside the recommendations. The APS team will liaise with the anesthesiologist,
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the parent team and the ward staff on the most appropriate mode of analgesia throughout the
peri-operative period, on an individual case basis.
4.
Please inform the APS team for any cancellation of APS requests.
What the OT recovery room staff should do
Preoperative
1.
After being informed of the daily pump allocation by 0830 the recovery room staff shall get
the pumps and accessories ready, with proper labeling.
2.
The PCA trolley shall be adequately stocked with all the accessories and consumables.
Please let the APS team or the recovery room sister know of any problems.
Post-operative
1.
Control pain to an acceptable level in the recovery room using appropriate doses of opioid as
per pain relief protocol (see later).
2.
Make sure that the appropriate forms are filled in and signed by the anesthesiologist. Inspect
the pumps and make sure that they are properly set, batteries functional, and lines unclamped, labeled and connected to the correct patient access. All pump cartridges must be
locked. Switch on the pumps and check if they are programmed according to the nursing
observation chart. Refer to the corresponding anesthesiologist in case of doubt.
3.
Confirm with the corresponding anesthesiologist before starting the APS modality. Reeducate the patients on how to use the modalities properly. If the patient is deemed unsuitable for the device (narcotized patients with PCA, or patients in shock with CEI), stop the
pump, and inform the anaesthesiologist.
4.
Inform the APS team (DECT phone 6172 on weekdays 0800 - 1600, pager 1067 at other
times) when discharging the patients from the recovery room.
Handover the nursing
observation and APS follow up forms to the ward staff. Issue loan forms for the pumps,
including all the accessories. Put down patient particulars on the allocation board next to the
recovery room control desk.
What the APS team should do
Pre-operative
1.
APS team will triage the elective requests and inform OT recovery room at around 0830. If
there are inadequate pumps to satisfy all requests, the APS team should inform the list
anaesthetist, and make an effort to re-allocate pumps to those who did not receive priority
earlier after the pain round at around 1000 a.m. Emergency and late elective requests will be
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processed similarly after the elective requests are catered.
Appropriate pumps should be allocated according to patient profile, resources available and
ward staff familiarity with APS routine.
2.
The APS team shall educate patients on how to use the PCA devices upon special request
from the anesthesiologist. It does not apply to the first case of the morning list as they are
already in the theatre before 0800
Post-operative
1.
Upon notification of patient’s discharge from the recovery room, the APS team shall review
the patient at the earliest convenience. The APS follow up form will be collected at the first
visit and kept in the acute pain folder for future reference.
The APS team shall make sure that all allocated pumps are traceable and operational.
2.
The APS team shall make an effort to discuss with the anesthesiologist, the parent team or
the general ward staff for any special request, deviations from the recommendations or any
concerns regarding patient’s peri-operative pain management. This is to ensure that all
parties can communicate and work together for the benefit of the patient.
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ARRANGING APS SERVICE FOR ICU PATIENTS
What the anaesthetist should do
1.
All elective / emergency post-operative requests shall follow the same protocols as other OT
patients
What the intensivist should do
1.
Please page the APS team (DECT phone 6172 during weekdays 0800 – 1600, other times
1067) for pumps.
2.
The intensivist shall be responsible for obtaining the pump, setting it up and monitoring it
during patient’s stay in the ICU.
Patients in the ICU are critically ill and unstable. The intensivist shall make adjustments on
the APS modality or regime according to the clinical needs.
All changes shall be
documented on the patient’s notes and the nursing observation chart.
Please inform the APS team in case of termination of service or technical trouble-shooting.
3.
Inform the Pain team (DECT phone 6172 on weekdays from 0800 till 1600, pager 1067 at
other times) when discharging the patients from ICU to facilitate the continuation of pain
management in the wards. Please remind the nurses to call if you are unable to do it yourself.
In case the pain relief regime is different from the recommendations listed in these guidelines
the APS team will switch them back to the standard recommendations before the patient is
discharged to the ward.
Please make sure that all forms and prescription orders are in accordance with the APS
protocols (see below).
What the APS team should do
1.
Pump allocation shall be made as per emergency OT cases. Please inform the recovery room
staff to prepare all the accessories for the ICU staff to collect.
2.
The APS team shall review the patient at the earliest convenience.
3.
Upon discharge from the ICU the APS team shall review and make sure the mode of
analgesia is appropriate to the destined wards. This is to make sure that all patients in the
ward follow the pain guidelines so as to ensure patient safety and staff familiarity.
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What the ICU nurses should do
1.
The intensivist is primarily responsible for setting up the pumps. Please inform the APS
team (pager 1067 / DECT phone 6172) for assistance if necessary.
2.
Make sure that the appropriate forms are filled in and signed by the intensivist. Stamps are
available at the desk opposite to the nursing control desk (3027/3026)
Inspect the pumps and make sure that they are properly set, batteries functional, lines unclamped, labeled and connected to the correct patient access. All pump cartridges must be
locked. Check if the pumps are programmed according to the nursing observation chart.
Refer to the intensivist in case of doubt.
Re-educate the patients on how to use the modalities properly. If the patient is deemed unsuitable for the device (narcotized patients with PCA, or patients in shock with CEI), stop the
pump, and inform the intensivist.
4.
Inform the APS team (DECT phone 6172 on weekdays from 0800 till 1600, pager 1067 at
other times) if not already done by the intensivist. Handover the nursing observation and
APS follow up forms to the ward staff. Please make sure that the correct prescription form is
used. Handover loan forms for the pumps, including all the accessories.
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REQUESTING FOR APS SERVICE FOR PATIENS IN THE GENERAL WARD
What the surgeon and ward nurses should do
1.
Postoperative and non-surgical trauma patients who complain of inadequate pain relief from
analgesics prescribed by the parent team may be referred to the acute pain team for
assessment and management.
2.
After assessed by the medical officer of the parent team, please page the pain duty MO (pager
1067). Please also send a consultation form to the Department of Anaesthesia and Intensive
Care for documentation by the pain team.
3.
As members of the APS team may be involved in other emergencies, they may not be
available immediately upon referral, and the parent team shall continue with their
conventional modes of analgesia.
What the pain team could do
1.
After assessing the patient, the pain team will adjust the medication, or arrange for alternate
modality of pain relief as appropriate depending on the cause and severity of the pain,
patient’s medical profile and resources available.
2.
Once a treatment modality is started, the pain team will take responsibility of the patient’s
pain relief and side effects associated with the pain relief treatment. The pain team will
follow-up the patient as many times as necessary or at least once daily.
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RECOVERY ROOM PROTOCOL
Principles
1. Inadequate pain relief after surgery increases morbidity and delays patient discharge from
recovery room.
2. A patient receiving the pain relief protocol requires constant assessment and monitoring. If the
recovery area is too busy to provide this level of patient supervision, alternative methods of
analgesia may be required.
3. The pain relief protocol should only be started by the anesthesiologist in charge of the case, who
is familiar with the anaesthetic, medical and surgical history of the patient. He must provide
adequate supervision for the nursing staff looking after the patient.
Practice
1.
At the recovery room of the Prince of Wales Hospital, the nursing staff have been trained and
instructed to administered intravenous opioid for postoperative pain relief.
They are
competent in monitoring, assessing and managing the adverse effects and complications in
post-anaesthetic patients.
2.
Any patient who complains of distressing pain following surgery may be prescribed one of the
following analgesia protocols. This includes patients who are prescribed intravenous patientcontrolled analgesia (IV PCA) as they are recovering from the anaesthetic. Remember that
these patients will only obtain pain relief from the PCA if they are able to understand and
activate the control button.
3.
If you intend to prescribe intravenous opioid according to these protocols in the recovery room
please chart it in the patient’s anaesthetic chart and inform the nursing staff.
4.
Your patient should be comfortable, with a pain score of < 4 when they are discharged from
the recovery room. Please assess your patient before you discharge them to the general ward.
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Opioid Protocol
Morphine (1 mg/ml)
Adults
1.
Dilute 15 mg morphine to 15 ml with normal saline
2.
Dose: 1-2 ml (1-2 mg) every 5 minutes as required
3.
For adult > 60 who is/or < 50 kg, 1 ml boluses may be more appropriate
4.
Total dose limit to be stated by anesthesiologist. If pain not relieved with dose limit, the
nursing staff will inform the anesthesiologist to reassess the patient.
Paediatric patients
1.
Morphine 20 mcg/kg q5min intravenously up to 5 doses, then review
(See chapter on paediatric analgesia)
Ketorolac Protocol
Exclude contraindications before giving NSAID.
Ketorolac (30 mg/ml) iv or im
Adults under 65 years of age
1.
Dose: 30 mg bolus followed by 10 - 30 mg Q6H to a max of 120 mg daily
Adults 65 years and older
1.
Dose: 10 mg bolus followed by 10 - 30 mg Q6H to a max of 60 mg daily
Nursing instructions
1.
Please refer to the nursing guidelines – recovery room pain relief. (See below)
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SETTING UP INTRAVENOUS PATIENT-CONTROLLED ANALGESIA
The following guidelines are recommended when using the GRASEBY 9300 pumps, GRASEBY
3300 pumps and ABBOTT APM-II pumps. These settings may be altered according to individual
patient’s requirement during subsequent follow-up and reassessment.
Graseby 3300
1. Use Terumo 50 ml syringes with luer lock, as the device has been programmed for use with
this syringe, connect to free standing extension lines with pre-attached anti-siphon valves.
2. Dedicated intravenous line is recommended, use anti-reflux valve without 3-way stopcock.
3. Dilute 60 mg Morphine with total of 60 ml saline (final concentration: 1 mg/ml)
4. See section on Graseby 3300 for information on how to use the pump
Recommended initial program
Bolus dose
1-2 ml
Lockout period
8 min
Max. 4 hr dose limit
0.3 mg/kg
5. Many studies had shown that basal infusion during PCA neither improves the quality of
analgesia nor the quality of sleep. Basal infusion is therefore not recommended.
Graseby 9300
1. The pump should be programmed for PCA only. Ask the recovery room staff or the APS team
(DECT phone 6172 / pager 1067) for assistance in programming the pump.
2. Use 250 ml internal reservoir cassettes, with anti-siphon valve included, and free standing 140
cm extension tubing
3. Dedicated intravenous line is recommended, use anti-reflux valve without 3-way stopcock.
4. Dilute 150 mg Morphine with total of 150 ml saline (final concentration: 1 mg/ml)
5. Remember to aspirate all air bubbles from the drug mixture bag via a 3-way stopcock or a
female-female connector (comes with the 250ml internal cassette)
6. Recommended program: same as Graseby 3300 (see above)
7. See sections on Graseby 9300 for information on how to use the pump.
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Abbott APM-II PCA
1. Use the 100 ml saline bag, another 40 ml of sterile saline, and the Abbott APM-II cartridge
together with the anti-siphon valve and extension tubing
2. Dedicated intravenous line is recommended, use anti-reflux valve without 3-way stopcock.
3. Dilute 150 mg Morphine with total of 150 ml saline (final concentration: 1 mg/ml)
4. Remember to aspirate all air bubbles from the drug mixture bag before priming the cartridge
5. Set the pump for PCA boluses only, using ml as the unit of delivery, with air sensitivity at high
level, and 4 hour limit activated
6. Recommended program: same as Graseby 3300 (see above)
7. See sections on Abbott APM-II for information on how to use the pump.
The Y-piece connector
1. In case when only one intravenous line is available the following Y-connector can be used to
accommodate both the infusion and PCA. It is available in the OT PCA trolley.
2. Please be reminded that this is only for the exceptional case, and it is reserved only for
anaesthetists and members of the pain management team.
Pat ient 's IV cannula
Ant i-ref lux valve
PCA Min vol ext ension
Non-ret urn valve
( One-way)
IV drip
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Paediatric PCA regimen
1. Basic arrangements are similar to adult PCA.
2. As the handset of the Graseby 3300 may be too hard for the paediatric patients, use the Graseby
9300 or the Abbott APM-II only.
Recommended initial program
Morphine dilution
0.5 mg/ml
Bolus dose
0.03 ml/kg (0.015 mg/kg)
Lockout period
10 min
Max. 4 hr dose limit
0.5 ml/kg (0.25 mg/kg)
For more information, see section on paediatric analgesia
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SETTING UP PATIENT-CONTROLLED EPIDURAL ANALGESIA
Introduction
1. Patient-controlled epidural analgesia using pethidine is used at the PWH. Pethidine is selected
based on its more favorable pharmacokinetic profile for PCEA when compared to morphine or
fentanyl. Currently, PCEA using local anaesthetic is not used at this institution.
2. The Abbott APM-II is preferred in delivering the PCEA. If it is not available the same program
can be applied to the Graseby 9300 pump.
Recommended PCEA Pethidine regimen
Pethidine concentration
10mg/ml
Bolus dose
1-2ml (10-20mg)
Lockout period
8 min
Maximum 4 hr dose limit
3mg/kg
Basal infusion
zero
Abbott APM-II and Graseby 9300
1. Setting is the same as for intravenous PCA
2. Dilute 1500 mg Pethidine into a total of 150 ml saline (10 mg / ml)
3. Make sure that they are labeled and connected to the epidural port Always use a filter to
connect the epidural catheter to the PCA extension tubing.
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SETTING UP CONTINUOUS EPIDURAL INFUSION ANALGESIA
Introduction
1. It has been shown that epidural infusion of local anaesthetic + opioids can significantly reduce
postoperative complications.
2. In order to minimize the amount of the solution used, the epidural catheter should be placed as
close to the required dermatomes as possible. We recommend using:

Mid-thoracic (T4-8) for upper abdominal and thoracic surgeries

Low thoracic (T8-12) for lower abdominal surgeries

Lumbar for lower limbs and pelvic surgeries
3. Epidurals can be associated with complications such as hypotension, spinal infection or
hematoma. Such complications may affect the patient well after the operation. Please exercise
caution especially in high risk patients for major surgery (e.g.: multi-lobar liver resections,
kidney transplants).
Regimes
Bupivacaine and Fentanyl
1. Mix 60 ml of 0.5% Bupivacaine, 16 ml (800 mcg) of Fentanyl into the 250 ml saline bag
2. Final concentration: Bupivacaine 0.09%, Fentanyl 2.5 mcg/ml
Final total volume: 326 ml (please set the reservoir / cassette volume to 320 ml. This is to
make sure that it will alarm before the medication bag run out.)
3. Label the medication bag using the green additive gum label.
Ropivacaine and Fentanyl
1. Mix 40 ml of 1% Ropivacaine, 16 ml (800 mcg) of Fentanyl into the 250 ml saline bag
2. Final concentration: Ropivacaine 0.13%, Fentanyl 2.6 mcg/ml
Final total volume: 306 ml (please set the reservoir / cassette volume to 300 ml. This is to
make sure that it will alarm before the medication bag run out.)
3. Label the medication bag using the green additive gum label.
Equipment
To reduce the need for refills of epidural infusion in busy surgical wards, we recommend using the
Abbott APM-II or the Graseby 9300 (with external reservoir cassette) for infusions.
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Abbott APM-II
1. Set the pump for continuous epidural infusion only, with low air sensitivity
2. Make sure that patient always has an intravenous line inserted when an epidural device is in
use.
3. See sections on Abbott APM-II for information on how to use the pump
Graseby 9300
1. The pump should be programmed for continuous infusion only. Please ask the recovery room
staff or the APS team (pager 1067 / DECT phone 6172) for assistance in programming.
2. Use the external reservoir cassette and the anti-siphon valve, and connect it to the 140 cm
extension tubing.
3. See section on Graseby 9300 for information on how to use the pump
Securing the epidural catheters
1. No golden method so far. The catheter site should be dressed with a large transparent dressing
with Micropore around the edge. The filter should be comfortably sited at the infraclavicular
fossa and tagged with an “EPIDURAL” label.
Recovery Room
1. Patient should be observed in the recovery room for at least one hour until haemodynamic
stability is achieved. Ensure adequate sensory blockade before discharge patients to the ward.
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DUTIES OF THE DAYTIME PAIN MO
Introduction
1. At the Prince of Wales Hospital, one (or more) medical staff is rostered on weekdays to be the
pain management MO. He is an integral part of the APS team on that day.
2. The aims of the pain MO module are:
 fulfill the operational need for the clinical supervision of the acute pain service, and / or
other clinical duties as arranged in the roster;
 fulfill the requirement for training towards FHKCA or FANZCA;
 expose the trainee to aspects of acute and chronic pain management in preparation for their
examinations;
 expose the trainee to pain medicine as a choice for further sub-specialisation
 education of undergraduate medical students
3. Appendix 1 and 2 refers to the minimum requirement for the pain medicine rotation for
training towards FHKCA and FANZCA respectively.
Duties of the Pain MO at PWH
Acute pain services
1. The pain MO and nurse take over from the overnight Obstetric/pain MO at the 5/F common
room at 0800. This includes a hand-over of APS patients who are first seen in the previous
shift, those developed significant complications or difficulty in pain management, and handing
over the pager 1067. All parties are expected to be present and punctuality is essential. In case
the overnight person is engaged in other urgent clinical duties, the rest of the team will wait
until everyone is available.
2. After the hand-over, the nurse will allocate pumps and inform the recovery room. The pain
MO should be familiar with this process as he/she may be requested to allocate pumps in the
event of the absence of pain nurses.
3. All new pain MO should be familiar with the acute pain service guidelines.
4. The pain MO will then conduct the morning acute pain round with the nurse. All patients
under the care of the APS team must be assessed.
5. During the acute pain round, the pain MO is required to
 assess for the effectiveness and side effects of the pain management;
 review the equipment and medication prescribed;
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 make the appropriate clinical decision to terminate, change or adjust the pain management
regimen, and treat any adverse effect;
 document and sign any prescription, patient’s progress notes and pain follow-up forms;
 trouble shoot simple problems related to the infusion pumps and set-up of the system;
 supervise the pain nurse and medical students
6. The pain MO will be responsible for acute pain consultation from the wards. The pain nurse
may assist, under supervision, if the pain MO is engaged in other clinical duties and is not
immediately available.
7. The pain MO shall hand-over to the night Obstetric/pain MO at 1600 at the 5/F common room.
If the daytime pain MO is engaged in other clinical duties (see below) and is not available, he
shall authorize the pain nurse to conduct the handover without delaying other clinical duties.
The handover should include clinical information of all APS patients, as well as forthcoming
patients to be reviewed, transfer of pager 1067, and other relevant matters. The pain MO or
nurse shall highlight the problematic cases for the night Obstetric/pain MO to review.
Chronic pain services
1. The pain MO at the PWH shall attend the pain consultations, chronic pain rounds, clinics and
procedure sessions.
2. If the pain MO is rostered for the morning OT pain procedure session, he/she should attend the
OT session first, and at the discretion of the pain specialist he/she will join the pain nurse after
the pain procedure session to deal with any clinical matters arisen during the acute pain round.
3. The pain MO will be given the opportunity to assist and perform pain management procedures
under the supervision of the pain specialist.
4. The pain MO is responsible for clerking inpatients admitted to the wards for pain management
procedure in OT. These patients may be admitted to hospital on the day before or the day of
procedure. The pain OT list should be drafted and submitted to the department secretaries
before 1400 the afternoon before the OT session.
5. If there are no patients on the OT list, please inform the pain specialist AND the OT control
before 1500 so that manpower arrangements can be made. Queries should be directed to the
pain specialist.
6. There are 2 chronic pain clinics at the Prince of Wales Hospital. The pain MO will be required
to clerk, assess and discuss the management plan for new patients attending the clinic.
7. Both pain clinic sessions are in the afternoon. The pain MO shall assist in the clinic until it
ends.
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8. The pain MO is also responsible for seeing in-patient chronic pain consultations under the
supervision of the pain specialist. When the DPM trainee is available he will have the priority
to review the patient.
9. All in-patient chronic pain consultations must be seen within the next working day by the
assigned pain MO.
10. All non-urgent consultations should wait until after the pain clinic or other anaesthetic duties
are accomplished.
11. All in-patient chronic pain consultations must be discussed with the senior pain doctor rostered
on that day (either the DPM trainee or the specialist). It may be more appropriate to discuss the
case before the pain MO document anything on the medical record.
12. The pain MO is expected to join the team on the regular chronic pain rounds.
13. The pain MO may be required to attend pain management sessions at different hospitals in the
NTE cluster.
Other clinical duties
1. Currently the pain MO may be required to attend in-patient pre-anaesthetic consultations and to
provide anaesthesia at peripheral locations. Please note that all pre-anaesthetic consultations
must be seen within next working day.
2. The pain MO may be required to teach medical students during the acute pain module.
3. The pain MO is one of the essential staff of the department when the Black Rainstorm signal or
the Tropical Cyclone signal (no. 8 or above) is hoisted. He/she shall remain on duty according
to the department guidelines.
Education and training
1. The pain MO will be required to complete a presentation on a topic on pain management,
either in the departmental CME meetings or the NTE pain CME meetings
2. The pain MO is expected to self-study on pain management under the tutorship of the pain
specialists. A list of core topics is listed in the Appendix 3.
3. The pain MO will be required to log all acute and chronic pain cases that have been under
his/her care during the pain rotation.
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Appendix 1
FHKCA training requirements on pain management
The following is an extract from the HKCA policy document “Vocational Training Guide for
Anaesthesiology”. The full version http://www.hkca.edu.hk/vtganaes.pdf is available from the
college website.
Paragraph
Statement
1.8
The Clinical Anaesthesia experience [referred to under section 1.6.2 and 1.6.4] must
include an adequate exposure to all of the following CORE areas in anaesthesia. To
ensure adequate exposure, a trainee is expected to have managed a minimum
number of cases in each core subspecialty1 (as defined in the brackets ) over the 6
years of training
1.8.1 Anaesthesia for general surgery /urology /gynaecology (500 cases)
1.8.2 Anaesthesia for orthopaedics and traumatology (500 cases)
1.8.3 Obstetric anaesthesia (100 cases) and obstetric regional analgesia (50 cases)
1.8.4 Neuro-anaesthesia (100 cases)
1.8.5 Thoracic anaesthesia (50 cases)
1.8.6 Paediatric anaesthesia (100 cases of children < 6 years, including neonates)
1.8.7 Anaesthesia for Head & Neck / ENT/ Oro-facio-maxillary ( 00 cases)
1.8.8 Emergency / trauma anaesthesia (500 cases)
1.8.9 Acute pain management (300 patient-days)
1.9
Apart from the CORE areas, some experience in each of the following NON-CORE
subspecialties1 would be required, particularly for future subspecialty development.
Trainees will be required to complete two modules from category 1 and a minimum
of 20 cases from category 2.
1.9.1 Category 1 NON-CORE modules
1.9.1.1 Ophthalmic anaesthesia (50 cases)
1.9.1.2 Day surgery anaesthesia ( 100 cases)
1.9.1.3 Anaesthesia in non-operating theatre locations including but not limited
to Organ Imaging
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Suite, Endoscopy Suite, Cardiac Catheterisation Laboratory, ECT (50 cases)
1.9.1.4 Pain medicine ( 50 chronic / cancer pain cases)
1.9.2 Category 2 NON-CORE Modules
1.9.2.1 Major vascular anaesthesia
1.9.2.2 Cardiac anaesthesia
1.9.2.3 Transplant anaesthesia
1.9.2.4 Neonatal anaesthesia
1.10
Elective options [referred to under Section 1.6.4]
1.10.1 Trainees may undertake the following or a combination of the following as
part of their elective training:1.10.1.1 Clinical anaesthesia
1.10.1.2 Intensive / critical care medicine
1.10.1.3 Pain medicine
1.10.1.4 Other clinical specialties apart from anaesthesia, intensive / critical care
medicine and pain medicine (most of the hospital based specialties will
be accepted except pathology)
1.10.1.5 Research related to anaesthesia and/or intensive / critical care medicine
and/or pain medicine
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Appendix 2
FANZCA training requirements on pain management
This is an extract from the ANZCA policy documents (TE10: Recommendations for Vocational
Training Programs) relevant to pain training for anaesthetists. More details are available from the
websites:
http://www.anzca.edu.au/revfanzca/module10.htm and
http://www.anzca.edu.au/publications/profdocs/traineduc/te10_2003.htm
Recommendations for Vocational Training Programs (TE10)
Paragraph
Statement
2.7
The Training Modules outline a series of required learning experiences within the
overall Training Program, including but not limited to:
2.7.5 Pain Medicine
Trainees require 50 sessions (1/2 days) of pain medicine experience. While it
will be acceptable for the majority of this experience to be in acute pain
management, trainees must obtain experience in the management of chronic
and cancer pain.
MODULE 10 - Pain Medicine - Advanced Module
Duration required: A minimum 50 sessions of clinical experience is required in Pain Medicine
(Modules 1 and 10) - TE10 (2003) Recommendations for Vocational Training Programs.
This Module must be completed during Advanced Training, preferably during ATY1 and ATY2. It
may be completed as a single-block clinical rotation in pain management if the training institution
can offer it, but may otherwise be completed in the normal course of clinical duties.
Trainee's Aims
This Module builds on clinical experience in pain management learned during Basic Training.
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The aim of Module 10 is for Trainees to acquire clinical abilities and skills in managing perioperative post-traumatic, acute medical and persistent pain as an anaesthetist (but not to the level
of a FFPMANZCA specialist). This includes learning to integrate and apply knowledge and skills
in clinical management, such as in:

Assessing pain

Taking a "pain history" and examination

Providing peri-operative and other acute pain relief

Identifying and managing patients with persistent pain, including referral when appropriate,
to pain medicine specialists

Working in an interdisciplinary management paradigm
Learning Objectives
These are what the Trainee needs to learn. They are presented as:

Knowledge

Clinical management ("knows how") that applies knowledge and clinical skills to manage
the patient

Skills (clinical and technical)

Attitudes and behaviors
Assessment
The Module 10 Supervisor will validate the Trainee's completion of the module in accordance with
the process outlined in College Professional Document TE2. This will involve the Trainee
assessing whether she/he has achieved the core aims (Trainee's aims) of the module and fulfilled
the minimum clinical experience. The Module 10 Supervisor will review the Trainee's Learning
Portfolio as part of this assessment.
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The Supervisor of Training and other Consultants will evaluate the Trainee's overall performance
in the In-Training Assessment (ITA) process. Aspects of clinical performance, education skills,
and attitudes will be reviewed. The ITA will remain a formative assessment conducted every six
months, independent of Module assessment.
The Primary and Final Examinations will be summative assessments of the Trainee. Knowledge of
basic sciences in Module 10 will be assessed in the Primary Examination. Principles of pain
management, clinical management, and clinical skills (including regional blocks and relevant
anatomy) in this Module will be assessed in the Final Examination.
The Learning Portfolio is an integral tool for self-assessment (as well as for recording clinical
experience and developing study plans). The Trainee is expected to self-evaluate his/her education
skills and learning experience from the Learning Portfolio. For example, the Learning Portfolio
should show the Trainee's progress through the Module, as records of clinical experience (sessions),
nerve blocks learned, topics reviewed, and oral presentations delivered.
Relevant ANZCA Professional Documents for Module 10
PS3
Guidelines for the Management of Major Regional Analgesia
PS9
Guidelines on Conscious Sedation for Diagnostic, Interventional Medical and Surgical
Procedures
PS15
Recommendations for the Perioperative Care of Patients Selected for Day Care Surgery
PS19
Recommendations for Monitored Care by an Anaesthetist
PS20
Recommendations for Responsibilities of the Anaesthetist in the Post-Operative Period
PS37
Statement on Local Anaesthesia and Allied Health Practitioners
PS38
Statement Relating to the Relief of Pain and Suffering and End of Life Decisions
PS41
Guidelines on Acute Pain Management
Relevant FPM Professional Documents for Module 10
PM2
Requirements for Multidisciplinary Pain Centres Offering Training in Pain Medicine
Reference Guidelines in Acute Pain Management
NHMRC Guidelines - Acute Pain Management: the Scientific Evidence
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Appendix 3
The MO/resident will be required to know:
 tools and clinical skills of assessing a patient in pain;
 the physiology of acute pain;
 the pharmacology of commonly used pain relief medications;
 the setup and how to operate a pain medication delivery system
 the advantages and disadvantages of different acute pain relief methods
 outcome measurements of pain management;
 tools for chronic pain assessment
 the pathophysiology of chronic pain
 assessment and management of cancer pain
 the advantages and disadvantages of different chronic pain relief methods
 pharmacotherapy
 psychological intervention
 physical therapy
 interventional techniques
 alternative medicine
 Specific chronic non-cancer pain conditions and their management
 Neuropathic pain
 CRPS
 Post-herpetic neuralgia
 Trigeminal neuralgia
 Myofascial pain
 Back pain and sciatica
 Phantom pain
 Headache including migraine
 Intractable angina
 Other aspects of knowledge, aptitude and skills applicable to the HKCA or the ANZCA training
programme.
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DUTIES OF THE PAIN NURSE
Introduction
1. Pain management team acknowledges & respects fully the standards & practices of parent
teams.
2. Pain nurse is working under supervision of the pain medical officer on duty.
3. Pain nurse would not prescribe nor alter prescriptions on drug prescription sheets from any
medical staff. Upon cessation of pain control devices they may cancel the relevant prescriptions.
4. Pain nurse would assess & adjust pain control devices & other pain related management orders
e.g. O2 therapy, pain observation frequency, re-programming of such devices, and termination
of pain service.
5. In case of complications, standing orders as prescribed on observation record should be applied.
Hospital resuscitation protocols should be followed during emergencies.
6. Parent team will be notified of patient’s condition as appropriate.
Acute pain service (APS)
1. Provide clinical care to patients on pain relief treatment under APS.
2. Participate in APS patient-handover.
3. Organize allocation of pumps to users.
4. Conduct follow-up & review of APS patients.
5. Attend to ward consultation for acute pain service.
6. Attend to queries regarding matters related to APS from doctors, nurses & patients.
7. Attend to trouble shooting when appropriate.
8. Giving boluses of the APS analgesics under the supervision of the pain MO.
9. Supervise ward nurse in care of APS patients.
10. Participate in preoperative patient education.
11. Maintain pain relief pumps & other APS equipment.
12. Check & maintain stock of APS equipment & consumables.
In-patient chronic pain consultation
1. Assist doctor in patient clinical care & management.
2. Participate in patient assessment & screening.
3. Participate in patient education on pain & pain management.
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4. Collaborate with parent team’s treatment.
5. Ensure proper inpatient consultation record keeping.
Pain management procedures
1. Keep record of all pain management procedures.
2. Arrange patient admission for pain procedure.
3. Assist doctor in pain management procedure.
4. Assist in subsequent follow up & patient care after procedure.
Out patient pain clinic
1. Provide managerial support to ensure smooth running of outpatient pain clinic.
2. Assist doctor in patient clinical care & management.
3. Participate in patient education on pain & pain management.
4. Participate in patient assessment & screening.
Administrative & Management
1. Provide managerial support to ensure smooth running of APS, inpatient & outpatient chronic
pain service.
2. Keep record of APS data & chronic pain service data.
3. Prepare & send monthly pain services (APS, CPS, pain clinics & pain procedures) data to
department heads.
4. Collect and compile outcome data for acute and chronic pain services.
5. Liaison with ward staff on matters related to APS & chronic pain services.
6. Assist in development & promulgation of guidelines to maintain smooth running of acute pain
service & chronic pain service.
7. Plan & conduct quality assurance & other audits on acute & chronic pain services.
8. Supervise clerical assistant to pain service.
9. Supervise clerical staff in handling enquiries.
10. Liaise with the operating theatre, EMSD and various ward staff for maintenance of pain
equipment & fixtures.
Patient Education
1. Provide clinical education to both APS and chronic pain in-patients
2. Liaison with other disciples, organize and participate in out-patient education programs.
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3. Report to doctors & involved disciples of patient’s progress & problems.
Staff Education
1. Organize & participate in continuing nursing & medical staff education & refresher courses on
pain management at NTE cluster.
2. Orientate new medical staff commencing pain service duty.
3. Assist in supervision of medical students.
Research
1. Plan & conduct nursing related research projects in pain management.
2. Assist & collaborate with doctors on other research projects on pain management.
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ACUTE PAIN SERVICE FOR THE NIGHT OBSTETRIC/PAIN MO
Due to the expanding APS and the ever busy obstetric anaesthesia service, the following flowchart
has been designed to assist the Night Obstetric / Pain Medical Officer to deal with acute pain
consultations from the ward.
Paged by ward staff
MO
Triage
Able to attend
Unable to attend
Can wait > 1 hour
Cannot wait > 1 hour
Attend
Patient
WAIT
See
patient
when
able
CONTACT
Surgical
team for
assistance
REVIEW
case when
able
The surgical team should be able to assess the patient, give iv fluid challenge and prescribe
supplementary analgesia (e.g.: single injection NSAID or opioid) under the supervision of the
Obs/Pain MO. In all circumstances, the Obs/Pain MO MUST review the patient as soon as he/she
is available.
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PAIN MO GUIDELIENS FOR MANAGING PATIENTS WITH APS DEVICES
Follow up
1. Patients must be seen by the pain team immediately after the operation and then at least daily
by the pain team. Assess:
 Pain severity (using appropriate scoring system)
 Patient stability (blood pressure, SpO2, sedation score)
 Other relevant neurological testing (sensory, motor and urinary function)
 Side-effects (sedation, pruritis, nausea and vomiting)
 System set-up (venous / epidural site, dressings, connections, pump programme and
history, power)
2. All relevant information should be documented in patient’s notes and APS follow-up sheets.
3. The Pain MO should resolve to one of the following options for each patient:
 Continue current analgesia
 Stop current analgesia
 Modify, such as addition of co-analgesics (see below), re-programming, switching to
other APS modality, etc.
 Management of side effects or other trouble-shooting
3. Terminate APS service by crossing out the prescription order for the APS device. Make sure
that patients receive adequate analgesia upon cessation of APS device. Please complete the
follow-up form together with the patient satisfaction score and return it to the acute pain folder.
4. In case of un-certainty please discuss with the senior pain MO or the pain specialist. For
special cases (e.g. when the practice deviate from the recommendations) please liaise with the
anesthesiologist or the parent team concerned.
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Problem solving
Inadequate analgesia
1. All patients with inadequate analgesia must be attended at the earliest convenience. When the
pain-duty MO is engaged in other urgent clinical duties, the medical staff of the parent team
may be consulted for immediate rescue measures. Once the urgent duty is over the pain-duty
MO shall review the case as soon as possible.
2. Check that the pump is running and the reservoir / infusion bag not empty.
Exclude
disconnections or occlusions.
3. Review the set-up and programme of the APS device.
4. Stable patients with intravenous PCA may receive boluses of morphine 0.02mg/kg
intravenously at 5 minute intervals up to 0.1 mg / kg.
5. Stable patients with epidural / nerve blocks should have their sensory level checked. If the
sensory level is inadequate, increase the basal infusion rate by 50%. If pain is distressing, give a
