PCA-ERR-001 medical runtime_error ai_generated true

AI programs a pediatric PCA pump with adult lockout intervals for morphine, leading to respiratory depression in a 6-year-old

ID: medical/pediatric-pca-pump-override

Also available as: JSON · Markdown · 中文
88%Fix Rate
85%Confidence
1Evidence
2024-03-14First Seen

Version Compatibility

VersionStatusIntroducedDeprecatedNotes
GE Healthcare Aisys CS2 v8.0 active — — —
Baxter PCA Syringe Pump v3.4 active — — —
Smiths Medical CADD-Solis v5.2 active — — —

Root Cause

Pediatric Patient-Controlled Analgesia (PCA) requires a minimum lockout interval of 8-10 minutes for morphine, not the adult standard of 6 minutes, because children metabolize opioids faster and have narrower therapeutic windows, risking respiratory depression.

generic

中文

儿科患者自控镇痛 (PCA) 要求吗啡的最小锁定间隔为 8-10 分钟，而非成人标准的 6 分钟，因为儿童代谢阿片类药物更快且治疗窗口更窄，存在呼吸抑制风险。

Official Documentation

https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/pain-management/pediatric-pca-guidelines.pdf

Workarounds

  1. 88% success Set lockout interval to 10 minutes and bolus dose to 0.02 mg/kg for morphine PCA in a 6-year-old; verify using the Broselow tape or weight-based pediatric nomogram 
    Set lockout interval to 10 minutes and bolus dose to 0.02 mg/kg for morphine PCA in a 6-year-old; verify using the Broselow tape or weight-based pediatric nomogram
  2. 92% success Use a dedicated pediatric PCA protocol that enforces a minimum lockout of 8 minutes and a maximum 1-hour limit of 0.1 mg/kg; program pump with 'Pediatric Mode' if available 
    Use a dedicated pediatric PCA protocol that enforces a minimum lockout of 8 minutes and a maximum 1-hour limit of 0.1 mg/kg; program pump with 'Pediatric Mode' if available
  3. 95% success For a 6-year-old weighing 20 kg, program: bolus = 0.4 mg, lockout = 10 min, 1-hr limit = 2 mg; document in MAR and double-check with a second nurse 
    For a 6-year-old weighing 20 kg, program: bolus = 0.4 mg, lockout = 10 min, 1-hr limit = 2 mg; document in MAR and double-check with a second nurse

中文步骤

  1. Set lockout interval to 10 minutes and bolus dose to 0.02 mg/kg for morphine PCA in a 6-year-old; verify using the Broselow tape or weight-based pediatric nomogram
  2. Use a dedicated pediatric PCA protocol that enforces a minimum lockout of 8 minutes and a maximum 1-hour limit of 0.1 mg/kg; program pump with 'Pediatric Mode' if available
  3. For a 6-year-old weighing 20 kg, program: bolus = 0.4 mg, lockout = 10 min, 1-hr limit = 2 mg; document in MAR and double-check with a second nurse

Dead Ends

Common approaches that don't work:

  1. 75% fail

    Higher bolus doses increase peak serum concentration and risk of apnea without addressing the underlying clearance mismatch

  2. 85% fail

    Lockout interval is independent of concentration; a lower concentration with the same interval still allows too frequent dosing in children

  3. 95% fail

    Eliminating lockout removes the safety mechanism and can lead to cumulative overdose if the child presses the button repeatedly