PCA Patient Controlled Analgesia

In traditional pain management protocols, opioids are administered as protocols, fixed doses at fixed dose intervals or as a fixed-rate infusion; however, fixedthis approach is less than ideal for managing pain. PatientPatient-controlled analgesia (PCA) is a well tolerated and effective method of pain control, especially in the postoperative period.

PCA offers flexibility in dose size and dose interval in individual patients. Patient satisfaction is high with PCA and pain relief is generally better than with conventional therapy, particularly where there is appropriate patient selection and education. Although it was initially thought that less opioid would be used with PCA and that the length of hospital stay would be reduced, this has not been confirmed.

PATIENT CONTROLLED ANALGESIA



Form of systemic opioid therapy Self administered frequent small doses - more closely matches the need of the patient PCA device : microprocessormicroprocessorcontrolled pump Programming the dose, intervals, max. dose per set time and basal rate

BODY GUARD INFUSION PUMP

BASIC VARIABLES OF PCA

    

LOADING DOSE DEMAND DOSE LOCKOUT INTERVAL BACKGROUND INFUSION RATE 1 -AND 4 -HOUR LIMITS

MORPHINE

 CONCENTRATION

- 1 MG / ML  CONTINUOUS INFUSION RATE -1 MG /ML  LOCKOUT PERIOD - 10-15 MIN. 10 BOLUS - 1 ML

PCA
120 100 80 60 40 20 0 0 1 2

or

IM ?

intramuscular PCA

Select the patient

     

Not too old, too confused, too young Mild to moderate pain Short duration of pain Early postop. period - ? Patient with PCA not need pain treatment ? Same side effects like systematically opioids

PCA
  

MORPHINE 1 MG / ML FENTANYL 10 QG/ML 0.2 MG/ML

HYDROMORPHONE


PETHIDINE

5 -10 MG/ML

Feature Usual PCA regimen (demand dose; lockout time):a IV IM SC ED IN Time of relative onset (min): single IV bolus single IM dose
t

Morphine

Pethidine (meperidine)

Fentanyl

1mg; 5minb 5mg; 20min 1mg; 10min NA;NA -

10-20mgb; -

NA 20-40g; 1-10minb 5g; 2min 25g; 6minc

6 20

6 17

2 NA

max (min): single IV bolus single IM dose 19 48 13 30 4 NA

Duration of effect (min): single IV bolus single IM dose Approximate clinically equivalent IV bolus dose (mg) Clearance (L/min) IM absorption half-life (min) 96 110 10 1 7.7 20 39 100 1 10 7 NA 0.1 0.6 NA

PCA - INSTRUCTIONS


NO SYSTEMIC NARCOTICS OR OTHER CNS DEPRESSANTS TO BE GIVEN EXCEPT AS ORDERED BY THE ACUTE PAIN SERVICE. NO OTHER INFUSIONS OR MEDICINE MAY BE GIVEN THROUGH THE PCA CONNECTED - IV ACCESS ROUTE. PCA NOT TO BE DISCONTINUED EXCEPT BY ACUTE PAIN SERVICE

PatientPatient-controlled analgesia update

Clinical bottom line Patient-controlled analgesia with opioid produces modest improvement in pain relief compared to the same opioid given conventionally. Patients preferred it, and there were no more or fewer adverse events reported.
B Walder et al. Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain. Acta Anaesthesiologica Scandinavica 2001 45: 795-804.

Painful conditions and techniques for which patient-controlled analgesia has been used patient-

      

Postoperative pain Cancer pain Painful medical conditions : sicklesickle-cell crisis acute pancreatitis Labour Oocyte pickup for assisted reproduction techniques

Analgesic requirements variable

There are a number of reasons why patients differ in their opioid requirements:

   

differing degree of painful stimulus variability in opioid kinetics in the blood variability in the kinetics of CNS uptake of opioids variability in the number and distribution of opioid receptors within the CNS differences in patients' perception of and attitude to their pain accuracy of the infusion device.

