Infusion Therapy – Pain Management: Parenteral Therapy SECTION: 25.30 Strength of Evidence Level: 3 __RN__LPN/LVN__HHA

PURPOSE: a. On a case-by-case basis, a physician may elect To provide accurate and safe administration of to have Naloxone in the home. parenteral therapy. b. A specific physician order is required if Naloxone is in the home. CONSIDERATIONS: 7. Central Venous access is recommended for continuous administration to 1. Parenteral administration of opioid analgesic maintain uninterrupted level of analgesic in the medications can be useful in optimizing pain control home. with reduced systemic side effects. 2. Parenteral administration may be indicated for Dosage: severe or intractable pain when: 1. Dosage should be titrated to optimize a. Oral, transdermal or rectal analgesic individual pain control while minimizing adverse medications can be useful in optimizing pain effects of medication. control with reduced systemic side effects. 2. Convert intermittent SQ, IV or PO b. Patients experience nausea and vomiting or dosage to comparative parenteral dosage utilizing cannot swallow oral medications. the Equianalgesic Chart (See Attachment A.) For c. Contraindication to rectal medication. initiation of continuous parenteral therapy determine d. Large oral doses cause unacceptable systemic the total daily usage of patient’s current intermittent complications. therapy and convert using the Equianalgesic Chart 3. Parenteral administration of analgesics may be: as follows: a. Intermittent or bolus. a. Calculate total daily oral dose that patient b. Continuous infusion (infusion control device received during the previous 24 hours. required). b. Multiply total daily oral dose by the conversion c. Continuous infusion with supplemental bolus for factor for the specific narcotic analgesic for the breakthrough pain (infusion control device total daily subcutaneous dose. required). c. To determine the subcutaneous dose per hour, 4. Infusion devices include: divide the total daily subcutaneous dose by 24. a. External Ambulatory PCA Pump. 3. The dose and/or rate of infusion can b. Implanted Devices-Infusaid, SynchroMed usually be safely increased in increments of 10-20% (Medtronic). of current dose or rate of infusion of by increasing 5. Drug therapy alternatives include: the basal rate by 50% of the total daily bolus a. Morphine may be administered via IV, IM, SC or requirement for PCA patients. The patient should be intraspinal route. Morphine has a short half-life observed and monitored for 1 to 2 hours after and no toxic or active metabolites. increasing dosage for untoward effects. b. Hydromorphone is useful when Morphine is poorly tolerated or ineffective. Adverse Reactions/Side Effects: c. Meperidine is short acting, and is not 1. In the case of respiratory recommended for use in chronic, severe pain depression, reduce the rate of infusion or stop the since it has a CNS toxic metabolite infusion for a short period of time to reverse (normeperidine) that accumulates with repeated respiratory depression. Consult physician for dosing. instruction. Severe respiratory depression may d. Fentanyl and Sufentil are very potent opiate necessitate the use of a narcotic antagonist (i.e., agonists with a rapid onset of action and shorter Naloxone). Obtain specific physician order prior to duration of action than morphine. They are administering Naloxone. generally used epidurally in an attempt to lower 2. Gastrointestinal: narcotic requirements and improve analgesia or a. Nausea and vomiting, motion may aggravate avoid nausea and epidural side effects of other these symptoms. Antiemetics may be helpful in narcotics. treating nausea and vomiting but may be e. Clonidine (Duraclon), a centrally-acting additive to other unwanted side effects of the analgesic can be used in combination with an analgesic. opiate agonist for the treatment of severe pain b. Constipation is caused by the anticholinergic that is not controlled by the use of an opiate action of most of the opioid analgesics used. agonist for the treatment of severe pain that is Patients receiving pain management therapy not controlled by the use of an opioid alone. should be placed on a high fiber diet and take 6. Routine use of Naloxone in the home is not laxatives or a stool softener on a regular basis. recommended because administration can Adequate hydration may also be helpful in precipitate acute withdrawal and lack of pain control. reducing symptoms. Proper administration requires continual monitoring 3. Analgesics may cause by a healthcare professional. drowsiness, seizures, agitation, restlessness, confusion, tremors and somnolence. Changing to an Infusion Therapy – Pain Management: Parenteral Therapy SECTION: 25.30 Strength of Evidence Level: 3 __RN__LPN/LVN__HHA

