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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Pain Management

AFCH PACU Regional Analgesia Therapy - Pediatric - Supplemental [3005]

AFCH PACU Regional Analgesia Therapy - Pediatric - Supplemental [3005] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pain Management


AFCH PACU - Regional Analgesia Therapy - Pediatric - Supplemental [3005]
Regional Analgeisa -. Use the FLOOR in the ORstarted Use this order set for regional analgesia being
Supplemental order set to order epidurals to be started on the floor. -Pediatric -Therapy
Only Anesthesiology Acute Pain Service (APS) or Anesthesiology staff may initiate, modify or discontinue
epidural therapy. Refer to policy number: 8.92
Patient Care Orders
Vital Signs [92522]
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 15 minutes times 4 with initiation of epidural
infusion, then every 4 hours., Post-Op/Phase II
Vital Signs [NURMON0013] SEE COMMENTS, Starting today, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Every 2 hours times 4 if changes are made to the
epidural infusion or rate., Post-Op/Phase II
Measure Respiratory Rate Depth & Regularity
(Full Minute) [NURMON0028]
SEE COMMENTS, Starting today, Routine, EVERY 2
HOURS Measure for 1 full minute., Post-Op/Phase II
Patient Monitoring [92523]
monthsmonitoring is required for patients < 12 respiratory -Cardio
Assess Sedation Level [NURMON0060] SEE COMMENTS, Starting today, EVERY 2 HOURS.
Note: Awaken only if unable to distinguish between
normal sleep and sedation., Post-Op/Phase II
Assess for Changes in Sensation and Strength of
Extremities [NURMON0060]
SEE COMMENTS, Starting today, Every 4 hours while
awake., Post-Op/Phase II
Assess Patient's Pain Rating [NURMON0060] SEE COMMENTS, Starting today, Every 4 hours while
awake and as needed if patient develops pain at
insertion site, diffuse back pain, spinal headache, or if
inadequate pain control., Post-Op/Phase II
Pulse Oximetry [NURMON0009] CONTINUOUS, Starting today, Routine, Post-
Op/Phase II
Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [139420]
Cardio-Respiratory Monitor - Pediatric - Without
Rhythm [NURMON0074]
CONTINUOUS, Routine, Please complete the Notify
Provider order below, including specification for
apnea > *** seconds. If indicated, order pulse
oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider:
Post-Op/Phase II
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds, Post-
Op/Phase II
Page 1 of 7
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Activity: Lumbar Epidural [92524]
Reposition Patient [NURACT0005] Type:
Routine, SEE COMMENTS, Starting today, Every 2
hours and assure that there is no pressure on bony
prominences if patient has motor block (extreme
numbness or weakness)., Post-Op/Phase II
Procedure Site Care [92525]
Procedure Site Care [NURWND0015] CONTINUOUS, Starting today, Routine
Wound Type: Other (Comment) (Catheter insertion
site)
Wound Site:
Wound Location:
Assess Frequency: EVERY 8 HOURS
Care Frequency: 1X DAILY
Wash With:
Irrigate/Rinse With:
Apply (Must also enter separate medication order to
obtain drug):
Primary Dressing:
Secondary Dressing:
Post-Op/Phase II
Contingency Parameters for Patients Ages < 6 Months (PCA Pediatric) [19809]
Notify Provider Ages < 6 Months (PCA Pediatric)
[NURCOM0001]
Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <: 16
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >: 5
Pulse Oximetry < (%): 90 or need for supplemental
oxygen
If urine output < (mL):
Other: Sedation score = 3 or greater
If patient is on Acute Pain Service, notify Surgery first
to determine if pain is related to a surgical
complication, then may notify Acute Pain Service by
paging #7246 or "PAIN". If there is no response after
paging #7246, call paging or the pediatric attending
anesthesiologist on call "ANESTHESIA PEDS
STAFF".
Contingency Parameters for Patients Ages 6 Months - 2 Years (PCA Pediatric) [138116]
Page 2 of 7
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Notify Provider Ages 6 Months - 2 Years (PCA
Pediatric) [NURCOM0001]
Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <: 12
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >: 5
Pulse Oximetry < (%): 90 or need for supplemental
oxygen
If urine output < (mL):
Other: Sedation score = 3 or greater
If patient is on Acute Pain Service, notify Surgery first
to determine if pain is related to a surgical
complication, then may notify Acute Pain Service by
paging #7246 or "PAIN". If there is no response after
paging #7246, call paging or the pediatric attending
anesthesiologist on call "ANESTHESIA PEDS
STAFF".