 

Device may be simple or complex



A PCA device : a pump with reservoir of drug, and a handset that administers a dose of drug when activated by the patient. This may be a microprocessor-controlled system, able to implement microprocessorsystem, complex instructions programmed by the prescriber and keep a record of the patient-device interactions, or it may be a simple disposable pump patientpowered by mechanical means such as a spring or an elastomeric drug reservoir. A `smart pump', where an infusion is given at a rate proportional to the number of demands made by the patient, has been suggested but only a small number of patients have used the system to date. Such systems take some of the control away from the patient. As patient control is considered to be fundamental to the safety of PCA, the safety of all systems that give the patient opioid additional to that requested needs to be carefully evaluated.

General principles


No benefit from complex dosage regimens . . .or from background infusions .or The clinician decides which drug to use and the size of each dose, while the patient determines the timing of the doses Lockout interval must be appropriate Determining appropriate demand dose size Loading with analgesic

Loading dose


The loading dose accelerates attainment of an effective blood level of the opioid at the initiation of therapy. Since there is marked inter-patient variability in the amount of analgesic required for pain relief, the loading doses must be titrated to effect. Many studies have demonstrated a five-fold variability in the quality of IV opioid required to produce equivalent analgesia after surgery.

The loading dose should be repeated every 5 -10 minutes so that the effect of the dose is felt before the next dose is administered.

Loading dose
The size of the loading dose is influenced by:


Lean body weight (Male: 50+2.3 x Ht.(in.)-60; Female: 45.5 +2.3 x Ht(in.)-60) 50+ Ht.(in.)-60; 45. Ht(in.)-60) Age (>65 years dose decreased by 25%) (>65 25%) Physical status (dose decreased by 25-50% in debilitated patients) 25-50% Opioid tolerance (increase the dose 25-50%) 25-50%) If the initial 3 to 4 loading doses are ineffective, the loading dose can be increased by 25-50% after an appropriate assessment of the patient's 25-50% pain level and the side effects of the opioid (primarily sedation).

Problems with PCA



The risk of serious adverse events associated with PCA is low. The risk is increased when the patient's degree of control over drug administration is reduced, such as when a background infusion is added. There are a number of reports every year of patients put at risk by mistakes made by staff when initiating PCA.

Risk of respiratory depression

background infusions PCA use in the elderly concomitant sedative medications a large demand dose with a short lockout interval.

Sedation and Respiratory Depression



The first action should be to administer oxygen, followed by the addition or adjustment of drug !
y If sedation score = 3 and respiratory rate = 10: Administer oxygen and halve the size of the PCA dose y If sedation score = 3 and respiratory rate <10: STOP PCA, obtain Naloxone 0.4 mg/10cc 0.9% NS and inject 1-2 cc q. 1-2 minutes until patient is back to his or her normal baseline (titrate to effect) and offer nonopioid analgesic y For children who are somnolent, difficult to arouse, or have a RR less than the age-appropriate baseline as noted on pediatric order sheet, STOP PCA and call primary service. Naxolone dose for reversal of respiratory depression with pediatric patients is 2 -5 mcg/kg, repeated q. 2 - 3 minutes (titrate to effect).

Take precautions against medication errors !

Problems do arise from staff errors.  Continuous staff training is advised, and staff should be present whenever the PCA programme is changed.
 

PCA manufacturers have responded to these concerns by producing systems that can be customised to default to the settings that are generally used at any particular hospital thus minimising staff programming errors. Accidental overdoses have been reported, usually where the patients or visitors mistook the PCA push button for the nurse call button, or where the patient's spouse took control of the PCA handset.

Assessment


The timing for assessment of the efficacy of pain relief is dependent upon the situation. If the patient is in severe pain requiring upward titration of analgesics, pain assessment should be completed frequently (e.g., every 15 minutes). In general, pain should be assessed approximately 15-30 15minutes after administering parenteral medication and 60 minutes after administering oral medication. During the initial 24-hour postoperative period, pain 24should be assessed at least every 2 to 4 hours. If pain is well controlled, the pain intensity should be assessed routinely with vital signs.

