2. Definition :
• Patient Controlled Analgesia is an effective
method of pain relief that gives the patient a
sense of control over their pain.
History:
• First developed as a research tool.
• First pump ,”Cardiff Palliator” was introduced
in UK in 1976.
• Thus continuing the popularity of PCA.
3. Indications of PCA
• Major operations and NPO
• Marked incident pain
• Cancer Pain
• Strongly motivated and appropriately educated for
use PCA
4. Why do we need PCA ?
Patient has Pain
Sedation
Analgesia
Absorption from
Injection Site
Injection Given
Prepare
Injection
Calls Nurse
Nurse Responds
“Screening”
Sign out of
Medications
PCA
X
5. Patient experiences effect of drug
Drug works
Patient administers drug
Patient experiences pain
Mechanism of PCA
Good pain relief?
Wait!
Yes No
7. Postoperative Pain
Treatment
Multimodal
Therapy
Local anesthetics (LA)
infiltration
Acetaminophen
Anti-inflammatory agents,
COX-2 inhibitor
LA via peripheral
nerve catheters
Local anesthetics
Opioids
2-Agonists
NMDA antagonists
COX-2 Inhibitors
Opioids
2-Agonists
Acetaminophen
N-methyl-D-aspartate
(NMDA) antagonists
Slide courtesy of Raymond Sinatra, MD and modified for educational purposes
8. Routes:
PCA can be given through different routes and with different
drug compositions.
• Intravenous
• Epidural
• Peripheral Nerve Catheter
• Transdermal
9. Multimodal therapy
• Key Practice Guidelines Recommendations
American Society of Anesthesiologists Task Force on Acute Pain Management.
Anesthesiology. 2012;116(2):248-273.
Anesthesiologists who manage perioperative pain should,
after thoughtfully considering the risks and benefits for the
individual patient, use therapeutic options such as:
• Epidural or intrathecal opioids
• Systemic opioid patient-controlled analgesia (PCA)
• Regional techniques
10. Basics of a PCA
For all modes of PCA the basic variables are
• Initial loading dose( to titrate upto MEAC)
• Demand dose (on activation of demand dose)
• Lockout interval (to prevent overdose)
• Background infusion (constant rate of infusion)
• 1-h and 4-h limits (to program the device to limit the patient)
12. OPIOID : Titrated to reach MEAC and
maintain constant plasma concentration
Grass, JA., Anesth Analg 2005;101:S44–S61
13. PCA has many advantages
But ….
• Narrow therapeutic index of opioids.
• Potential for human error.
Serious safety issues that increase treatment costs and
limit use, while also compromising quality of care.
Meissner B. et al . Hospital Pharmacy, 2009, Volume 44,pp 312–324
14. Side Effects
Intravenous PCA (opioid based)
• Nausea and Vomiting
• Pruritus
• Sedation and confusion
Epidural PCA
• Motor Blockade
15. Macintyre P.E., British Journal of Anesthesia, 2001, 87(1)
PCA
SAFETY
PATIENT
FACTORS
EQUIPMENT
FACTORS
MEDICAL AND
NURSING STAFF
Factors Affecting Safety of PCA
16. • PATIENT’S AGE
• PSYCHOLOGICAL CHARACTERISTICS
• CONCURRENT DISORDERS
• OPIOID-TOLERANT PATIENTS
• INAPPROPRIATE USE OF PCA
Macintyre P.E., British Journal of Anesthesia, 2001, 87(1)
Patient Factors
17. EQUIPMENT FACTORS
• DISPOSABLE PCA DEVICES Vs ELECTRONIC PCA
DEVICES
• Efficacy and side effect may be comparable.
• Disposable delivers a fixed volume.
• Electronic more flexible in timing and dose.
• Recommended that one type / one model of PCA pump is
used throughout the organization to reduce PCA
medication errors.
Macintyre P.E., British Journal of Anesthesia, 2001, 87(1)
San Diego Patient Safety Taskforce ,PCA Guidelines of Care, 2008
18. MEDICALAND NURSING STAFF
FACTORS
• OPERATORS ERROR
• Incorrect programming
• Incorrect checking procedures
• THE LEVEL OF KNOWLEDGE NURSING AND
MEDICAL STAFF
19. Nurses, can be a significant
barrier to errors.
• Learn to use the PCA pumps in facility and
maintain proficiency.
• Accept only PCA orders written.
• Ability to enter a prescription into a PCA pump
regularly.
• Develop a list of patients who are good PCA
candidates.
• Another nurse independently check when initiate
PCA.
• Good monitoring.
D’Arcy Ivonne, www.Nursing2008.com |
20. Some suggestion for safety ( ISMP )
Institute for Safe Medication Practice
• Assess vulnerability to serious errors.
• Limit concentrations.
• Distinguish custom concentrations.
• Clarify the label.
• Match the Medical Record to the label.
• Employ an independent double-check.
ISMP. Misprogramming PCA concentration leads to dosing errors.
August 28, 2008 issue. www.ismp.org/d/SpecialFollowUp.pdf
22. Nurse controlled Analgesia
It allows the nurse to give a small dose of the analgesic to the
pediatric patients.
Parents must be given educated about the PCA
either via a handout or verbally . They must be informed that –
• The Nurse would frequently come to assess the child’s pain
score.
• Only the nurse is allowed to press the button on the pump.
• Parents must be well informed of the potential side effects of the
drugs used in the PCA , so they can be watchful.