Contingency Parameters for Patients Ages 3 Years Through 10 Years (PCA Pediatric) [138118]
Notify Provider Ages 3 Years Through 10 Years
(PCA Pediatric) [NURCOM0001]
Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <: 10
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >: 5
Pulse Oximetry < (%): 90 or need for supplemental
oxygen
If urine output < (mL):
Other: Sedation score = 3 or greater
If patient is on Acute Pain Service, notify Surgery first
to determine if pain is related to a surgical
complication, then may notify Acute Pain Service by
paging #7246 or "PAIN". If there is no response after
paging #7246, call paging or the pediatric attending
anesthesiologist on call "ANESTHESIA PEDS
STAFF".
Contingency Parameters for Patients Ages > 10 Years (PCA Pediatric) [138123]
Page 3 of 7
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Notify Provider Ages > 10 Years (PCA Pediatric)
[NURCOM0001]
Provider to Notify: Provider
If systolic blood pressure > (mmHg):
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C):
If temperature < (C):
If heart rate > (bpm):
If heart rate < (bpm):
If respiratory rate >:
If respiratory rate <: 8
If blood glucose > (mg/dL):
If blood glucose < (mg/dL):
If pain score >: 5
Pulse Oximetry < (%): 90 or need for supplemental
oxygen
If urine output < (mL):
Other: Sedation score = 3 or greater
If patient is on Acute Pain Service, notify Surgery first
to determine if pain is related to a surgical
complication, then may notify Acute Pain Service by
paging #7246 or "PAIN". If there is no response after
paging #7246, call paging or the pediatric attending
anesthesiologist on call "ANESTHESIA PEDS
STAFF".
Notify Surgery [137711]
Nursing Communication [NURCOM0022] ONCE, Starting today For 1 Occurrences, If patient on
Acute Pain Service notify surgery to determine if pain
is related to a complication
Medications
Epidural/Perineural Infusions [92528]
Bupivacaine and opioids are NOT recommended for infants < 6 months. Use chloroprocaine or
ropivacaine.
Maximum local anesthetic doses for pediatric epidurals:
• Bupivacaine - 0.4-0.5 mg/kg/hr for patients > 6 months
• Ropivacaine - 0.5 mg/kg/hr for patients > 6 months or 0.2 mg/kg/hr in infants < 6 months
• Chloroprocaine - 3-15 mg/kg/hr. Suggested rate - 0.2-1 mL/kg/hr depending on level of insertion
Procedure-Specific
Recommendations -
CLICK HERE
URL: https://intranet.anesthesia.wisc.edu/index.php?
title=Pediatric_Regional_Anesthesia_Recommendations_for_Specific_Procedures
chloroprocaine neuraxial infusion [700388] Epidural, CONTINUOUS
.
Post-Op/Phase II
EPIDURAL NERVE BLOCK infusion PEDS -
NOTE: Pump #1 [700946]
Epidural, CONTINUOUS, Post-Op/Phase II
EPIDURAL NERVE BLOCK infusion PEDS -
NOTE: Pump #2 [700946]
Epidural, CONTINUOUS, Post-Op/Phase II
PERIPHERAL NERVE BLOCK infusion [700948] Peripheral Nerve, CONTINUOUS, Post-Op/Phase II
Note: Send Medications To: [950055] ONCE For 1 Doses, IntraOp
Note: RPh Release a Regional Analgesia Infusion
(s) and Maintain Regional Analgesia Catheter
Orders. Send Regional Analgesia Infusions to
AFCH OR [950018]
ONCE For 1 Doses, IntraOp
Page 4 of 7
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Single Shot Neuraxial Regional Analgesia
Administered [NURTRT0059]
ONCE For 1 Occurrences, Routine, Morphine Sulfate
Preservative-Free given date *** time ***, Post-
Op/Phase II
Note: Stop regional analgesia solution at 0600
[950018]
ONCE Starting tomorrow at 6:00 AM For 1 Doses
Stop regional analgesia solution at 0600
Post-Op/Phase II
Maintain Regional Analgesia Catheter
[NURVAD0054]
CONTINUOUS, Starting today, Routine
Type of catheter:
Location:
Post-Op/Phase II
Analgesics - Scheduled [92531]
ketOROLAC (TORADOL) injection - NOTE:
Suggested dose 0.5 mg/kg/dose (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS For 72
Hours