Modify treatment to achieve effective pain control with minimal harm and side effects.

Nausea/Vomiting
Evaluation of postoperative nausea is to ensure stable vital
signs and adequate control of pain . Unfortunately, opioids stimulate nausea and may require treatment (Cohen et al., 1992; Wang, 1996; gan et al., 1998; 1992; 1996; 1998; Chung et al., 1999) or alteration of pain therapy to allow the 1999) patient to be nausea free with pain control . Because of high incidence of nausea, prophylactic antiemetic therapy is often given (Chen et al., 1996; Pitkanen et al., 1997; 1996; 1997; Helmy, 1999; Gan et al., 1997) 1999; 1997) The choice of antinausea agent is driven by patient factors and prior antinausea therapy. For example, if a dopamine antagonist was given for nausea earlier, the addition of a serotonin antagonist may be more helpful than a second dopamine antagonist. antagonist.

Lethargy/Sedation/Respiratory Depression


Evaluation is paramount to treatment of sedation. Respiratory depression secondary to opiates is preceded by lethargy and sedation; treatment is the same for this side effect. After causes of sedation other than analgesics have been addressed, adjusting the selected pain therapy is required (Kenady et al., 1992; Eriksson-Mjoberg et al., 1997; Passchier et al., 1993). 1992; Eriksson1997; 1993). If significant overdose of analgesics is suspected, use of reversal agents is indicated (naloxone 0.4 mg intramuscular/intravenous). If respiratory depression persists, this dose may need to be repeated and other causes considered.

Itching/Pruritis


Once allergic reactions have been ruled out, treatment of pruritis in the presence of appropriate opioid therapy is with antihistamines and opioid antagonists (Cohen et al., 1992; Gan et al., 1997). 1992; 1997).

With regional analgesia techniques, it may be possible to eliminate the opioid component.

Numbness/Weakness


Numbness is not associated with analgesics other than local anesthetics and the cause should be sought. Numbness in the affected area in the presence of regional analgesia should be evaluated (possible subarachnoid hematoma, abscess) and the dose adjusted. Weakness can be seen with analgesics usually in conjunction with other signs of relative overdose. Weakness seen with regional techniques should be minimized to allow for ambulation with assistance if desired.

Myoclonus/Seizures


SeizureSeizure-like activity in the postoperative setting should be evaluated and treated. Some opioids, meperidine in particular, are associated with seizures and myoclonus. While very high doses of local anesthetics can cause seizures, this is unlikely in the postoperative setting unless a large amount is actually given.

Hallucinations


Hallucinations in the postoperative patient can be due to a variety of causes including change in surroundings, sleep deprivation and intraoperative medications (H2 blockers, (H2 anticholinergics, opiates).

Evaluations of hallucinations are often decided by "trial and error" techniques.

Dysphoria


Postoperative dysphoria is unsettling to the patient and family and difficult to evaluate. Sometimes reassurance can be all that is needed, but it may also require changing of pain management techniques.

It is more common with mixed opioid agonists/antagonists and antidopaminergic medications.

Urinary Retention
 Urinary

retention is a common side effect of pharmacologic pain management and is more common after neuraxial dministration

Hypotension


Hypotension due to systemic analgesics is rare and is likely due to hypovolemia and loss of sympathetic drive with appropriate analgesia. Hypotension from neuraxial opioids alone is unlikely. Hypotension with regional analgesia techniques is common and treated by replenishing fluids and altering the local anesthetic dose. Short term therapy can be accomplished with vasopressors until the above can be addressed.

Monitoring !

All Patients

Patients on Opiates

Epidurals

BP HR VAS Sedation Resp SpO2 Motor Insert Score Rate Block Site 3h 3h 3h 1h 1h 1h 3h 24 h

3 " 100 10 92% . .

SEDATION SCALESCALE-

01234-

FULLY AWAKE MILD SEDATION SEDATED BUT AROUSABLE

,
DEEP SEDATION, NOT RESPONDING NOT RESPONDING

"

  

RESCUE