HOW TO USE THE POP PLAN

 

(1) While the baby is in Operating Room, order a fentanyl drip.

 Expected  Duration of Pain After Surgery

The starting rate is 1 mcg/kg/hr if the baby is opioid naïve ["new" to fentanyl].

If the baby has already been on a fentanyl drip, the rate should be increased [perhaps even doubled] upon return (Max: 12mcg/kg/hr).

 

(2) Order a loading dose of fentanyl in case the baby returns in pain (NPASS SCORE >2) and needs a bolus dose fast.

 

Order as: Loading dose fentanyl 1 mcg/kg slow IV push. Repeat as needed every 15 minutes until NPASS score <3.

For a baby already on fentanyl, loading dose should be equal to one hour's worth of the drip rate.

 

Example: Baby has been on 3 mcg/kg/hr preop.  On return, rate is increased immediately to 6 mcg/kg/hour.

                Loading dose, if needed, will be 6 mcg/kg.

 

(3) Order Tylenol, scheduled "around-the-clock".

It can be given PO if possible, or PR, and should be ordered as follows:

Tylenol PO:

Loading dose: 20mg/kg Once

<32 weeks gestational age: 15 mg/kg PO Q 8hrs

≥ 32 weeks gestational age: 15 mg/kg PO Q 6hrs

Tylenol PR:

Loading dose: 30 mg/kg Once

< 32 weeks GA: 20 mg/kg PR Q 12 hrs

≥ 32 weeks GA: 20 mg/kg PR Q 8hrs

Term: 20 mg/kg PR Q 6hrs

It should not be given to infants with hepatobiliary disease.

 

(4) Order a PRN [breakthrough] dose of fentanyl to use for increasing pain or prior to handling/painful procedures.

 

The PRN [breakthrough] dose should be equal to 1 hour's worth of fentanyl drip.

Order "PRN fentanyl, one hour's worth of drip Q 1 hr".

 

If the baby's pain gets worse, and the PRN dose is needed for 2 hours in a row, you will need to:

 

(5) Order the fentanyl drip to be increased.  If you started at 1 mcg/kg/hr, go up to 2. If you started out with a higher rate, raise the rate high enough to make a difference.

 

Example:      Preop fentanyl rate was 5 mcg/kg/hr. 

Postop, rate was increased to 10 mcg/kg/hr.

PRN dose of 10 mcg/kg was given 2 hours in a row, so the drip was increased to 12mcg/kg/hour (generally a 20% increase is a good idea).

 

So, either an order should be entered "fentanyl drip may be increased to _____ if PRN dose is needed for 2 hours in a row".  Or an order could request that the MD/NNP be contacted at this time for subsequent orders.

 

5 easy Steps:

1) Order a fentanyl drip

2) Order a loading dose of fentanyl

3) Order Tylenol

4) Order a PRN fentanyl dose

5) Order "the fentanyl drip should be increased if PRN dose needed 2 hours in a row"

Or,

If a fentanyl drip will not be used, fentanyl boluses must be scheduled, not PRN.  Bolus doses of fentanyl should be scheduled every 1 or 2 hours and not >3 hours.