Recommended for bladder spasm
Post-Op/Phase II
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10-15
mg/kg/dose [800005]
15 mg/kg, Oral, 4 X DAILY
NOTE: Suggested dose 10-15 mg/kg/dose
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) suppository -
NOTE: Suggested dose 20 mg/kg/dose [34152]
Rectal, EVERY 4 HOURS, Post-Op/Phase II
gabapentin (NEURONTIN) soln - NOTE:
Suggested dose 5mg/kg (Maximum 200 mg/dose)
[65814]
5 mg/kg, Oral, 3 X DAILY
NOTE: Suggested dose 5mg/kg (Maximum 200
mg/dose)
Post-Op/Phase II
Analgesics - Scheduled [215225]
ketOROLAC (TORADOL) injection - NOTE:
Suggested dose 0.5 mg/kg/dose (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS For 72
Hours
Recommended for bladder spasm
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, 4 X DAILY, Post-Op/Phase II
gabapentin (NEURONTIN) cap [54258] 200 mg, Oral, 3 X DAILY, Post-Op/Phase II
Analgesics - Scheduled [215246]
ketOROLAC (TORADOL) injection - NOTE:
Suggested dose 0.5 mg/kg/dose (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS For 72
Hours
Recommended for bladder spasm
Post-Op/Phase II
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, 4 X DAILY, Post-Op/Phase II
gabapentin (NEURONTIN) cap - Note:
Recommended Dose = 5 mg/kg Maximum Dose =
300 mg [54258]
Oral, 3 X DAILY, Post-Op/Phase II
Analgesics - As Needed For Incident Pain [92532]
ketOROLAC (TORADOL) injection - NOTE:
Suggested dose 0.5 mg/kg/dose (Maximum 15
mg/dose) [800050]
0.5 mg/kg, Intravenous, EVERY 6 HOURS PRN For
72 Hours, pain, Post-Op/Phase II
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 10-15
mg/kg/dose (Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, EVERY 4 HOURS PRN, pain/fever,
incident pain
NOTE: Suggested dose 10-15 mg/kg/dose (Maximum
650 mg/dose)
Post-Op/Phase II
oxycodone soln - NOTE: Suggested dose 0.1
mg/kg/dose [45975]
0.1-0.2 mg/kg, Oral, EVERY 3 HOURS PRN, pain,
incident pain, Post-Op/Phase II
Analgesics - As Needed For Uncontrolled Incident Pain [92533]
Page 5 of 7
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

HYDROmorphone PF (DILAUDID) injection
RANGE - NOTE: Suggested dose 0.005-0.01
mg/kg/dose (Maximum 0.8 mg/dose) [750050]
0.005-0.01 mg/kg, Intravenous, EVERY 30 MINUTES
PRN, uncontrolled incident pain, for 3 Minutes
NOTE: Suggested dose 0.005-0.01 mg/kg/dose
(Maximum 0.8 mg/dose)
Post-Op/Phase II
MORPHine PF injection - NOTE: Suggested dose
0.025-0.05 mg/kg/dose (Maximum 4 mg/dose)
[750057]
0.025-0.05 mg/kg, Intravenous, EVERY 30 MINUTES
PRN, pain, uncontrolled incident pain, for 4 Minutes
NOTE: Suggested dose 0.025-0.05 mg/kg/dose
(Maximum 4 mg/dose)
Post-Op/Phase II
FENTanyl PF injection RANGE - NOTE:
Suggested dose 0.5-1 mcg/kg/dose (Maximum 50
mcg/dose) [750047]
0.5-1 mcg/kg, Intravenous, EVERY 30 MINUTES
PRN, uncontrolled incident pain, for 1 Minutes
NOTE: Suggested dose 0.5-1 mcg/kg/dose (Maximum
50 mcg/dose)
Post-Op/Phase II
Antispasmodics - Recommended for orthopedic or skeletal muscle spasms [111066]
diazepam (VALIUM) soln - NOTE: Suggested
dose 0.05-0.1 mg/kg/dose (Maximum 5 mg/dose)
[36676]
0.05-0.1 mg/kg, Oral, EVERY 6 HOURS PRN, Muscle
Spasms
NOTE: Suggested dose 0.05-0.1 mg/kg/dose
(Maximum 5 mg/dose)
Post-Op/Phase II
diazepam (VALIUM) injection - NOTE: Suggested
dose 0.05-0.1 mg/kg/dose (Maximum 5 mg/dose)
[36675]
0.05-0.1 mg/kg, Intravenous, EVERY 6 HOURS PRN,
Muscle spasms
NOTE: Suggested dose 0.05-0.1 mg/kg/dose
(Maximum 5 mg/dose)
Post-Op/Phase II
Side Effect Management [184325]
naloxone (NARCAN) injection - Maximum Dose =
2 mg [800199]
1 mcg/kg, Intravenous, EVERY 5 MINUTES PRN,
opioid overdose, see Admin Instructions
Administer over 2 minutes Give up to 4 doses for
respiratory rate less than 8 breaths/min or sedation
score of 5 or greater Notify Acute Pain Service
immediately for naloxone administration.