4 ml bolus of either the same solution or 0.125-0.25% bupivacaine and monitor the blood
pressure every 5 minutes for 30 minutes.
6. All top-ups should be done and supervised by the Pain MO. The Pain MO also has to review
the patients after the increment.
7. Consider co-analgesic eg IV/IM ketorolac.
8. Other considerations with ineffective analgesia include surgical complications, patient
confusion, tolerance to analgesics, or presence of neuropathic pain. If still not effective, consult
pain specialist.
Hypotension
1. All patients with hypotension must be attended at the earliest convenience. When the pain-duty
MO is engaged in other urgent clinical duties, the medical staff of the parent team may be
consulted for immediate rescue measures. Once the urgent duty is over the pain-duty MO shall
review the case as soon as possible.
2. Find out the cause of hypotension and determine the level of sensory blockade as well.
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3. Give fluid ± vasopressors.
4. If other causes of hypotension are excluded and the level of sensory blockade adequate, stop the
infusion for few hours and reassess later. Recommence the infusion at a lower rate.
5. If pain relief inadequate, continue the infusion after fluid ± ephedrine, consider co-analgesic eg
iv/im ketorolac.
6. Consider converting to non-regional modes of analgesia if hypotension remained a problem
whenever adequate blockade is established.
Respiratory depression
1. This is life threatening and must be attended immediately. When the pain-duty MO is
engaged in other urgent clinical duties, the intensivist on call should be consulted for
immediate rescue measures. Once the urgent duty is over the pain-duty MO shall review the
case as soon as possible.
2. All patients with significant sedation (difficult to arouse) are at risk of developing respiratory
depression and should be treated. Classical signs such as pin-point pupils or slow respiratory
rate are not sensitive, and arterial desaturation (reduced SaO2) is certainly too late.
3. Resuscitate immediately if patient is physiologically unstable. Secure patient’s airway,
breathing and oxygenation with manual ventilation and oxygen supplement. Inform ICU.
4. Stop APS device immediately. Review the physical set up, connections, programme and
consumption history. Document any abnormalities in patient’s notes and follow up sheet.
5. Naloxone should be available in every clinical area in the emergency trolley. It is usually not
required for mild cases. Consider Naloxone if patient is at risk of developing significant
sedation and deterioration. Dose: 0.1-0.2 mg iv/im/sc and repeat at 3 minute interval until
patient recover or when a maximum of 10 mg is given.
6. Review and exclude total spinal blocks and local anaesthetic toxicity for patients with epidurals
or other head and neck regional blocks.
Pruritus
1. Give chlorpheniramine 5 mg iv or im. If tolerating oral intake, prescribe oral preparation 4 mg.
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2. Consider Naloxone at 0.01 mg bolus iv, especially for pruritis associated with spinal opioids.
Urinary Retention
A trial of 30 minute is allowed. Perform up to two “in-and-out” catheterizations. Insert an
indwelling catheter if necessary.
Leg weakness
1. Consider stopping the epidural LA infusion and review in 2 hours. If leg weakness resolves,
restart infusion with reduced concentration of LA by 30%. Review in another 2 hours, and
consider alternate mode of analgesia if weakness recur or if pain become difficult to control.
2. If leg weakness persists despite discontinuation of epidural infusion, please continue close
neuro-observation and look for signs of hematoma / abscess (such as back pain, root pain, fever,
urinary retention or incontinence). Inform the neurosurgeon on-call if the clinical picture is
compatible. Offer another mode of analgesia for rescue.
Paresthesia
1. Mild paresthesia in the blocked dermatome may be expected.
Consider reducing the
concentration of LA.
2. Follow the leg weakness protocol if the paresthesia is dense and disturbing to the patient, or if it
did not resolve with reduction in LA concentration.
3. Beware of high level (thoracic) paresthesia as it may indicate progression of a high block. Stop
infusion and assess the level of block.
Difficulty in Removing the Catheter
1. If difficulty is encountered, try to flex the back as much as possible. Pull the catheter out with
a constant force. If it fails, contact the OT senior on call.
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Unilateral or Patchy Neurological Blockade
1. Consider withdrawing the epidural catheter by 1 cm and top-up with another bolus of epidural
LA. Consider switching to non-regional modes of analgesia.
When Should the Catheter Be Removed?
1. When pain can be satisfactory managed by other modes of analgesia, or if the catheter failed to
provide adequate analgesia despite adequate dose.
2. Haemodynamic instability from other causes like hemorrhage
3. Evidence of sepsis or bleeding tendency (corrected prior to removal)
Prevention of infection
1. Use bacteria filter
2. Epidural site should be examined at least every day while the catheter is in situ, and once more
within 1 day after catheter removal.
3. Epidural site dressing should be changed every 2-3 days if prolonged use anticipated
4. Premixed drugs for infusion should be discarded after 48 hours if unused
Please remember to document all critical events in the follow-up charts, patient notes and critical
incidence forms.
Drugs stocked in the ward
1. Ephedrine 30 mg ampoule
2. Metaraminol 10 mg/ml vial
3. Naloxone 0.4 mg ampoule
4. Fentanyl 100ug ampoules
5. Buipivacaine 0.5% vial
6. 250ml normal saline bag
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Equipment stored in ward
1. 0.22 um bacteria filter
2. 140 cm minimum volume extension tubing
3. Keys for pumps
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GUIDELINES ON CO-ANALGESIA (last update: July 2004)
Indications
1. When pain is not adequately relieved by PCA opioid or epidural LA infusion
2. When side effects of opioid are distressing
Contra-indications
1. Patients with history of allergies to Non-steroidal anti-inflammatory drugs (NSAID) or
paracetamol, asthma, personal or familial history of atopy or Steven-Johnson syndrome.
2. Patients with history of dyspepsia, gastric ulcer or GI bleeding, renal impairment, hypovolemia,
bleeding tendencies e.g.: after massive transfusion (for NSAID), liver impairment (for
paracetamol), or sedation tendency (for opioids)
3. Patients undergone procedures that carry high bleeding risk e.g.: after brain surgery (for
NSAID)
4. Pain such as intestinal colicky pain or neuropathic pain may respond better to other therapy.
Non-opioids
1. Paracetamol (tablet / syrup / suppository)
Adult oral: 0.5 - 1.0 g q6h
Adult rectal: 1-2 gm q6h
Paediatric oral: 15 mg/kg q6h
Paediatric rectal: 30 mg/kg q6h
2. Diclofenac = Voltaren (tablet / injectable)
Adult oral: 25 mg tds or SR 100 mg daily
Adult im: 25 mg q8h for 2 days
Paediatric oral: 0.5-2 mg/kg/day
3. Ketorolac = Toradol (injectable)
Adult im/iv: 15 mg q6h for 2 days
NB: reduce dose for elderly / renal impaired patients
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4. Indomethacin = Indocid (capsule / suppository)
Adult oral: 25-50 mg tds
Adult rectal: 100 mg bd
Paediatric oral: 2 mg/kg/day
Paediatric rectal: 2 mg/kg/day
5. Naproxen = Naprosyn (tablet)
Adult oral: 250 mg tds
6. Ibuprofen = Brufen (tablet)
Adult oral: 200 mg q6h
7. Mefenamic = Ponstan (capsule)
Adult oral: 250 mg q6h
8. Piroxicam = Feldene (capsule)
Adult oral: 10 mg bd
9. Sulindac = Clinoril (tablet)
Adult oral: 200 mg bd
10. Ketoprofen = Orudis (injectable)
Adult im: 50 mg q6h up to 3 days
COX-2 specific NSAIDs on special request
1. Parecoxib = Dynastat (injectable)
Adult iv/im: 40 mg q12-24h.
Sample only. Need endorsement from senior staff of Department of A&IC
2. Celecoxib / Rofecoxib: only with authorization from Department of Medicine
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Anti-spasmodic
1. Hyoscine methobromide = Holopon: 1 mg tds po
2. Hyoscine butylbromide = Buscopan: 20 mg im / sc / iv
Opioid co-analgesic
These are used only for weaning off the APS devices and should be prescribed by the pain MO
only. Adding another opioid can confuse the regime, and increase the likelihood of side-effects. If
a partial agonist is used, the efficacy of full agonist such as morphine may be reduced, and so far
there is no evidence to show that one is better than any other.
1. Dextropropoxyphene = Doloxene (tablet)
Adult oral: 64 mg qid
2. Dihydrocodeine = DF118 (capsule)
Adult oral: 30 mg qid
3. Codeine (tablet / syrup)
Adult oral: 30 mg qid
Paediatric oral: 0.5 mg/kg q4h
4. Tramadol (capsule / syrup / injectable)
Adult oral: 100 mg tds
Adult im/iv/sc: 100 mg qid
Paediatric oral/im/iv/sc: 1-2 mg/kg single dose
5. Dextropropoxyphene 32.5 with Paracetamol 320 = Dologesic (tablet)
Adult oral: 2 tab qid
6. Dextropropoxyphene 65 with Aspirin 380 with Caffeine = Doloxene Co (capsule)
Adult oral: 1 tab qid
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PAEDIATRIC PAIN RELIEF
Introduction
1. Simple invasive procedures can be done under sedation or topical anaesthesia with EMLA
cream.
2. After minor procedures, oral or rectal non-opioid analgesics (e.g. paracetamol, NSAIDs) are
often adequate.
3. Oral opioids (e.g.: codeine, morphine) can also supplement these simple analgesics. APS
modalities such as intravenous PCA opioids and epidurals may also be suitable in selected
cases that can understand and follow instructions.
4. Paediatric patients in severe pain or those who cannot comply may need iv opioids, either by
nurse controlled analgesia or by infusion, under close monitoring.
5. Regional techniques performed during anaesthesia e.g. nerve block; caudal analgesia, etc are
effective for postoperative pain relief. Simply infiltrate the wound with local anaesthetics can
be of great help.
Commonl analgesics
Paracetamol
15 mg/kg q6h ie 60 mg/kg/day orally, (syrup 125 mg in 5 ml)
30 mg/kg q6h for rectal use (suppository 125 mg or 250 mg)
Diclofenac
1 mg/kg q12h orally
Indomethacin
1 mg/kg q12h orally or rectally
Tramadol
1 mg/kg single dose orally or im or iv
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Codeine
0.5 mg/kg in q4h orally
(Syrup 25 mg/5 ml)
Morphine
1. OT recovery room protocol
0.02 mg/kg q5min iv up to 5 doses, then review
2. PCA protocol
Morphine concentration 0.5 mg/ml
Bolus dose
0.03 ml/kg (0.015 mg/kg)
Lockout period
10 min
4 hr dose limit
0.5 ml/kg (0.25 mg/kg)
3. Oral
0.2 mg/kg q4h up to maximum of 1 mg/kg/day (syrup 1 mg/ml)
4. Continuous iv opioid infusion (not for neonates)
Morphine concentration
0.1 mg/ml
Infusion rate
Start at 0.01 mg/kg/hr (titrate 0.01-0.06 mg/kg/hr)
*This modality of pain relief should only be started after discussion with the pain
management team.
Other useful drugs
Metoclopramide
0.1 mg/kg q8h po/im/iv (tab 10 mg, syrup 5 mg/5 ml)
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Chlorpheniramine
0.4 mg/kg/day in 3 divided doses (tab 4 mg, syrup 2 mg/5 ml) po
0.2 mg/kg single dose single iv/im injection
Naloxone
10-50 mcg/kg iv, repeat at 3 minute intervals till responsive, followed by 1-5 mcg/kg/hour infusion
till the offending opioid is eliminated.
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FORMS AND STAMPS FOR THE ACUTE PAIN SERVICE
Introduction
Documentation is an important part of the APS for these reasons:

Communication between the APS team and the ward staff

Reinforcement of monitoring and safety measures

Facilitate hand-over and continuation of care

Auditing, research and quality assurance
Forms
1. Booking form
This is available at the 5th Floor common room (next to the door) or the operating theatre
control desk. The collection boxes are located next to the forms.
Please complete all particulars and return before 0800 on the day of elective surgery.
2. Acute pain follow-up form
This is available at the operating theatre PCA trolley, the acute pain folder and the intensive
care unit.
This form must be completed upon initiation of all APS device. Upon discharge of patients
from the recovery room, the APS team will be informed, and during the first follow-up the
APS team will retrieve the follow up form, and it will serve as the patient record within the
team. It must be updated each time during the acute pain round. After completion of the last
follow-up, please put it in the “completed follow up” section of the acute pain folder. It will be
audited and archived by the APS team. Please document all pain related clinical matters on
this form.
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3. APS nursing observation form
This is kept at the same places as the follow-up form. Again it must be completed upon
initiation of the APS device. It is for charting patient observations by the ward nurses, and it
will remain in patient’s folder even after the APS device is not in use. Please put down any
specific nursing orders (e.g.: frequency of observation) on this form.
4. Patient’s progress notes
Please put down our standard post-op. orders for all patients at the initiation of the APS device.
They are summarized in the large blue stamp at the PCA trolley. Please sign and put down
anything you want to tell the primary team (e.g.: oxygen supplement).
5. Patient’s prescription forms
Details of APS orders have to be documented in the yellow prescription form. One stamp for
each regime is available at the PCA trolley. Please use the responding stamp, date and sign
accordingly. Please prescribe anti-emetics as appropriate.
Cross out all sedatives or narcotic analgesic prescription on both the yellow and white
prescription forms, and on the side of the yellow form please stamp please add another stamp
to remind others not to do so.
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Stamps for yellow prescription form:
Left: PCA regimes
Right: epidural regimes
Warning stamps for the side of the yellow prescription form
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GRASEBY 3300 PUMP
Introduction
At present all Graseby 3300 have been configured only for intravenous PCA without background
infusion. This device should be hooked onto the iv pole by the patients’ bedside during use.
Syringe Barrel
Clamp
Syringe Plunger
Clamp
Cover
Flap
Polycarbonat e
Cover
Pat ient
Hist ory Key
LED
Display
Setup
1.
Use a Terumo 50 ml syringe with luer lock as the pump has been programmed to recognize
this model and size. When placing syringe, lift up the barrel-clamps gently and slide the
syringe onto position. Make sure that that the barrel-clamp is securely fastened on to the
body syringe and the plunger-clamp is then clamped onto the syringe plunger. The plungerclamp can be adjusted into the clamped-position only when the two little buttons on the
plunger surface (of the plunger-clamp) are depressed.
2.
Always use the extension tubing together with the anti-siphon valve.
3.
Make sure that the handset is connected tightly to the nipple at the back of the pump. The
pump will fail to activate even if there is a partial leak in the tubing and connections, and
there are no alarms for that.
4.
Always connect the pump to the AC supply. The AC power indicator lamp will illuminate.
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The batteries will be fully charged if the pump has been connected to main (AC) power for at
least 14 hours. When fully charged, the batteries will last for approximately 8 hours under
normal operating conditions.
5.
Secure tightly onto IV pole at or below the level of the patient to prevent potential siphoning
effect.
6.
Make sure that the key is detached from the PCA after setting up the pump.
7.
Please refer to the manual for technical details.
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GRASEBY 3300 PUMP QUICK REFERENCE GUIDE
Function buttons
On/off
This button switches on and off the power to operate the pump.
Start/Stop
This button turns on and off the PCA program
Enter
This button reviews the preset PCA program
Patient history
This button reviews the total amount of analgesic used, number of actual demands and number of
successful demands.
 or 
This button is for programming the PCA settings. Only to be used by the anaesthesiologist or the
pain team.
Patient connection
1. Always use the extension tube (140 cm) with anti-siphon valve
2. A dedicated iv access is preferable. Use an iv cannula > 22G with an anti-reflux valve.
Stopcocks are not allowed.
3. Tegaderm and micropore dressing for easy observation of cannula insertion site.
4. In case of difficulty with intravenous access and only one line is available for both intravenous
fluid and PCA, the Y-piece can be applied. It is only available to the pain team staff
Trouble shooting
1. Pump problems
i. unable to start PCA
- check that the syringe is fitted correctly
- check that the syringe plunger clamp is firmly applied onto the plunger
- check that the cover is closed properly
ii. spontaneous PCA doses
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- intrinsic pump fault
- electromagnetic interference
- exclude siphoning effect
- check that the syringe plunger clamp is firmly applied onto the plunger
- check for cracks, leak in the system
iii. spontaneous reprogramming e.g. electromagnetic interference
iv.unable to trigger demand
- inform Pain Team as pump needs to be withdrawn and checked
2. Unable to trigger PCA demand
i. poor patient’s technique
ii. faulty demand button
iii. disconnected or loose (leaking) connection tubing
iv. pump failure
- DO NOT test demand button with system still connected to patient if fault is suspected
- inform Pain Team if fault is suspected
3. 4 Hourly Dose Limit Exceeded Alarm
- may occur if dose limit exceeded
- silence alarm
- ensure patient not over sedated
- if patient not using PCA well - needs re-education
- if using PCA well but still high pain score - inform Pain Team
4. Occlusion Alarm
- check patency of IV cannula
- exclude kink, occlusion, obstruction in the system eg extension tubing
5. AC Failure / Low Battery Alarm
- check and reconnect power cable to main AC supply
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Alarms
Graseby 3300 PCA pump has 3 different alarm sound types
1. Loud continuous alarm
2. Quiet “chirping” alarm
3. Loud “pulsed” alarm
Loud Continuous Alarm
Cause:
An interval fault condition is detected
e.g.
*FAULT CODE 7*
This alarm cannot be silenced
Action:

Press off

Disconnect the AC main cable

Inform Pain Team
Cause:
WARNING:
LOW BATTERY
Loud continuous (2 mins duration)
Very low battery
This alarm cannot be silenced
Action:

Switch off the pump

Reconnect the AC main cable

Switch on pump
Quiet “Chirping” Alarm
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Accompanied by an explanatory message on the display at 10 sec intervals
Cause:
WARNING:
COVER NOT CLOSED (CLOSE
COVER & PRESS START)
Cause:
WARNING:
PUMP NOT RUNNING
PRESS START
Cause:
WARNING:
SYRINGE NEARLY EMPTY
(LESS THAN 3.0 mls)
Action:

Prepare next syringe if PCA is to be continued.
Cause:
WARNING:
MAINS FAILURE
PUMP NOW ON BATTERY
Action:

Reconnect AC mains cable as soon as possible.
Cause:
WARNING:
LOW BATTERY
Action:
Reconnect AC main cable now. This alarm cannot be silenced.
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Loud Pulsed Alarm
Cause:
PUMP STOPPED:
OCCLUSION
(RELEASE PLUNGER CLAMP)
The infusion line is blocked.
Action:

Open cover, release syringe plunger clamp and deal with occlusion
Cause:
PUMP STOPPED:
SYRINGE REMOVED
Action:

Replace syringe.
Cause:
PUMP STOPPED:
TOTAL DOSE LIMIT
XXX g IN Y HOURS EXCEEDED
Action:

Find out causes for excessive usages

Inform Pain Team
Cause:
PUMP STOPPED:
BY EXTERNAL
MONITOR
A monitor alarm has triggered and stopped the pump
Action:
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
Check that PCA programme has not altered

