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IP - Anesthesia Intravenous Patient Controlled Analgesia - Pediatric - Supplemental [5556]

IP - Anesthesia Intravenous Patient Controlled Analgesia - Pediatric - Supplemental [5556] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Pain Management


IP - Anesthesia Intravenous Patient Controlled Analgesia - Pediatric -
Supplemental [5556]
Pediatric PCA Fast Facts URL: https://uconnect.wisc.edu/clinical/references/pain-
management/references-
guidelines/resources/name-85464-en.file
URL:
Patient Care Orders
Vital Signs [198955]
Measure Respiratory Rate Depth & Regularity
(Full Minute) [NURMON0092]
EVERY 2 HOURS, Routine, Measure for 1 full minute,
Post-Op/Phase II
Patient Monitoring [198956]
Assess Pain Rating [NURMON0060] SEE COMMENTS, Starting today For Until specified,
EVERY 4 HOURS. Measure using appropriate scale.,
Post-Op/Phase II
Assess Sedation Level [NURMON0060] SEE COMMENTS, Starting today, EVERY 2 HOURS.
(Note: Awaken only if unable to distinguish between
normal sleep and sedation, or if change in respiratory
pattern (regularity) or depth of respiration.), 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, Phase II
Discharge
Pulse Oximetry [NURMON0009] CONTINUOUS, Routine, Pulse oximetry is required
for any patient with a continuous infusion., Post-
Op/Phase II
Contingency Parameters for Patients Less than 6 Months Old (PCA Pediatric) [198960]
Page 1 of 6
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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

Notify Provider [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: If patient is on Acute Pain Service, notify
surgical team first to determine if pain is related to a
surgical complication, then notify Acute Pain Service
by paging #7246 or "PAIN". If patient not on Acute
Pain Service, notify team who placed PCA
order,Sedation score = 3 or greater
Post-Op/Phase II
Contingency Parameters For Patients 6 Months - 2 Years (PCA Pediatric) [198961]
Notify Provider [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 surgical team first to
determine if pain is related to a surgical complication,
then notify Acute Pain Service by paging #7246 or
"PAIN". If patient not on Acute Pain Service, notify
team who placed PCA order
Post-Op/Phase II
Notify Provider Ages 3 - 10 Years (PCA Pediatric) [198965]
Page 2 of 6
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

Notify Provider [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 < (%): 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 surgical team first to
determine if pain is related to a surgical complication,
then notify Acute Pain Service by paging #7246 or
"PAIN". If patient not on Acute Pain Service, notify
team who placed PCA order
Post-Op/Phase II
Contingency Parameters for Patients > 10 Years (PCA Pediatric) [198978]
Notify Provider [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 surgical team first to
determine if pain is related to a surgical complication,
then notify Acute Pain Service by paging #7246 or
"PAIN". If patient not on Acute Pain Service, notify
team who placed PCA order
Post-Op/Phase II
Medications
Pediatric PCA Guidelines URL: https://intranet.anesthesia.wisc.edu/index.php?
title=Pediatric_PCA_Guidelines
PCA by Proxy [198979]
Initiate PCA by Proxy Assessment
[NURCOM0110]
ONCE, Post-Op/Phase II
Patient Controlled Analgesia (PCA) Infusion for patients <50 kg (Single Response) [199204]
Page 3 of 6
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

MORPHine in sod chloride 0.9% 60 mg/60 mL
PCA syringe [755278]
Intravenous
Basal Rate Instructions:
RN Bolus Dose (mg):
RN Bolus: May Repeat every:
Hold continuous infusion (not demand dose) for
sedation score of 3 or greater
Post-Op/Phase II
HYDROmorphone in sod chloride 0.9% 12 mg/60
mL PCA syringe [755280]
Intravenous
Basal Rate Instructions:
RN Bolus Dose (mg):
RN Bolus: May Repeat every:
Hold continuous infusion (not demand dose) for
sedation score of 3 or greater
Post-Op/Phase II
FENTanyl 1250 mcg in 25 mL PCA syringe
[755284]
Intravenous
Basal Rate Instructions:
RN Bolus Dose (mcg):
RN Bolus: May Repeat every:
Hold continuous infusion (not demand dose) for
sedation score of 3 or greater
Post-Op/Phase II
Patient Controlled Analgesia (PCA) Infusion for patients > or = 50 kg (Single Response) [213229]
MORPHine in sod chloride 0.9% 60 mg/60 mL
PCA syringe [755279]
Intravenous
Basal Rate Instructions:
RN Bolus Dose (mg):
RN Bolus: May Repeat every:
Hold continuous infusion (not demand dose) for
sedation score of 3 or greater
Post-Op/Phase II
HYDROmorphone in sod chloride 0.9% 12 mg/60
mL PCA syringe [755281]
Intravenous
Basal Rate Instructions:
RN Bolus Dose (mg):
RN Bolus: May Repeat every:
Hold continuous infusion (not demand dose) for
sedation score of 3 or greater
Post-Op/Phase II
FENTanyl 1250 mcg in 25 mL PCA syringe
[755285]
Intravenous
Basal Rate Instructions:
RN Bolus Dose (mcg):
RN Bolus: May Repeat every:
Hold continuous infusion (not demand dose) for
sedation score of 3 or greater
Post-Op/Phase II
Add Patient to IAPS Pain Service Patient List [205282]
Add Patient to IAPS Pain Service Patient List
[CON0266]
ONCE
Continuous Infusions [194425]
ketamine (KETALAR) infusion PEDS [800149] Intravenous, CONTINUOUS, 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
Page 4 of 6
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org

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
Antispasmodics - Recommended for orthopedic or skeletal muscle spasms [192389]
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
Page 5 of 6
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:04 AM
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08/2017CCKM@uwhealth.org

General [192390]
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
Medications - Bowel Management
Bowel Management [184326]
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 strict NPO and
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 4 ounces of water. Hold for strict NPO and
loose stools
NOTE: Suggested dose for patients 25 kg or greater is
17 g/dose
Post-Op/Phase II
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
Oral, Post-Op/Phase II
As Needed - First Line [199209]
lactulose (CEPHULAC) soln - NOTE: Order for
patients less than 5 years of age [75426]
1.65 g, Oral, 1 X DAILY PRN, constipation
NOTE: Order for patients less than 5 years of age
Post-Op/Phase II
lactulose (CEPHULAC) soln - NOTE: Order for
patients 5-11 years of age [75426]
3.3 g, Oral, 1 X DAILY PRN, constipation
NOTE: Order for patients 5-11 years of age
Post-Op/Phase II
lactulose (CEPHULAC) soln - NOTE: Order for
patients 12 years or older [75426]
6.65 g, Oral, 1 X DAILY PRN, constipation
NOTE: Order for patients 12 years or older
Post-Op/Phase II
senna-docusate (SENOKOT-S) 8.6-50 mg per tab
[60530]
Oral, Post-Op/Phase II
As Needed - Second Line [199210]
bisacodyl (DULCOLAX) rectal suppository
[35231]
10 mg, Rectal
Administer if first line agent fails
Post-Op/Phase II
glycerin (PEDIATRIC) rectal suppository [153728] 1 suppository, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails.
Post-Op/Phase II
phosphate (FLEET PEDIATRIC) enema - NOTE:
Order for children 2-11 years [37522]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
Post-Op/Phase II
phosphate (FLEET) enema - NOTE: Order for
children 12 years or older [37517]
1 enema, Rectal, 1 X DAILY PRN, constipation
Administer if first line agent fails
Post-Op/Phase II
Page 6 of 6
Printed by STRAKA, KEVIN F [KFS1] at 8/8/2017 10:38:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org