alternative medication may alleviate these 5. Programmable pumps that deliver analgesic symptoms. Patients may benefit from dose medication should be verified for correct reduction or adjunctive medication treatment. programming prior to initiation of therapy. 4. Vasodilation, hypotension, pruritus, flushing, sweating and allergic reaction. PROCEDURE- Administration Antihistamines are sometimes useful in treating 1. Adhere to Standard Precautions. these symptoms of adverse effects. If 2. Explain procedure to patient. antihistamines are not effective or contraindicated 3. Verify orders with physician: then an alternative analgesic medication should be a. Route, dosage, method of employed. administration, duration of therapy. Monitoring: b. Adjunctive medication for constipation, 1. Vital signs (including respiratory rate) should be nausea, vomiting or CNS side effects. monitored periodically during the course of therapy 4. Review patient’s medical history and assessment, and according to the needs of the individual patient. including current pain assessment and vital signs. 2. Assess the patient response to therapy by 5. During therapy, the patient should be closely determining the level of comfort using an monitored for response to therapy and side effects appropriate pain scale (0 - 10 intensity scale where that necessitate immediate physician contact. 0 = no pain, 10 = worse pain) and report changes to Those side effects include: physician. a. Nausea and vomiting. 3. Evaluate the patient for any other adverse effects b. Respiratory depression. that might be caused by the medication and report c. Hypotension. to physician as appropriate. d. Confusion or lethargy. e. Allergic reaction to medication. Drug Interactions: 6. Monitor vital signs and pain assessment. 1. CNS depressants (i.e., alcohol, benzodizepines, 7. Assess level of comfort and patient’s reaction to phenothiazines) cause additive sedative effects. pain therapy. 2. Cimetidine and phenytoin delay hepatic metabolism 8. Provide psychosocial support. of opioids that will likely enhance the effect of the 9. Review signs and symptoms of reactions with opioid. patient/caregiver. 3. Aminophylline and sodium bicarbonate solutions 10. Discuss care plan and reassess goal of therapy and cause precipitation with morphine solution and are document on the plan of care. not compatible. 11. Document patient’s response to pain management measures. EQUIPMENT Patient/Caregiver Education: None 1. Use of infusion device including troubleshooting. PROCEDURE- Prior to Administration [Note: Only the patient should self-administer a 1. The patient shall meet the admission criteria and bolus dose to avoid accidental oversedation, have an appropriate indication for pain management respiratory depression and even death.] therapy. 2. Storage and disposal of 2. Physician orders shall include: controlled substances. a. Name of drug, concentration dosage in 3. Side effect recognition and mg/hour, dosage and frequency of bolus dose management related to narcotics: as appropriate, route and type of pump to be a. Respiratory depression. used. b. Nausea, vomiting. b. Limits or range of continuous infusion and bolus c. Constipation. dose to be set in programming the ambulatory d. Changes in sensorium. infusion pump. e. Side effects associated with intraspinal c. Subcutaneous, intravenous (peripheral or administration of narcotics such as pruritus, central) or intraspinal (epidural or intrathecal) urinary retention, tolerance, catheter migration route. or meningitis. d. Site care. 4. Care and management of 3. Assessments shall utilize a pain intensity tool and central venous access devices. should address location, duration, onset, 5. Care and observation of subcutaneous needle site characteristics of pain, patient’s goals for pain relief and management of problems (as appropriate) or: and alleviation or causative factors. a. Needle irritation. 4. All patient-controlled analgesics should be infused b. Leakage. via infusion pump or autoinfusion. c. Dislocation. Infusion Therapy – Pain Management: Parenteral Therapy SECTION: 25.30 Strength of Evidence Level: 3 __RN__LPN/LVN__HHA

d. Rotation/dislodgement. 6. Care and observation of the intraspinal catheter if it exists via the skin on the abdomen or is attached to a port that is accessed through the abdomen.

AFTER CARE: 1. Document in patient’s record: a. Procedure and observations. b. Instructions given to patient/caregiver. c. Patient’s response to procedure. d. Communication with physician.