Inform Pain Team

Press START if safe to do so
Please refer to the acute pain team in case of queries, other kinds of trouble shooting or any
other technical / clinical problems.
Switching off
Switching
Press STOP. Insert the key into the pole clamp lock and turn through
Off:
90o. This opens the syringe cover.
Press STOP again
Press the OFF button to switch the pump off.
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GRASEBY 9300 PUMP
Introduction
The Graseby 9300 is an ambulatory peristaltic pump for PCA or continuous infusions. It operates
on batteries (2 alkaline AAA batteries) and can be carried by a fabric pouch. This is to facilitate
patients’ ambulation. It can accommodate different medication reservoirs (see below) for different
purposes.
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Setup
1. There are two kinds of cassette: the 250 ml internal cassette for PCA, and the external cassette
with spike for continuous infusions. Both cassettes carry internal locking so that once detached
from the pump they are automatically invalid. This is to avoid inadvertent reuse of old
cassettes. Make sure that they are firmly connected to the pump before starting.
2. The pump uses two alkaline AAA batteries. On average new batteries will last for 7 days, and
in general infusions consume more power than PCA mode.
3. You can prime the internal cassettes either by a female-female connector or a 3-way stopcock.
All air bubbles must be aspirated before the cassette is attached onto the pump body, as the
internal lock will prevent further manipulations afterwards. You can also prime the system by
pushing on the PURGE button two times and hold while the pump is in the unlocked mode.
This will give a 2ml bolus enough for the tubing.
4. Always use the anti-siphon valve attached inside the cassette package, and the 140 cm
extension tubing.
5. The Graseby 9300 pump has 2 levels of keypad lock. Please select full lock (with both lock
signs highlighted) by pushing on the KEY button and entering the code 9300 by using the ▲
and ▼ buttons, followed by the KEY button again.
6. The cassette should be locked by the pain team.
7. Please refer to the manual for technical details.
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GRASEBY 9300 PUMP QUICK REFERENCE GUIDE
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Note:
Please contact Pain Team by Pager 1067 / DECT phone 6172 whenever in doubt
about integrity of PCA / CI pump eg. pump fallen to ground - disconnect PCA / CI
line from patient first and inform Pain Team
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Warnings and Alarms
DISPLAY
POSSIBLE CAUSES
ACTION
1. STOP infusion
WARNING: LOW
Battery charge is low.
BATTERY
2. Press OFF and replace batteries (size
AAA)
3. Press ON and START
WARNING: EMPTY
Cassette nearly empty.
CASSETTE
1. Press STOP and change cassette
2. Reset the cassette volume
3. Press START
1. Press
CASSETTE EMPTY
Cassette empty.
and STOP and change
cassette
2. Reset the cassette volume
3. Press START
WARNING: PUMP
NOT RUNNING
Pump stopped and
Press START or OFF
unused.
1. Press
OCCLUSION
Tubing is clamped.
2. Clamp tubing with Blue clamp
Kinked tubing. Tubing
too narrow. Blockage at
infusion site.
3. Clear occlusion
4. Open clamp
5. Press START
1. Press
CASSETTE NOT
FITTED
Cassette removed while
pump is running or
cassette not loaded
properly.
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2. Inform pain team
Warnings & Alarms
1. Press
AIR IN LINE OR
EMPTY
Air in cassette tubing.
Cassette empty.
and STOP
2. Clamp tubing
3. Disconnect patient tubing
4. PURGE to remove air or
Remove and replace empty cassette
1. Press
CASSETTE VOL TOO Cassette volume has not
SMALL
2. Reset the cassette volume
been re-entered for new
cassette.
1. Press OFF
FAULT XX
Pump Failure
2. INFORM Pain Team
3. Engineer attention is necessary
Note: If two alarm conditions occur at the same time, silencing one may result in another alarm
being displayed.
Please refer to the acute pain team in case of queries, other kinds of trouble shooting or any
other technical / clinical problems.
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ABBOTT PAIN MANAGER (APM-II) PUMP
Introduction
The Abbott APM-II is a multi-purpose infusion pump. It is a peristaltic pump with external
medication reservoirs connected to specific cartridges. It can be programmed to deliver infusions,
PCA or a combination of both. Most of the programme can be re-configured. It is embedded in a
rectangular PVC box together with the medication bag under lock and key, and the whole complex
is to be attached on a pole / drip stand.
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Setup
1. The Abbott APM-II operates on 2 alkaline batteries (9 Volt size D) that can maintain up to 5
days on maximal workload. Alternatively it can be connected to a transformer for external
power. That is the case in the obstetrics suite. Transformers are available at the obstetrics
suite.
2. This pump uses an external cartridge for all modes of analgesia. It also has a built-in air filter,
anti-siphoning valve and extension tubing. During the initial set up make sure that the tubes
are not kinked inside the plastic case
3. Make sure that the keypad is locked before starting. To unlock, slowly press ENTER, then ▲
twice. Lock by slowly press ENTER, then ▼ thrice.
4. Make sure that the case is locked before sending it to the ward. Keys are kept in the recovery
room (PCA trolley), the acute pain folder, the labour ward, the ICU and all the surgical and
orthopediac wards.
5. Please refer to the manual for technical details.
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ABBOTT PAIN MANAGER (APM-II) PUMP QUICK REFERENCE GUIDE
Procedures for entering a new program
1.
Press RUN / STOP to stop the pump
2.
Press REVIEW / CHANGE
3.
Press 2 1. CHANGE PROGRAM
2. NEW PROGRAM
4.
Press NO to clear only the current program (The pump enters the programming mode, then
you can set the new program now, after the air sensitivity setting is confirmed the pump enters
the stop mode.)
5.
Press RUN / STOP to restart the pump.
Procedures for renewing the drug mixture
1.
Prepare the drug mixture a/c prescription
2.
Aspirate all the air from the fluid bag
3.
Press RUN / STOP to stop the pump
4.
Press ENTER + ▲ + ▲ to unlock the keypad
5.
Clamp the tubing
6.
Open the lockbox with the key
7.
Remove the spike from the empty fluid bag
8.
Insert the spike into the new fluid bag
9.
Hang the bag inside the lockbox & lock it
10. Make sure the tubing is not kinked
11. Press RESET then 2 , it show "NEW CONTAINER” and the total volume will be
automatically reset
12. Press ENTER + ▼ + ▼ + ▼ to lock the keypad
13. Release clamp & press RUN / STOP to restart the pump
14. Make sure “TOTAL X.X ML” with a bar running clockwise
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Check Consumption (Demand / Good) or Container Information
1.
2.
3.
4.
5.
No need to stop the pump.
Press HISTORY
Press 2 then press 1
Press ▲ to review the consumption, or press ▲ consecutively three times to check *VTBI
(container information)
Press any other keys to return to original display.
To display shift information
1. No need to stop the pump.
2. Press HISTORY
3. Press 2 then press 2 to display shift information.
4. Press ▲ to review the consumption, or press ▲ consecutively three times to check *VTBI
(container information).
5. Press any other keys to return to original display.
* VTBI=volume to be infused
Review program
1.
2.
3.
4.
No need to stop the pump.
Press REVIEW / CHANGE
Press 1 then press ▲ to review the program or press ▼ to scroll backwards.
The pump will automatically return to the original display if no key is pressed within 30
seconds.
Alarms and Troubleshooting
Occlusion
1.
2.
3.
4.
5.
Press SILENCE to mute the alarm.
Press RUN / STOP to stop the pump.
Check the reasons for occlusion.
Ensure the patency of the delivery circuit.
Press RUN / STOP to restart the pump.
Check Cartridge
1.
2.
3.
4.
Press SILENCE to mute the alarm.
Press RUN / STOP & open pump latch.
Remove cartridge & tubing.
Align dot in red circle of cartridge.
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5.
6.
Reinsert cartridge in pump.
Press RUN / STOP to restart the pump.
Almost Empty
Delivery will complete in less than 30 min. for rates above 1 ml/hr.
1. Press SILENCE to mute alarm for two minutes.
2. Press RUN / STOP to stop the pump & clear the message.
Low Battery
1.
2.
3.
Press SILENCE to mute the alarm.
Change batteries (Two 9V alkaline batteries) or connect to AC power.
Press RUN / STOP to restart the pump.
Malfunction Alarms
The system detects a mechanical or computer problem. The alarm cannot be muted.
1.
Record the malfunction codes on the observation chart.
2.
Press ON / OFF to turn the pump off.
3.
Disconnect AC power & / or remove batteries.
4.
Inform Pain Team.
Check Printer Alarm
This alarm will be activated when the PRINTER key is pressed accidentally.
1.
Press PRINTER key again to de-activate it.
Air-in-line Alarm
1.
Press SILENCE
2.
Press RUN / STOP to stop the pump.
3.
Unlock the keypad with ENTER + ▲ + ▲
4.
Disconnect the tubing from the patient.
5.
Press PURGE to expel the air bubbles.
6.
Lock the keypad with ENTER + ▼ + ▼ + ▼
7.
Press RUN / STOP to restart the pump.
Please refer to the acute pain team in case of queries, other kinds of trouble shooting or any
other technical / clinical problems.
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NON-AXIAL REGIONAL ANALGESIA
Introduction
Regional analgesia techniques may provide excellent pain relief for trauma and postoperative
patients. Some of these techniques such as continuous brachial plexus analgesia, intrapleural
analgesia, paravertebral blockade and femoral/lateral cutaneous nerve of thigh/obturator (3 in 1)
blockade may be possible for postoperative pain relief with a catheter inserted peri-operatively. If
you wish to commence regional analgesia, you may request for the Abbott APM-II or the Graseby
9300 infusion pumps.
Brachial Plexus Infusion
1. For intra-operative anaesthesia, give 0.5% bupivacaine at 0.5 ml/kg slowly with increments.
GA is optional.
2. For postoperative analgesia, use 0.125% bupivacaine at 0.1-0.2 ml/kg/hr. Start at the lower
rate in recovery room. The rate may be adjusted when appropriate during reassessment.
3. For the continuous infusion in the ward, add 80 ml bupivacaine 0.5% into a 250 ml normal
saline bag. This will give bupivacaine 0.125% and a volume of 330 ml. The ward nurses
should be able to change and refill the infusion drug if the drug mixture is charted and clear
instruction written on the relevant charts.
4. Chart p.r.n. Dologesic 2 tabs q4h p.r.n orally and Voltaren 25 mg q8h or morphine 5 mg q4h
intramuscularly depending on contraindications.
5. Please fill in the pain follow-up form and the observation chart as for other pain patient. The
pain team will follow-up these patients as any other patients on PCA or epidural infusion.
6. The catheter may be left in-situ for 3-4 days.
Paravertebral Infusion
1. For intra-operative anaesthesia it is usually used to supplement a general anaesthesia.
2. Use 0.25% Bupivacaine for post-operative analgesia. Withdraw 100 ml saline from a 250 ml
saline bag, then dilute 150 ml of 0.5% Bupivacaine into the remaining 150 ml of saline,
making a total volume of 300 mls.
3. A stamp for the regime is available at the PCA trolley. Please be reminded that the total
volume of the reservoir is 300 mls and the pumps should be programmed accordingly.
Suggested infusion rate: 5-10 mls per hour.
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4. Chart rescue opioids (e.g.: morphine 5 mg q4h subcutaneously p.r.n.) or oral co-analgesics if
patient can tolerate oral intake.
5. Fill in the forms as per other patients with APS devices. The APS team will review the patient
as scheduled.
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PRIVATE PATIENTS’ FEE
Please note that private charges have been revised and will be charged according to the S.S No. 4
to Gazette No. 13/2003:
Section 1 Private Charges
1. Inpatient Charges
1.2
Doctor Fee: Daily Medical Attendance / Consultation
$1500
This will cover all fees related to in-patient pain-related consultations and follow ups, including
acute pain round, chronic pain round and other follow-up visits whenever a medical doctor is
present.
Please fill in the appropriate charge form PWH 101 when acute pain service is terminated. Thank
you.
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NURSING GUIDELINES – RECOVERY ROOM PAIN RELIEF
Principles
1.
Inadequate pain relief after surgery increases morbidity and delays patient discharge from
recovery room.
2.
A patient receiving the pain relief protocol requires constant assessment and monitoring in the
recovery room (RR).
If the recovery area is too busy to provide this level of patient
supervision, alternative methods of analgesia may be required.
3.
The anesthesiologist who prescribed the protocol must provide adequate supervision of the
patient and the nursing staff looking after the patient.
4.
The pain relief protocol should only be started by the anesthesiologist in charge of the case,
who is familiar with the anaesthetic, medical and surgical history of the patient.
Medical Protocols
Morphine (1 mg/ml)
Adults
1.
Dilute 15 mg morphine to 15 ml with normal saline
2.
Dose: 1-2 ml (1-2 mg) every 5 minutes as required
3.
For adult > 60 who is/or < 50 kg, 1 ml boluses may be more appropriate
4.
Total dose limit to be stated by anesthesiologist. If pain not relieved with dose limit, the
nursing staff will inform the anesthesiologist to reassess the patient.
Paediatric patients
1.
Morphine 20 mcg/kg q5min intravenously up to 5 doses, then review
(See chapter on paediatric analgesia)
Ketorolac Protocol
Exclude contraindications before giving NSAID.
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Ketorolac (30 mg/ml) iv or im
Adults under 65 years of age
1.
Dose: 30 mg bolus followed by 10 - 30 mg Q6H to a max of 120 mg daily
Adults 65 years and older
1.
Dose: 10 mg bolus followed by 10 - 30 mg Q6H to a max of 60 mg daily
Nursing Protocol
1. If a patient complains of pain or request analgesia, assess the pain score to determine the
severity of pain. If the pain score is > 4, inform the anesthesiologist in-charge of the patient.
Inadequate pain relief should be treated without undue delay.
2. The anesthesiologist may prescribe the recovery room pain relief protocol.
3. The opioid must be prescribed by name e.g.. “IV morphine protocol”. Label the syringe with
the drug name and concentration, and patient name.
4. All patients should be on supplementary oxygen.
5. Assessment must include BP, pulse, SpO2, pain score, sedation score, RR every 5-10 minute.
6. Flush IV line with saline or IV fluid after injecting opioid.
7. Stop pain relief protocol when the patient is comfortable. Patient need not to be completely pain
free to be comfortable.
8. This protocol may precede the commencement of PCA opioid. Start PCA when patient is
adequately awake and pain moderate. Stop pain relief protocol when PCA is started.
9. Inform the anesthesiologist responsible for that patient of any side effects e.g. hypotension, low
urine o/p, SpO2, severe, nausea, vomiting, itchiness.
10.Side effects may be treated if treatment drugs already charted e.g. antiemetic. If not, inform the
anesthesiologist.
11.Refer to the anesthesiologist responsible for that patient for any queries related to the protocol.
12.Inform duty anesthesiologist if the anesthesiologist responsible for that patient is not available.
13.Inform the pain team (DECT phone 6172 on weekday 0800-1600, pager 1067 at other times)
when patients with PCA or epidurals are discharged from the recovery room. This is to make
sure that the pain team knows where to follow the patient up.
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Inform anesthesiologist if:
1. Sedation score of 3 or greater
2. Respiratory rate of 8/min or less
3. Nausea or vomiting
4. Severe itch
5. Systolic blood pressure of less than 90 mmHg or 20% lower than baseline blood pressure
Sedation score
1 = alert
2 = drowsy, easy to arouse
3 = difficult to rouse
4 = unconscious, not arousable
S = normally asleep, easy to rouse.
Pain score
Where possible, record the verbal analogue pain scale using the ruler or the verbal numeric scale.
The patient should be asked to rate their pain on a scale of 0 to 10
0 = no pain
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NURSING GUIDELINES – CARE OF PATIENTS ON PATIENT CONTROLLED
ANALGESIA (PCA)
PCA patient on return from OT
1. Pain Team has been informed by the OT recovery room staff and they will review the patient at
their earliest convenience.
2. Place the PCA pump at or below the level of the patient.
3. The Graseby 3300 pump need external power source. After plugging into the socket, make sure
the “AC” light panel is lit.
4. Check that the PCA tubing and connections are correct and tightly fitted.
5. Separate nurse calling button from the PCA button.
6. Confirm that patient is familiar with PCA
7. Make sure that he is the only person allowed to press the demand button except in the case of
Nurse controlled analgesia (NCA)
PCA programme
1. Do not leave the PCA key on the pump to prevent unauthorized programming. Keep it in the
DDA cupboard.
2. Check that PCA pump is programmed as charted.
3. PCA programme should not be changed by anyone except Pain Team.
PCA system
IV PCA
1. A dedicated peripheral line is recommended for PCA. Special Y-piece connectors are reserved
for cases when only one line is available for both infusions and PCA. It is only available to the
pain management team.
2. No stopcock should be used in the PCA system.
3. Separate IV access must be available while patients are still on PCA.
PCEA
1. If PCA is used via the epidural route, a bacterial filter 0.22 m must always be on the line.
2. System should be clearly labeled “Epidural Infusion”.
3. No other drugs to be injected into the epidural analgesia line.
4. Separate IV access must be available while patients are on epidural infusion
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Drug Chart
1. Check that prescription for PCA drug refilling is charted. If not, inform the pain team.
2. Check that anti-emetic P.R.N. is prescribed.
3. No co-analgesics, other opioid analgesia or central depressant is allowed during the use of PCA
except prescribed or agreed to by pain team.
4. Supplementary oxygen should be given to all patients on PCA for the first 24 hours or as
ordered by anaesthetist until reviewed by pain team.
Charting of Observation
Use Acute Pain Service Observation Chart. Observations should be made hourly until reassessed
by the pain team for:

Blood pressure and Pulse

SPO2

Urine Output and CVP if catheters are present

Pain Score

Sedation Score

Respiratory Rate

Number of Demands and Good

Leg weakness (if on epidural PCA or PCEA)
Refilling & Changing of PCA Syringe
Preparation of drugs:

Wash hands before preparing the drugs

For Graseby 3300 always use a NEW 50 ml Terumo syringe with luer lock for refilling

3 checks 5 rights with another nurse for all drugs and dilution when mixing the drugs as
prescribed in the “As required” column of the drug chart.

