ACUTE PAIN SERVICE

PATIENT CONTROLLED ANALGESIA

What is patient-controlled analgesia?

 PCA is a method of analgesia delivery system whereby a computerised syringe pump is set to deliver small boluses of opioids whenever patient presses a button, according to patient s need.  Routes: intravenous epidural subcutaneous

WHY PATIENT CONTROLLED ?

 Wide variation of analgesic requirements between patients  Postoperative analgesic requirement is cyclical and varies considerably  Available when patient requires it - eliminates pain cycle

PAIN CYCLE
Sleeps
3H

PAIN

Call nurse Nurse respond

Pain relief
30 min

Injects pt

Assess pt

Prepare drug

Team leader DDA

PATIENT CONTROLLED ANALGESIA

Advantages
 Self administration
dose matches patient requirement patient autonomy

 Painless, single puncture only for IV line  No need for medical staff to administer drugs
reduces nursing workload

 No delay getting medication for pain

reduces patient anxiety

 Good for incident pain

PATIENT CONTROLLED ANALGESIA

Disadvantages
 Not suitable for all patients  Need for expensive equipments  Possibility of programming error and machine malfunction  Education of nurses, doctors and patients necessary

PATIENT-CONTROLLED ANALGESIA
Contraindications
 Patients who do not want to use  Patients who do not know how to use
eg: children, senile adults

 Patients who are unable to use

eg: head injured, bilateral fracture of hands

 Untrained staff

PATIENT-CONTROLLED ANALGESIA
Drugs used  Morphine  Pethidine  Fentanyl

PATIENT-CONTROLLED ANALGESIA
Features of PCA machine
       Syringe pump Microcomputer for programming Activation device Lock and key for authorised access Delivery system Display window Alarm

PATIENT-CONTROLLED ANALGESIA
Programming features
     Loading dose Bolus dose Lockout interval Background infusion Hourly dose limit

PATIENT-CONTROLLED ANALGESIA
Loading dose
 The initial dose of drug given when PCA is started  Used for patients who are in severe pain when PCA is started to achieve analgesia faster.  For PCA morphine usually 2-3 mg

PATIENT-CONTROLLED ANALGESIA
Bolus dose
 The amount of opioid that the PCA machine will deliver when the demand button is pressed  Settings for PCA morphine
Age < 60 years: 1 mg Age > 60 years: 0.5 mg

 Settings for PCA pethidine

Age < 60 years: 10 mg Age > 60 years: 5 mg

 Can only be changed by trained APS staff

PATIENT-CONTROLLED ANALGESIA
Lock-out interval
 The time after a successful patient demand, during which no further dose of drug will be delivered  Safety feature of machine  For PCA morphine or pethidine 5 minutes  Can only be changed by APS staff

PATIENT-CONTROLLED ANALGESIA
Background infusion
 A continuous infusion of the drug is delivered irrespective of patient demands  Usually not set in adults  Used only in paediatric patients

PATIENT-CONTROLLED ANALGESIA
Hourly dose limit
 The maximum amount of drug the machine will deliver in one hour  Maybe set as a safety precaution to prevent overdose  Often not set for adults

PATIENT-CONTROLLED ANALGESIA
Programming modes
 PCA only  PCA + continuous mode  Continuous mode only

PATIENT-CONTROLLED ANALGESIA
Recommended settings  Loading dose
2-4 mg if patient in severe pain when PCA started

 Lockout interval
5 minutes

 4 hour dose limit

not set

 PCA dose (morphine)

1 mg < 60 years old 0.5 mg > 60 years old

PATIENT-CONTROLLED ANALGESIA
Recommended settings PCA morphine adult < 60 years old
      Concentration = 1 mg/ml Mode = PCA only No loading dose PCA dose = 1 mg Lock-out interval = 5 minutes 4 hourly dose limit = not set

PATIENT-CONTROLLED ANALGESIA
Recommended settings PCA morphine adult > 60 years old
      Concentration = 1 mg/ml Mode= PCA only No loading dose PCA dose = 0.5 mg Lock-out interval = 5 minutes 4 hourly dose limit = not set

PATIENT-CONTROLLED ANALGESIA
Common problems
      Problem with understanding how to use PCA Unsatisfactory pain relief Fear of addiction to morphine Nausea and vomiting Problems with alarms Reluctance to ambulate because of PCA machine

PATIENT-CONTROLLED ANALGESIA
Nursing tips
    Repeat instructions frequently Motivate patient to get well Aim towards patient self-care Maintain confident and cheerful disposition

PATIENT-CONTROLLED ANALGESIA
Side effects
Due to drugs used  Respiratory depression  Nausea and vomiting  Sedation  Urinary retention  Ileus  Pruritus

PATIENT-CONTROLLED ANALGESIA
Side effects
Due to IV line  Thrombophlebitis  Accumulation of opioid in IV line ( need for anti-reflux valve)

PATIENT- CONTROLLED ANALGESIA

When to stop PCA
 When patient is taking orally
(convert to oral analgesia)

 When patient requests  When patient does not need analgesia (when daily dose of morphine is minimal)