Use Multiple Strategies to Optimize PCA Safety

You’ll see a spotlight on PCA safety...partly due to new “Standardize 4 Safety” (S4S) guidance from ASHP.

This joins previous S4S guidance, which focused on adult and pediatric continuous IV infusions...and compounded oral liquids.

Compare your PCA concentrations to the new guidance...identify any mismatches...and make a plan to update.

Try to use one standard PCA concentration for adults and peds. But identify when exceptions may be needed, such as lower pediatric-specific concentrations...or a higher concentration for oncology.

If using multiple concentrations, avoid 10-fold differences. For example, if you use hydromorphone 1 mg/mL for most patients, use hydromorphone 0.05 mg/mL for some neonates...rather than 0.1 mg/mL.

Ensure concentrations and dosing units match in all areas...the EHR, smart pump libraries, printed labels, etc.

Identify other strategies that can be layered to optimize PCA safety...and ensure updates are made to protocols, policies, etc.

Avoid mix-ups with PCA meds using approaches such as separate storage and tall man lettering (HYDROmorphone, morphine, etc).

Confirm that PCA demand doses are appropriate.

For many opioid-naive adults, start with 1 mg of morphine or a rough IV equivalent, such as hydromorphone 0.2 mg or fentanyl 10 mcg...with a 10-minute lockout period.

Limit continuous basal PCA rates to opioid-TOLERANT patients.

If possible, deprescribe meds that may increase risk of respiratory depression with opioids. For example, ensure other opioids are stopped while patients are getting a PCA opioid.

Verify that protocols include monitoring for pain, sedation, and respiration (end-tidal CO2, etc)...and orders for prn naloxone.

Ensure double checks are required when programming pumps.

Post signs with PCAs that warn visitors not to push the PCA button. Educate that a sedated patient won’t press the button...but overriding this safeguard for them can lead to respiratory arrest.

Key References

  • (1-31-23)
  • (1-31-23)
Hospital Pharmacist's Letter. February 2023, No. 390217


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