Usual PCA prescription :
Graseby 3300
Morphine 60 mg diluted to 60 ml with normal saline (1 mg/ml)
Graseby 9300 or Abbott APM-II
i. Morphine 150mg diluted to 150 ml with normal saline (1mg/ml)
ii. Pethidine 1500mg diluted to 150ml with normal saline (10mg/ml)
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
Label the syringe/cassette clearly with
i. Name of drug
ii. Dilution
iii. Date and time of preparation
iv. Patient’s name and bed
v. The person who prepare the drugs

Ensure right route for PCA: intravenous or epidural

Make sure cannula is functioning; no sign of tissue, displacement or kinks

Ensure no stopcock tap in PCA line

Expel air in the syringe/cassette and connect to the extension tube with anti-siphon valve

Recheck all connections and clamps for proper installment before restarting PCA

Check that PCA programme is not cleared or altered during syringe/cassette change

Chart refilling of drugs on patient’s drug chart
Stopping PCA

The pain team usually stops the PCA when satisfactory pain relief is achieved by oral analgesic
medication or as the pain improves with healing after a few days.

When PCA or epidural infusion is stopped, please make sure that parenteral and/or oral opioid
analgesia is prescribed on the “As Required” column of the drug chart.

Please return the PCA infusion pump to OT recovery room or the labour ward according to the
loan form issued as soon as possible.

Discard the remaining opioid drugs.

Inform Pain Team if pain is poorly controlled by parenteral opioid after stopping PCA.

The pain team will review the patient again if necessary.

Contact Pain Team Pager 1067 /DECT phone 6172 for any query.
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NURSING GUIDELINES – CARE OF PATIENTS ON CONTINUOUS EPIDURAL
INFUSION ANALGESIA
CEI patient on return from OT
1. Check that the CEI tubing and connections are correct and tightly fitted.
2. Place pump by the patient.
3. Both the Graseby 9300 and Abbott APM-II run on alkaline batteries.
CEI programme
1. Do not leave the key on the pump to prevent unauthorized programming. Keep with DDA
cupboard key.
2. Check that CEI pump programmed as charted.
3. CEI programme should not be changed by anyone except Pain Team.
Continuous infusion
1. A bacterial filter 0.22 m must always be on the line
2. No stopcock in continuous infusion system
3. System should be clearly labeled “Epidural Infusion”
4. No other drugs to be injected into the epidural analgesia line
5. Infusion to be altered by anaesthetists only
6. Separate intravenous assess must be available up to at least 4 hours after cessation of epidural
infusion
Drug Chart
1. Check that prescription for CEI drug refilling is charted. If not, inform Pain Team.
2. Check that anti-emetic P.R.N. is prescribed.
3. No co-analgesics, other opioid analgesia or central depressant is allowed during the use of CEI
except prescribed or agreed to by Pain Team.
4. Supplementary oxygen should be given to all patients on CEI for the first 24 hours or as
ordered by anaesthetist until reviewed by pain team.
Charting of Observation
Use Acute Pain Service Observation Chart. Observations should be made hourly until reassessed
by the pain team for:
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
Blood pressure and Pulse

SPO2 in major postop. cases or as indicated

Urine Output, CVP if catheters present

Pain Score

Sedation Score

Respiratory Rate

Leg weakness
Refilling of Drugs for Epidural Local Anaesthetic Infusion
Preparation of drugs:
Strict adherence to aseptic techniques is important for the prevention of infection.

Wash hands before preparing the drugs

3 checks 5 rights with another nurse for all drugs and dilution when mixing the drugs as
prescribed in the “As required” column of the drug chart

The drug mixture should be added to a 250 ml bag of normal saline as charted

Usual continuous epidural infusion prescription:
Use a 250 ml bag of normal saline, add
i. Bupivacaine 0.5%
60 ml (300 mg)
ii. Fentanyl (50 mcg/ml)
16 ml (800 mcg)
This 326 ml mixture will give Bupivacaine 0.1% + Fentanyl 2.5mcg/ml (0.00025%)
NB: some patients may be using Ropivacaine instead of Bupivacaine:
i. Ropivacaine 1%
40 ml (400 mg)
ii. Fentanyl (50 mcg/ml)
16 ml (800 mcg)
This 306 ml mixture will give Ropivacaine 0.13% + Fentanyl 2.6 mcg/ml

Label the bag of drugs - fluid mixture clearly

After mixing the drug, aspirate air form the bag of fluid or drug mixture

Reset total cassette volume to:
320 ml for Bupivacaine-Fentanyl mix, and
300 ml for Ropivacaine-Fentanyl mix

Check pump programme is not cleared or altered

Connect the drug mixture to the spike of the pump at one end and make sure that the extension
from the pump is connected to epidural filter

Recheck for any loose connections and the right infusion rate before restarting the infusion
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
Chart “Refilling of drugs” on the patient drug chart

Discard epidural mixture after 48 hours if not finished and change to a new bag
Resetting total cassette volume
This volume fixes the total volume that the pump will infuse. It should correspond to the volume
of the drug mixture in the fluid bag. When the volume of the bag is low, the pump will alarm and
notify the user that the volume of drug is low, and that the bag of drug mixture will need refilling
or changing. The pump will then switch to a preset ‘Keep vein open’ (KVO) rate at 1 ml/hour
until the bag of drug is refilled and the cassette volume reset. Hence each time a new bag of drugs
is put up, this volume has to be readjusted. You will need the access code to change the cassette
volume. Please refer to the above quick reference guidelines.
Stopping continuous epidural infusion

The pain team usually stops the continuous epidural infusion when satisfactory pain relief is
achieved by oral analgesic medication or as the pain improves with healing after a few days.

When epidural infusion is stopped, please make sure that parenteral and/or oral opioid
analgesia is prescribed on the “As Required” column of the drug chart.

Please return the epidural infusion pump to OT recovery room as soon as possible.

Discard the remaining opioid drugs.

Inform Pain Team if pain is poorly controlled by parenteral opioid after stopping CEI.

The pain team will review the patient again if necessary.

Contact Pain Team Pager 1067 / DECT phone 6172 for any query.
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NURSING GUIDELINES – MONITORING AND SIDE EFFECTS
Although postoperative PCA or CEI analgesia are effective and improve patient recovery and
satisfaction, side effects of therapy may occur. Nausea, vomiting, pruritis, urinary retention as well
as sedation and respiratory depression may occur with opioid use and hypotension, paresthesia and
leg weakness may occur with epidural analgesia. When a patient is on PCA or continuous epidural
infusion, he must be monitored closely especially for the first 24 hr during the recovery from
general anaesthetic.
For the safe and effective analgesia, several parameters must be monitored:
1. Vital signs - Hourly BP, Pulse rate, (Urine output, SpO2, CVP in critically ill cases)
2. Pain chart - Pain score, sedation level, respiratory rate, leg weakness (for epidural analgesia)
3. Side-effects - Nausea, vomiting, pruritis, paresthesia
Most of the side effects can be treated by the following drugs. If the side effects are not relieved
and the patient remains distressed, you should inform the pain team for reassessment. Reducing
the dose of opioid or local anaesthetic may help.
Treatment
Nausea, vomiting
Metoclopramide 10mg q6h p.r.n. iv/im/orally, other antiemetics eg
prochlorperazine, ondansetron, droperidol, or change/stop opioid
Pruritis
Chlorpheniramine 5 mg iv/im, 4mg orally, or change/stop opioid
Paraesthesia
Reduce LA infusion rate or LA concentration, or stop LA infusion
Leg weakness
Reduce LA infusion rate or LA concentration, or stop LA infusion
Urinary retention
Urinary catheter
Hypotension
Stop LA infusion, iv fluid bolus or metaraminol (vasoconstrictor)
Sedation
Reduce opioid dose, naloxone 0.1 mg boluses
Resp. depression
Reduce opioid dose, naloxone 0.1 mg boluses
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Note:

Ensure that no other sedative drugs are being prescribed without approval of the pain team.

Ensure only the patient pushes PCA button (except in the case of nurse controlled analgesia)

Inform pain team Pager 1067 / DECT phone 6172 when in doubt or adverse effects not
responsive to treatment
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PCA Nursing Standing Order
Oxygen supplement For 24 Hr
Vital signs - Hourly BP, P, Urine output, SpO2
Pain chart - Pain Score, Sedation Level, RR
Inform Pain Team (pager 1067 / DECT phone 6172) if
1. Inadequate pain relief, pain score > 3
2. Drowsy or over-sedated
3. Respiratory rate < 10/min
4. Abnormal vital signs eg hypotension, low urine output, SpO2
5. Severe nausea & vomiting, itch
6. Unrelieved PCA alarms
Crisis
If patient is
1. Un-arousable
2. Respiratory rate < 8/min
3. Apnoeic or respiratory obstruction
4. Severe hypotension (< 80/40)
Management
1. Immediately notify any medical staff that may be on hand
2. Call the switchboard (ext.2468) and advise of an arrest call. Then page the
Pain Team (pager 1067 / DECT phone 6172).
3. Administer oxygen via a tightly applied Ambu bag
4. If a patient has no respiration, administer Narcan (naloxone)IV: 0.1 mg.
This may be repeated within minutes if there is no response.
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Epidural Infusion Nursing Standing Order
Oxygen supplement For 24 Hr
Vital signs - Hourly BP, P, Urine output, SpO2
Pain chart - Pain Score , Sedation Level, RR, Paraesthesia, Leg weakness
Inform Pain Team (pager 1067 / DECT phone 6172) if
1. Inadequate pain relief, Pain score > 3
2. Drowsy or over-sedated
3. Respiratory rate < 10/min
4. Abnormal vital signs eg hypotension (< 90/40), low urine o/p, SpO2
5. Severe nausea & vomiting, itch
6. Leg weakness or numbness is present
Crisis
If patient is
1. Unarousable
2. Respiratory rate < 8/min
3. Apnoeic or respiratory obstruction
4. Severe hypotension (80/40)
Management
1. Immediately notify any medical staff that may be on hand
2. Call the switchboard (ext.2468) and advise of an arrest call. Then page the
Pain Team (pager 1067 / DECT phone 6172).
3. Administer oxygen via a tightly applied Ambu bag
4. If a patient has no respiration, administer Narcan (naloxone)IV: 0.1 mg.
This may be repeated within minutes if there is no response.
5. If hypotension, give colloid 250 ml stat. Have available metaraminol.
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USEFUL NUMBERS
Useful telephone extension numbers:
Resuscitation
2468
Department Anaesthesia & Intensive Care Main Office
2735
ICU
3026/3027
Operating Theatre Control
2527/2534
Recovery room
2532/2533
Useful hospital pager numbers
Duty Pain MO
1067 (24 hr)
Pain Nurse (DECT phone)
6172 (Mon-Fri: 0800-1600)
(Sat: 0800-1200)
Duty Obstetric Anaesthesia MO
1068 (24 hr)
ICU MO
1050
ICU senior
1065
OT MO
1054
OT senior
1040
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