Dilaudid PCEA GUIDELINES
(Patient Controlled Epidural Analgesia)

Rev 5/05, Pisini/Dixon

Patient Selection
OR / PACU Management

Solutions
Orders

Breakthrough Pain, Rx

Side Effects, Rx

Patient Selection 
* Appropriate clinical situation for epidural analgesia.
*
Adults, eighteen (18) years of age or older.
* Cognitive ability to use PCEA appropriately (age, mental status, medical condition).
* Segmental epidural catheters

OR / PACU Management
*
Bolus the epidural catheter with local anesthetic (bupivacaine or lidocaine).
* Confirm that the epidural catheter is functional (this should be done in PACU if not done pre-operatively).
* Document the sensory level following the local anesthetic bolus.

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Solutions
* Bupivacaine 0.125% with Dilaudid (hydromorphone) 10 mcg/ml (appropriate selection for the majority of patients).
* Bupivacaine 0.06% with Dilaudid (hydromorphone) 10 mcg/ml.  This solution should be considered in high thoracic catheters,  if there is hypotension, or if motor weakness occurs.

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PCEA Parameters (Orders)
-Infusion rate 5-10 ml/hr. Generally start at lower rate for higher catheters & elderly patients. Max. rate 12ml/hr.
-Demand Dose: 2ml
-Lockout interval: 20 minutes
-1 hour limit: 20 ml

Side effects such as sedation and respiratory depression must be closely monitored.

NEVER order a IV PCA or bolus dosing of opioids in addition to the PCEA

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Treatment of Breakthrough Pain
*
Confirm that the patient is using the PCEA demand doses appropriately.
* If analgesia is inadequate with Bupivacaine 0.125% with Dilaudid 10 mcg/ml infusing:
-
bolus epidural with Bupivacaine 0.25% and confirm function of epidural catheter.
- Confirmed functioning epidural catheter: increase infusion rate by 2ml/hr, up to 10ml/hr.
- Nonfunctioning epidural catheter: replace catheter.

 
* If analgesia is inadequate with Bupivacaine 0.06% with Dilaudid 10 mcg/ml infusing:
- bolus epidural with Bupivacaine 0.25% and confirm function of epidural catheter.
- Confirmed functioning epidural catheter: change concentration of local anesthetic from Bupivacaine 0.06% to 0.125%.
- Nonfunctioning epidural catheter: replace catheter.

If analgesia is inadequate, and the catheter has already been confirmed to be functional:
-bolus with 5ml of the solution which is infusing (can be done via the pump by programming a loading dose), and increase the infusion rate by 2ml/hr.
 

The maximum recommended rate is 12 cc/hr

NEVER order a IV PCA or bolus dosing of opioids in addition to the PCEA

Treatment of Side Effects

A. Sedation
-Mild: decrease infusion rate
-Severe:
    -turn infusion off. Remove dilaudid and resume infusion with local anesthetic only when more alert.
    -Naloxone if indicated.  Administer in increments of 10-20 mcg.  Initiate Naloxone infusion if necessary (suggested infusion rate 0.5 - 5.0 mcg/kg/hr)

B.  Respiratory Depression
-Mild: decrease infusion rate
-Severe:
-turn infusion off. Remove Dilaudid and resume infusion with local anesthetic only when patient is with respirations >10/minute.
-Naloxone if indicated.  Administer in increments of 10-20 mcg.  Initiate Naloxone infusion if necessary (suggested infusion rate 0.5 - 5.0 mcg/kg/hr)

C. Pruritis 
* Nalbuphine 2.5mg-5mg IVSS q 4 hours PRN.
* Benadryl 25-50mg IVSS/po q 4 hours PRN.
* Naloxone infusion if severe and not relieved with above (suggested infusion rate 0.5 - 5.0 mcg/kg/hr).
* Consider removing the Dilaudid from the solution, if severe and unrelieved by the above.

D. Nausea/Vomiting
* Ondansetron 4mg IVSS q 8 hours PRN x 3 doses
* Reglan 10mg IVSS q 4 hours PRN, (give 15 minutes after ondansetron if nausea not relieved).
* Consider removing the Dilaudid from the solution, if severe and unrelieved by the above).
Call Surgical MD if nausea not relieved by above.

 E. Motor Block
If Bupivacaine 0.125% is infusing, decrease rate by 2ml/hr. Consider changing solution to Bupivacaine 0.06%, particularly if the epidural is in the lumbar region.

If Bupivacaine 0.06% is infusing, decrease rate by 2ml/hr. Consider pulling catheter back 1cm.  Replace epidural at higher level (if catheter is nonsegmental).

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