CHAPTER 14A
Continuous Patient- and Nurse-Controlled Opiate Analgesia and Ketamine Infusions

Sharon Douglass and Michelle Whitehouse

SCENARIO

Sadie is a 15-year-old girl who was diagnosed with Crohn’s disease three years ago. Conservative management is no longer effective; therefore, she has been admitted electively for formation of a colostomy. A colostomy is when the colon (large intestine) is connected to the abdominal surface. It usually protrudes above skin level on the abdomen to help reduce the risk of skin irritation from faeces.

Before the procedure, the stoma nurse specialist or surgeon will talk to the child or young person (CYP) and family about the surgery and the stoma placement on the abdomen. Usually, the stoma would be low down on the left side, but final placement is dictated by where the affected part of the bowel is. Bowel contents travel through part of the colon, where the body absorbs some of the remaining water. Depending on where the stoma is, faeces that passes through the stoma may be semi-formed or fully formed, depending on the placement of the stoma.

Colostomy surgery can be performed either as a laparoscopic or an open procedure. Sadie is having a laproscopic procedure (keyhole), which minimises the interruption of all tissue and muscle layers. In addition, previous frequent acute exacerbations of her Crohn’s disease have resulted in thickening of the intestinal wall with swelling and scar tissue (Crohn’s and Colitis UK 2021).

It is essential to take into consideration any child’s underlying condition when planning postoperative pain management. In Sadie’s case non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and diclofenac are contra-indicated as one of the side effects is gastric irritation, which is already a symptom of Crohn’s disease. Therefore, suitable analgesia includes paracetamol, opiates, ketamine, and local anaesthetics to provide comprehensive multimodal pain management.

The route of administration must also be considered and in the immediate postoperative period, the oral route would not be appropriate for the following reasons: being nil by mouth, potential presence of a paralytic ileus, nasogastric tube on free drainage, nausea, and vomiting.

Also, Crohn’s is known to have a negative impact on absorption in the body and the development of scar tissue.The Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI 2012) recommend use of regular intravenous paracetamol alongside an advanced analgesic technique such as an intravenous opiate patient-controlled analgesia (PCA) infusion. When the anaesthetist visits Sadie and her family pre-operatively they discuss the options and decide on a Fentanyl PCA infusion. Refer to Box Activity 14.1.

ANSWERS TO QUESTIONS

Question 1a. What is a PCA?

Patient Controlled Analgesia

Patient controlled analgesia (PCA) is a technique that gives the CYP control over the amount of analgesia they receive, delivered via a lockable-programmed pump. A background continuous infusion dose may be prescribed to help maintain a therapeutic level of drug in the bloodstream which aids good analgesic effect. If the CYP experiences pain they are able to activate the bolus system by pressing the button on a handset attached to the pump, which allows a small bolus dose of drug to be administered intravenously.

Parents/carers/siblings should be advised about the dangers of pressing the button for the CYP. Only the child knows how much pain they are experiencing and therefore only the child should press the button. This is a safety feature of the machine as the child becomes sedated; they are unable to press the button successfully.

Question 1b. What is an NCA?

Nurse Controlled Analgesia (NCA)

A nurse-controlled analgesia (NCA) infusion provides background continuous analgesia with the options for additional boluses to be administered if required. The system is suitable for any CYP, regardless of age or cognitive ability. Infants and young children (less than 6yrs of age) would usually be prescribed and NCA along with CYP lacking the manual dexterity or cognitive ability to use a PCA.

Two registered nurses can deliver an immediate pre-determined bolus dose if the child is assessed to be in moderate to severe pain or prior to painful procedures or episodes. This can avoid delays from waiting for a doctor to administer a bolus dose, or the continuous infusion to be increased slowly over a period of one hour. The advantages of using an NCA rather than a continuous opioid infusion are that the programme allows an analgesic regime to be prescribed which is more flexible and may provide a better quality of analgesia.

Question 1c. What is a continuous Ketamine infusion?

Ketamine Continuous Infusion

Ketamine has historically been used as an anaesthetic drug but in recent years has proved to be a good analgesic when used in lower doses. The mode of action is different to the action of opioid drugs such as Morphine or Fentanyl, and therefore the use of Ketamine in combination with Morphine or Fentanyl can optimise pain management and reduce the dose of opiate needed, therefore helping to reduce opiate side effects (Chumbley 2010; Hadi et al. 2012). The Ketamine infusion is a continuous infusion with no bolus facility; the rate can be increased or decreased according to the CYP analgesic need.

Ketamine can be particularly beneficial postoperative pain management for CYP who are having complex surgery known to require more analgesia (e.g. major abdominal, orthopaedic, and spinal surgery). In addition, Ketamine as an effective alternative when opiates need to be avoided, for example:

CYP with opiate sensitivity or allergy
CYP requiring medication which increases central nervous system depression in combination with an opiate
CYP with inflammatory bowel disease (Lewin & Veleyos 2020).

Question 2. What opiates are used and what are the common side effects and key points to consider when administering opiates?

Morphine

Morphine is the standard, first line choice of opioid used in PCA infusions. Morphine reaches a peak effect in four to five minutes, which is why the lockout interval is five minutes, preventing the child from receiving further boluses before the analgesia has time to be effective.

