PCA is neither “ one size fits all “ or a “ set and forget “ therapy An Anesthesiologist style ………. no fixed dose of drug fits all patient make patient analgesia and take care

1. Patient Controlled Analgesia :
How to applied safely to patient ?
A.M.TAKDIR MUSBA
DEPARTMENT OF ANESTHESIOLOGY, INTENSIVE CARE AND PAIN
MANAGEMENT
FACULTY OF MEDICINE, HASANUDDIN UNIVERSITY
MAKASSAR-INONESIA

2. INTRODUCTION
 First developed as a research tool
 First introduce in UK, 1976
 The continuing popularity of PCA

3. Basic Principle
 “ when I feel pain, I press a button”
 PCA involve the on demand,
intermittent self – administration of a
predetermined dose of analgesic (
usually an opioid ) by a patient
 Intravenous, Epidural, s.c., Intranasal

4. Patient experiences effect of drug
Drug works
Patient administers drug
Patient experiences pain
Principle Concept
Good pain relief?
Wait!
Yes No

5. Cutting the time waiting
Patient has Pain
Sedation
Analgesia
Absorption from
Injection Site
Injection Given
Prepare
Injection
Calls Nurse
Nurse Responds
“Screening”
Sign out of
Medications
PCA
X

6. EFFICACY OF PCA
1. Intravenous opioid PCA provides better
analgesia than conventional parenteral
opioid regimens (Level I evidence )
2. Patient preference for iv PCA is higher
when compared with conventional
regimens (Level I evidence )
3. There is little evidence that one opioid via
PCA is superior to another with regards to
analgesic or adverse effects in general
(Level II evidence)
Acute Pain Management: Scientific Evidence, 3rd edition, ANZCA,
2010

7. Indication for PCA
 Major operations and NPO
 Contraindication to Epidural Analgesia
 Marked incident pain
 Cancer Pain
 Strongly motivated and appropriately
educated for use PCA

8. PAIN Vs ANALGESIC

9. Why Opioid Intravenous PCA
?
 Opioid analgesics are the cornerstone of
treatment for postoperative pain
 FK / FD opioids suitable for PCA
 Opioid phenomenon : analgesia occur at
lower dose than does sedation
 Intravenous patient controlled analgesia
(IV PCA) is a preferred route of
administration
◦ established efficacy
◦ sense of empowerment given the patient
◦ quick delivery and subsequent onset of pain relief

10. OPIOID : Titrated to reach MEAC and
maintain constant plasma
concentration
Grass, JA., Anesth Analg 2005;101:S44–S6

11. PCA “ Not just a pump “
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

12. FACTOR AFFECTING
SAFETY
Macintyre P.E., British Journal of Anesthesia, 2001, 87(1
PCA
SAFETY
PATIENT
FACTORS
EQUIPMENT
FACTORS
MEDICAL AND
NURSING STAFF

13. 1. PATIENT FACTORS
 PATIENT’S AGE
 PSYCHOLOGICAL
CHARACTERISTICS
 CONCURRENT DISORDERS
 OPIOID-TOLERANT PATIENTS
 INAPPROPRIATE USE OF PCA
Macintyre P.E., British Journal of Anesthesia, 2001, 87(1)

14. 2. 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 errorsMacintyre P.E., British Journal of Anesthesia, 2001, 87(1)
San Diego Patient Safety Taskforce ,PCA Guidelines of Care,

15. 3. MEDICAL AND NURSING
STAFF FACTORS
 OPERATORS ERROR
◦ Incorrect programming
◦ Incorrect checking procedures
 THE LEVEL OF KNOWLEDGE
NURSING AND MEDICAL STAFF

16. 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 |

17. Nurse training


18. THE PCA PRESCRIPTIONS
by Anesthesiologist
 Bolus dose
 Lockout interval
 Loading dose
 Background infusion
 Dose limit

19. PCA order example
 Drug : Fentanyl
 Solution Normal Saline
 Concentration 10 microgram/ml
 Bolus dose 10 microgram
 Lockout 6 minutes
• Drug : Morphine Sulphate
• Solution Normal Saline
• Concentration 1mg/ml
• Bolus dose 1 mg
• Lockout 8 minutes
• Background nil

20. One of the standard from San Diego Patient
Safety Taskforce : PCA Guidelines of Care
Weber LM; Ghafoor VL; Phelps P. Implementation of standard order sets for patient-controlled analgesia. Am J Health
Syst Pharm. 2008 Jun 15; Vol. 65 (12),pp.1184-91.
Pasero C, IV opioid range orders for acute pain management. AJN. February2007. Vol. 107, No. 2, pp.52-59.
Gammaitoni AR, Fine P, Alvarez N, McPherson ML, Bergmark S. Clinical application of opioid equianalgesic data. The
Clinical Journal of Pain 2003. 19: pp.286–297. Lippincott Williams & Wilkins, Inc., Philadelphia.

21. Opioid analgesics used in IV
PCA
opioids Drug conc.
( mg/ml )
Bolus dose
( mg )
Lockout
interval
( min )
Background
infusion rate
( mg/hr ) *
fentanyl 0.01 0.01-0.02 5-10 0.02 – 0.1
hydromorphone 0.2 0.1 – 0.5 5 - 10 0.2 – 0.5
meperidine 10 5-15 5-12 5-40
morphine 1 0.5 - 3 5-12 1-10
oxymorphone 0.25 0.2-0.4 8-10 0.1-1.0
Little evidence suggest major differences of
efficacy and side effects between opioids

22. PCA form

23. 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

24. Physician-Patient Alliance for Health & Safety

25. TAKE HOME MESSAGE
 PCA is neither “ one size fits all “ or
a “ set and forget “ therapy
 An Anesthesiologist style ……….
no fixed dose of drug fits all patient
make patient analgesia and take
care
Etches RC. Surg Clin North Am. 1999, 79:
272-73

26. THANK YOU VERY MUCH
FOR YOUR KIND ATTENTION