Post-Op/Phase II
diphenhydramine (BENADRYL) injection -
Maximum Dose = 50 mg [800106]
0.5 mg/kg, Intravenous, EVERY 6 HOURS PRN,
itching, Post-Op/Phase II
metoclopramide (REGLAN) injection - Maximum
Dose = 10 mg [800059]
0.1 mg/kg, Intravenous, EVERY 4 HOURS PRN,
nausea/vomiting, Post-Op/Phase II
ondansetron (ZOFRAN) injection - NOTE:
Maximum Dose = 4 mg [800202]
0.1 mg/kg, Intravenous, EVERY 6 HOURS PRN,
nausea/vomiting, itching
NOTE: Maximum Dose = 4 mg
Post-Op/Phase II
naloxone (NARCAN) 1 MG/ML 2.5 mg in sodium
chloride 0.9 % 250 mL infusion - Maximum Dose
= 100 mcg/hr [700242]
1 mcg/kg/hr, Intravenous, CONTINUOUS
Notify Anesthesiology Acute Pain Service of increased
pain after beginning infusion
Recommended for nausea/vomiting or itching.
Post-Op/Phase II
nalbuphine (NUBAIN) injection - Maximum Dose
= 2.5 mg [39994]
0.05 mg/kg, Intravenous, EVERY 6 HOURS PRN,
itching, for 3 Minutes, Post-Op/Phase II
Anticoagulants [92537]
Page 6 of 7
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

NOTE: NO anticoagulants unless approved by
Anesthesiology Acute Pain Service [950051]
4 X DAILY (NOTE ACKNOWLEDGE)
NO anticoagulants unless approved by
Anesthesiology Acute Pain Service. Approved:
Subcutaneous heparin up to 5000 units/dose 3 times a
day, heparin lock flushes and aspirin up to 325 mg 2
times a day. NOT approved: warfarin, dabigatran, IV
heparin, low molecular weight heparin, fondaparinux,
clopidogrel, ticlopidine, cilostazol, lepirudin, bivalirudin,
argatroban, abciximab, eptifibatide, tirofiban,
rivaroxaban
Post-Op/Phase II
Note: May give first dose of warfarin [950018] 4 X DAILY (NOTE ACKNOWLEDGE)
May give first dose of warfarin
Post-Op/Phase II
General [92530]
Note: Note: NO other opioids, sedatives or CNS
depressants unless approved by the
Anesthesiology Acute Pain Service [950018]
EVERY 8 HOURS
Note: NO other opioids, sedatives or CNS
depressants unless approved by the Anesthesiology
Acute Pain Service
Post-Op/Phase II
Bowel Management [199094]
polyethylene glycol (MIRALAX) oral packet -
NOTE: Suggested dose for patients less than 25
kg is 8.5 g/dose [61829]
Oral
Dissolve in 4 ounces of water. Hold for loose stools
NOTE: Suggested dose for patients less than 25 kg is
8.5 g/dose
Post-Op/Phase II
polyethylene glycol (MIRALAX) oral packet -
NOTE: Suggested dose for patients 25 kg or
greater is 17 g/dose [61829]
17 g, Oral, 1 X DAILY
Dissolve in 8 ounces water. Hold for loose stools
NOTE: Suggested dose for patients 25 kg or greater is
17 g/dose
Post-Op/Phase II
Page 7 of 7
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:49 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org