Peri-anaesthetic paediatric pain management: An audit of current practice

Abstract

Background: In our hospital, nursing staff provide pain management in the Peri-anaesthetic Care Unit (PACU) via a pain protocol prescribed case-by-case by the anaesthetist. In many cases, opiate assigned for the patient in theatre is transferred to the nurse in PACU with the patient. Aim: We conducted an audit to determine the proportion of protocols prescribed vs required, whether dosing was appropriate and to what extent opiate is transferred unnecessarily and/or without a prescription. Method: The audit took place over a calendar month from April 26, 2016. A proforma was transferred with all elective patients to PACU for the nursing staff to complete and collected anonymously. Emergency, after-hours and ICU cases were excluded. Results: The response rate was 49.7% (n=386). Following exclusions, 350 of a total 773 (45.3%) elective cases were analysed. Demographics: 201 (58%) Male vs 145 (41.2%) Female. Median age 6 years (SD 4.7; IQR 3.0 - 11.0), median weight 23.4 kg (SD19.6; IQR 15.0 - 39.0). Majority patients were prescribed a pain protocol (76.2% vs 23.9%). The most popular drug used was Fentanyl (n=197; 74.1%) vs Morphine (n=69; 25.9%). 210 cases (65.0%) had opiate transferred with them to PACU; 101 cases (28.9%) required opiate administration in PACU. 1 patient (0.3%) had opiate transferred without a prescription. The mean total dose Fentanyl prescribed was 1.4 mcg/kg (SD 0.85 IQR 0.9-1.7) vs mean amount transferred 1.9 mcg/kg (SD1.6; IQR 0.8-2.6) vs mean administered 0.83 (SD 0.60; IQR 0.4-1.1). The largest dose of fentanyl administered was 3 mcg/ kg, up to 8 mcg/kg was transferred. Amount of total opiate transferred per kilogram tends to increase as weight decreases?a weak but significant correlation (rs(175)= -0.36; p<0.01). A similar pattern was seen for morphine. Discussion: This audit finds that most patients having surgery in our unit are discharged to PACU having received adequate analgesia in theatre. We find that the majority of pain protocols prescribed are safe. In general, the mean amounts of opiate prescribed and transferred for use in PACU exceed those required by a factor of 2. Whilst this is not an unreasonable margin, the lack of a standard prescription leads to a wide variability in the dose practitioners prescribe and the amounts of opiate which are transferred to PACU, exemplified by the large spread in data. In some cases, the quantities involved are excessive enough as to constitute a risk to patient safety. The negative correlation in the spread implies that smaller, and potentially more vulnerable, patients are placed at disproportionate risk of an accidental overdose. Recommendations: Standard pain protocol should be implemented across the department based on a maximum dose per kg, prescribed in divided doses. The amount of opiate transferred should not be in excess of the total dose prescribed. This should be delivered to PACU in a standard concentration in an easily titratable syringe. The small minority of patients requiring further analgesia would thereby receive an anaesthetic review. Bespoke prescriptions, whilst sometimes necessary, would thereby receive greater clinical scrutiny. Education of staff to changes. Re-audit to check compliance.L6332769402020-11-05 <br />