Consensus Guidelines

Last modified by Lisa Stromquist on 2012/12/10 20:38

Recommendations

 

Guideline

 

ADOPT STANDARD CONCENTRATIONS of opioid solutions intended for continuous intravenous infusion, as noted below, and use these standard concentrations in combination with smart pumps for maximum safety and/or infusion dosing charts where smart pump technology is not available


Paediatric Specialty Hospitals

Includes: Level 3 NICU, PICU, Paediatric Intensivist on staff

Morphine: 0.2 mg/mL and 1 mg/mL
Hydromorphone: 40 mcg/mL and 250mcg/mL
Fentanyl: 10 mcg/mL and 50 mcg/mL


Community Hospitals 
Includes: General paediatric units, No PICU, Up to Level 2 NICU

LIMIT the parenteral administration of opioids for paediatric patients to morphine.

Morphine:0.2 mg/mL and 1 mg/mL

LIMIT the availability of injectable  morphine to 2 mg/mL ampoules in paediatric care areas.(Currently the lowest dose  of  morphine ampoule available in Canada)


Exception:

It is recognized that additional concentrations of opioids for continuous intravenous infusion may be required by hospitals that care for very-low-birth-weight babies and by hospitals that do not have pumps with the ability to deliver volumes to 0.01 mL/hr accuracy.


Standard concentrations of opioid solutions intended for continuous infusion should ideally be adopted in conjunction with maximal use of Drug Error Reduction Software (DERS) within smart pump technology. In the absence of DERS, it is imperative to ensure that other strategies, including infusion pump flow limits and dosing charts, are available to support the use of standard concentrations.

Use commercially prepared premixed intravenous solutions if available from the manufacturer.

If premixed IV solutions are not available commercially, prepare them in the pharmacy whenever possible. (Provide admixing guidelines for nursing staff for use when premixed, standard-concentration opioid solutions are not available.)

Exceptions: It is recognized that, hydromorphone or fentanyl may be required in certain situations.

RESTRICT ACCESS to hydromorphone to units where this drug is needed for specific paediatric patients or situations (e.g., for palliative care).

RESTRICT ACCESS to injectable fentanyl to units where this drug is needed for specific paediatric patients or situations (e.g., for rapid-sequence intubation of neonates in the neonatal intensive care unit




ADOPT STANDARD METHODS for preparing and administering intermittent bolus doses of opioid.

 

Develop admixing guidelines and calculation aids for use by nursing and pharmacy staff when preparing bolus opioid doses, and make these tools available at the point of care, as appropriate to practice.
Ensure that procedures for administration of intermittent bolus doses are developed by the organization.
INCLUDE the dosage by weight for ALL opioid orders for paediatric patients weighing 40 kg or less, expressed as:
- mg (or mcg)/kg/dose or 
- mg (or mcg)/kg/hr
For paediatric patients weighing less than 40 kg, prescribers’ orders should include the weight-based dose, as mg/kg or mcg/kg, along with the patient-specific dose.

Standard order sets (either electronic or preprinted) should express opioid doses for IV infusion in terms of the standard concentration(s) used by the organization and in a manner (e.g., mg/kg, mcg/kg/hr) and sequence that matches entries in medication administration records and programming choices on infusion pumps.

Use consistent terminology (e.g., for dosing units) when communicating drug information (via labels, handwritten or pre-printed orders, medication administration records, chart notations, and documents in electronic formats, including computer screens

LABEL EVERY DOSE of opioid intended for oral or parenteral administration

Label all containers for opioid medications (e.g., oral syringes, parenteral syringes and infusion bags). This includes opioids prepared on nursing units.

Ensure that, at a minimum, labels include the drug name and strength or total dose/total volume i.e morphine 1 mg/mL or 20 mg/20 mL

DEVELOP and DISSEMINATE institution-wide dosing and monitoring guidelines for opioids used in paediatrics, including recommendations for the initial dose and maximum doses for opioid-naive patients

Ensure that current protocols, guidelines, dosing charts (including equianalgesic charts for oral, Parenteral and transdermal (e.g.,by patch), and/or checklists for opioids are readily accessible to prescribers, pharmacists, and nurses, and ensure that these aids are used whenever opioids are prescribed, dispensed, administered, and monitored.

Initial maximum weight-based doses of opioids for paediatric patients (e.g., in mg/kg or mcg/kg per hour) should NOT exceed the usual starting dose for opioid-naive adults.

Ensure that the reversal agent naloxone (and guidelines for its use) is readily available wherever opioids are administered.
In mixed units, where adult and paediatric patients are being treated in the same area (e.g., emergency department, ambulatory care clinics, inpatient units),

SEGREGATE paediatric formulations of opioids from adult formulations
  
For hospitals without automated dispensing cabinets 
In mixed units, where adult and paediatric patients are being treated in the same area (e.g., emergency department, ambulatory care clinics, inpatient units), ensure that opioids intended for paediatric patients are physically separated from opioids intended for adult patients. For example, store paediatric opioids in a separate cupboard, similar to the use of separate crash carts for this patient population.

SEGREGATE, SEPARATE, and DIFFERENTIATE admixed opioid solutions intended for parenteral infusion from all other solutions intended for intravenous use.

 

Use a variety of differentiation strategies to prevent selection errors. For example, opioids intended for continuous infusion (which will have a large total dose in each container) should have a different appearance from other opioids to prevent inadvertent administration as an intermittent bolus dose.

Strategies to be considered include size of container, colour or other aspects of labelling, and use of auxiliary labels, as well as physical separation in the storage location.

To prevent mix-ups, the concentrations for hydromorphone and morphine suggested in the guideline for tertiary care are intentionally dissimilar. Additional differentiation strategies may be necessary for settings where both morphine and hydromorphone are needed, to prevent mix-ups between these medications, which have look-alike, sound-alike names

USE prefilled oral syringes for all liquid opioids for enteral administration

Package liquid opioids for enteral administration in patient-specific unit doses or in standard doses appropriate for paediatric patients and the particular clinical setting.

Use only oral syringes that cannot be connected to parenteral systems (e.g., IV tubing).

ADOPT INDEPENDENT DOUBLE CHECKS for prescribing, preparing and administering oral opioids (e.g. liquid), intravenous (continuous and intermittent) or epidural opioid medications.

Develop a policy requiring two clinicians (e.g., nurse, pharmacist, physician) independently verify the appropriateness of the prescription based on weight and indication), dose calculations, pump programming (e.g., initial set up and rate/dose changes, scheduled solution and tubing change, and patient transfers).

Pharmacy opioid independent check process should include appropriateness of the prescription dose based on weight and calculations, calculations of doses, sterile compounding, stocking of medications in Automated Dispensing Cabinets or narcotic drawers/cupboards.

Ensure that education on the independent double check process is provided to nursing, medicine  and pharmacy staff.

Consider use of checklists or tools that that support independent checks on critical information including documentation.
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Created by Lisa Stromquist on 2012/12/10 19:41