Analgesic

Patient Controlled Analgesia

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Patient Controlled Analgesia, PCA Pump, PCA Pump Settings

  • See Also
  1. Opioid
  2. Bowel Regimen in Chronic Narcotic Use
  3. Narcotic Overdose
  • Indications
  1. Hospitalized Patients with Acute Severe Pain (e.g. Sickle Cell Crisis, Acute Pancreatitis, Burn Injury)
  2. Severe Acute Exacerbation of Chronic Pain (e.g. metastatic cancer)
  3. Perioperative Pain Management
  4. Labor Analgesia
  • Contraindications
  1. Inadequate capacity or mental status to understand pump use
  2. High risk for respiratory depression (e.g. severe Sleep Apnea)
  • Technique
  1. Medications
    1. Opioid Analgesics (IV, epidural)
      1. Morphine is most common PCA pump Analgesic used
      2. Other PCA Opioids include Hydromorphone, Fentanyl and Fentanyl derivatives
    2. Local Anesthetics (epidural, Peripheral Nerve catheter)
      1. Ropivacaine is the safest of the Regional AnesthesiaLocal Anesthetics
      2. Other regional Anesthetics include Bupivacaine, levobupivacaine
  2. Routes
    1. Intravenous analgesia
      1. See Opioid Analgesic
    2. Epidural Analgesia
      1. See Epidural Anesthesia
    3. Peripheral Nerve catheter with Local Anesthetic (e.g. Ropivacaine)
      1. See Regional Anesthesia
    4. Transdermal analgesia
      1. See Transdermal Fentanyl
  3. Ordering
    1. PCA Pump use relies on clinicians, pharmacists and nurses to ensure safe initiation and maintenance
    2. Patients must understand the use of the PCA Pump (e.g. when to press the button, frequency and lockout)
    3. Patient visitors should be cautioned not to press the button for the patient
    4. Machine access should be secured for modification only by staff, to prevent machine tampering
  • Evaluation
  1. Assess patient for appropriateness for PCA Pump (esp. cognitive function, sedation)
  2. Assess patient Opioid history and degree of Opioid tolerance
  3. Obtain baseline assessment of respiratory status and sedation, and continue to monitor after initiation
    1. May consider additional monitoring (e.g. EtCO2)
  • Adverse Effects
  1. See specific agents infused (e.g. Morphine)
  2. Opioid Adverse Effects
    1. Examples: Vomiting, Constipation, Pruritus, respiratory depression
  3. Local Anesthetic Adverse Effects
    1. See LAST Reaction
  • Complications
  1. PCA Pump malfunction or misuse resulting in Opioid Overdose (risk of lethal Overdose)
    1. Runaway pump
      1. Excessive frequency or dose
    2. IV Anti-reflux valve malfunction
      1. Opioid refluxes into main IV infusion
    3. Medication Syringe malfunction
      1. Entire contents of syringe administered on initiation
    4. PCA by proxy
      1. Person other than the patient (e.g. family) presses the button to administer additional medication
  2. Epidural catheter and Peripheral Nerve catheter complications
    1. Infected line
      1. Risk of Spinal Infection or deep tissue infection
    2. Dislodged or migrated catheter
      1. Risk of longterm nerve injury
  • Efficacy
  1. Patients
    1. Offers more effective pain control and greater patient satisfaction
    2. Amount of Opioids use may be higher than what would have been used without PCA Pump
  2. Nurses
    1. Reduced overall nursing workload when frequent Analgesic dosing is need
  3. Costs
    1. Does not prolong hospital length of stay
    2. PCA Pump costs are higher than nurse administered dosing
  • Management
  • Step 1 - Calculate hourly dose for Morphine
  1. Typical Hourly Morphine Dose (mg/hour): (100 - age)/24
    1. Age 30: 3 mg hourly Morphine dose
    2. Age 50: 2 mg hourly Morphine dose
    3. Age 70: 1.25 mg hourly Morphine dose
  2. Typical hourly higher Morphine dose (double dose)
    1. Age 30: 6 mg hourly Morphine dose
    2. Age 50: 4 mg hourly Morphine dose
    3. Age 70: 2.5 mg hourly Morphine dose
  • Management
  • Step 2: Set Lockout periods and Maximums
  1. Maximum Lockout: 20 minutes
  2. Typical lockout period range: 6 to 12 minutes
  3. Set one hour or four hour maximums
    1. Example for one hour Morphine maximum: 10 mg
    2. Example for four hour Morphine maximum: 40 mg
  • Management
  • Step 3: Consider Background Continuous Infusion
  1. Indications
    1. Opioid Dependence
    2. Severe pain on awakening
  2. Calculation
    1. Set background rate <50% of anticipated requirements
    2. Typical adult background Morphine rate: 1 mg/hour
  • Management
  • Step 4: Determine PCA bolus Dose
  1. Bolus dose: (higher dose per hour)/(doses per hour)
  2. For lockout at 10 minute intervals: 6 doses
    1. Example: 30 year old with higher Morphine dose: 6 mg
    2. Dose: 1 mg IV Morphine boluses up to q10 minutes
  1. Hydromorphone (Dilaudid)
    1. Dose Estimate: 1.5 mg per Morphine 10 mg
    2. Typical bolus: 0.25 mg
    3. Lockout: 5-10 min
    4. Increased CNS side effects including excitation at high dose
  2. Fentanyl
    1. Typical bolus: 10 mcg
    2. Lockout: 5-10 min
    3. High potency, short duration and may require basal infusion rate
    4. Avoid in Obesity due to prolonged Half-Life (use Morphine instead)
  3. Sufentanil
    1. Typical bolus: 5 mcg/kg
    2. Lockout: 5-10 min
    3. High potency, short duration and may require basal infusion rate
    4. Less Postoperative Nausea and Vomiting than Fentanyl
    5. Avoid in Obesity due to prolonged Half-Life (use Morphine instead)
  • Management
  • Examples for Typical 30 year old
  1. Morphine
    1. Boluses: 1 mg
    2. Background infusion rate: 1 mg/hour (optional)
    3. Hourly maximum: 10 mg
    4. Lockout: 6 minutes
  2. Hydromorphone (Dilaudid)
    1. Boluses: 0.1 mg
    2. Background infusion rate: 0.1 mg/hour (optional)
    3. Hourly maximum: 1.5 mg
    4. Lockout: 6 minutes
  • References
  1. Pastino (2024) Patient-Controlled Analgesia, StatPearls, FL, accessed 11/4/2024
    1. https://www.ncbi.nlm.nih.gov/books/NBK551610/
  2. Etches (1999) Surg Clin North Am 79(2):297-312 [PubMed]
  3. Motamed (2024) Pharmacy 10(1):22 +PMID: 35202071 [PubMed]