FENTANYL

Fentanyl is a synthetic opioid, related to pethidine but with similar properties to morphine. It is short acting but has relatively long elimination half-life because of the rapid distribution in the body. Fentanyl has a rapid onset and is metabolised in the liver and metabolites excreted in the urine. It can be given IV, buccal, transdermal, or epidurally.

Fentanyl is reported to have less histamine release than Morphine and has a better side effect profile than Morphine. However, side effects of bradycardia and transient hypotension can occur following rapid IV administration and rarely occurs with a PCA or NCA bolus. Moderate to severe acute pain can be managed with a Fentanyl PCA/NCA. Fentanyl is used if the patient is experiencing inadequate analgesia or unmanageable side effects with a Morphine PCA/NCA.

KEY POINTS

Side effects include nausea and vomiting, pruritis, sedation, constipation, urinary retention, respiratory depression, and must be managed effectively.
When initiating strong opioids, always ensure appropriate anti-emetics (e.g. ondansetron) and laxatives are prescribed.
Patients will need to be carefully weaned from opiates if being used for long periods to avoid withdrawal abstinence syndrome.
Weak opiates such as codeine should not be used to treat pain in children under the age of 12 years, or in any patient who has undergone tonsillectomy or adenoidectomy (or both) or has symptoms of obstructive sleep apnoea (APAGBI 2013; MHRA 2013). Codeine is no longer routinely used and the opiate of choice for oral analgesia is Morphine Sulphate.

CAUTIONS

Morphine should be used with caution in patients with neuromuscular disorders and severe cardiac or respiratory conditions and renal impairment, due to increased risk of toxicity.
Patients with eGFR < 50mL/kg/min/1.73m2 are at significant risk of Morphine accumulation. As a result, Morphine should be used with extreme caution in this patient group.

Activity of living: maintaining a safe environment.

Question 3. Reflecting upon the nursing process and a model of care, how would the children’s nurse prepare this young person, Sadie, and her family for having a PCA infusion?

Assess: ensure that both Sadie and her parents/carers have an appropriate level of knowledge and understanding regarding PCA analgesia. This is essential to ensure that they can make an informed decision when approached for consent.

Plan: the children’s nurse must ensure that Sadie and her parents are given appropriate pre-operative preparation at ward level. This will involve explaining the physical and psychological impact of the surgery, postoperative recovery, and observations, and interventions associated with the analgesic technique used. All planned care should adopt an appropriate model of nursing, for example the Roper-Logan-Tierney Model (Holland et al. 2008, with Casey 1988).

Implement pre-operative interventions:

Pre-operative assessment – achieved through attending a pre-admission clinic (if available, or a discussion and demonstration pre surgery if possible).

Verbal information should be supported with written information leaflets, which the family may take home to read and digest the information at a later time. These can also be used to prepare Sadie further pre-operatively.

Discuss with Sadie and her family the importance of regular pain assessment, demonstrate available pain assessment tools, negotiate on the most appropriate and offer a demonstration on its use. The 0–10 Visual Analogue Scale would be appropriate for a 15-year-old young person, where 0 is ‘no pain’ and 10 is the ‘most imaginable pain’ (RCN 2009).

Discuss potential pain management options:

Patient controlled analgesia (PCA)
Regular intravenous paracetamol and step-down medication

Wherever possible demonstrate the use of the equipment which will deliver the analgesic technique. First, this enables recognition postoperatively, which reduces levels of anxiety, but more importantly it allows the nurse to assess whether the correct level of understanding and manual dexterity is present to ensure effective delivery of analgesia is achievable.

Evaluate all nursing interventions and documentation.

Question 4. What general aspects of nursing management would you need to address when considering PCA analgesia for Sadie?

Selection criteria for the CYP person

The CYP needs to be identified and assessed as suitable for this technique:

The cognitive ability to understand the relationship between pushing the button and medication being delivered.
To be aware that the expected outcome is pain relief and not necessarily the complete absence of pain.
Should have the manual dexterity to push the button of the device.
Equipment should be available and demonstrated on the ward, and parents advised not to press the button for their child.

Patient suitability – establish whether any contraindications are present:

These pre-requisites should be met before discussion and the informed consent of Sadie/carer obtained.

When analgesia is required for moderate or severe pain for 24 hours or more.

The workload of the ward allows the child to be observed closely.

Potential complications to consider and monitor for

Problems related to equipment
Equipment malfunction
Operator error
Tampering
Inappropriate patient or non-patient use
Side-effects related to opioids
Adverse drug reaction

Equipment required

Oxygen available at the bedside
Resuscitation equipment available on the ward/department
Naloxone available
Lockable infusion pump
PCA opioid prescription and observation chart
50 mls B/D plastipak syringe
Giving set with anti-reflux/anti-siphon valve
Pulse oximeter if advised by the anaesthetist
Opiate intravenous (IV) giving set label

Tags: Care Planning in Children and Young Peoples Nursing 2e

Mar 23, 2024 | Posted by admin in Uncategorized | Comments Off

Nurse Key

Fastest Nurse Insight Engine

Continuous Patient- and Nurse-Controlled Opiate Analgesia and Ketamine Infusions