patient controlled analgesia: return to nursing program

Patient Controlled Analgesia

Learning Outcomes

At the conclusion of this session, the participant will be able to:

• Describe the term Patient Controlled Analgesia (PCA)

• Discuss the indications and contraindications of PCA use

• Discuss the advantages of PCA• Discuss the pharmacological

principles of pain management

Learning Outcomes

• Discuss the PCA settings and definitions

• Discuss drugs commonly used for PCA

• Describe differences of a disposable PCA

• Describe correct IV line assembly when using PCA

Learning Outcomes

• Discuss requirements for patient assessment and monitoring

• Discuss the side effects and complications of opioid use

• Discuss the management of opioid related side effects

• Discuss the concept of multi-modal analgesia

PCA

Patient Controlled Analgesia (PCA): A method of administering IV analgesia where by the patient initiates boluses of analgesic agents via a delivery system.

Indications for use

• Moderate to Severe Pain that requires multiple doses of IV analgesia

• Acute Pain

Contraindications

• Patients who are cognitively impaired

• Patients with limited understanding, confusion or disorientation

• Patients who are physically unable to push the button

Advantages

• Patient autonomy• Improved patient satisfaction• Reduces nursing workload• Allows accurate evaluation of

analgesia

Advantages

• Individualised therapy, therefore decreased adverse effects

• Potentially consistent serum levels of analgesic – prevents large peaks and troughs

• Easy titration for painful incidences such as physiotherapy

• May be used effectively by children, however parents must be involved

Pharmacological Principles of Pain

Management

• The patients description of pain is our indicator of effectiveness.

• Smaller doses more frequently prevents large peaks and troughs in the plasma concentration.

• These principles apply to all drugs and routes of administration.

Pharmacological Principles of Pain

Management• Analgesic Corridor

Adapted from Macintyre and Ready (2001)

Settings

The PCA machine can be programmed to deliver:• Patient Demands only• Patient Demands and a Continuous

background infusion • A Continuous infusion only

(occasionally)

Settings

Drug Concentration• The concentration of analgesia per ml.• May either be mg/ml (eg. as for Morphine) or

mcg/ml (eg. as for Fentanyl)

Loading Dose• An initial bolus of analgesia, given prior to the

commencement of PCA• This is an optional function

PCA Bolus Dose • The pre-set bolus dose which is initiated by the

patient and administered via the PCA delivery system

Lock-out Interval • The pre-set time in which the patient can not

receive another bolus dose via the PCA delivery system, despite patient demand.

• A safety mechanism that prevents patient overdose

• Common Lockout Interval is 5 minutes

Settings

Background Infusion• A continuous infusion administered via the PCA

delivery system• This is an optional function

Hourly Dose Limit• A pre-set dosage limit that prevents the patient

receiving more than a designated amount of analgesia within a set amount of time

• This is an optional function and only programmed if prescribed

Settings

PCA Demands• The amount of demands for analgesia made by

the patient, via the PCA delivery system

PCA Deliveries• The amount of successful boluses given via the

PCA delivery system, following patient demand

Cumulative total • The total amount of analgesia administered via

the PCA delivery system

Settings

Drug Concentrations

Alaris PCAM

Morphine Pethidine Fentanyl

Dose 50mg 500mg 500mcgDiluent Diluted with N/Saline to a total of 50mls

Conc. 50mg/50ml =1mg/1ml

500mg/50ml =10mg/1ml

500mcg/50ml =10mcg/1ml

Pre programmed protocols:– Acute Morphine– High Risk Morphine – Pethidine– Acute Fentanyl– Tramadol– Chronic Morphine– Chronic Fentanyl (PCA & Infusion) – Ketamine

Drug Concentrations

Patient Assessment and Monitoring

Baseline observations including pain score and level of sedation should be performed and documented prior to the commencement of PCA.

• BP, RR, PR, Sedation Score, Pain Score (on movement) should be documentedo½ hourly for 4 hours after commencementoHourly for 8 hourso 2 hourly for 12 hourso 4 hourly thereafter (if patient is stable)

NB: Pain and sedation scores may be omitted if patient is sleeping (during normal sleeping hours). This may be documented as “S” on the observation chart.

Patient Assessment and Monitoring

• Document PCA use and pump settings:o Rate (mg/hr or mcg/hr)o Patient Demandso PCA Deliverieso Cumulative Totalo Additional clinician boluses if given

Patient Assessment and Monitoring

Additional Monitoring

and Documentati

on In addition to specific observations:

o Respiratory: depth and ability to deep breath and cough

o Side effects such as nausea, vomiting or pruritus

o SpO2 (if required)o Any changes to the PCA prescription

Pain Assessment

• Accurate pain assessment is a fundamental

factor in providing effective pain management • Assessment should be both at rest and on

movement

Pain Assessment

• Use Pain Assessment tools applicable to

patient’s condition:o Verbal Numerical Rating Scaleo Visual Analogue Scaleo Wong-Baker Faces Scaleo FLACC Scaleo Functional Activity Score

Side effects and Complications of

Opioid use

Respiratory• Apnoea• Respiratory Depression

Central Nervous System• Sedation (Primary indicator for

impending respiratory depression)

Gastrointestinal• Nausea and Vomiting• Decreased gut motility (constipation)

Genitourinary• Urinary Retention

Dermatological • Pruritus

Side effects and Complications of

Opioid use

Management of Respiratory Depression

and Sedation

• Administer Oxygen at 12lt/min via Hudson mask• Stop PCA / remove handset from the patient area• Alert APS team / medical officer immediately -

Consider MET call if there is no response• Prepare Naloxone ready for use• Maintain airway as necessary

Management of Apnoea

• Clear the airway and ventilate the patient using an air viva with 100% oxygen

• Check the pulse, if pulse is absent commence CPR

• Phone 999 for a CODE BLUE and notify them of location

• Stop PCA / remove handset from the patient area

• Administer Naloxone as ordered on APS chart

• Notify APS team

Naloxone

• Reversal agent used to treat opioid overdose

• Acts by blocking opioid receptors and therefore blocks the effect of opioids

• Should be carefully titrated to reverse the opioid related side effects, whilst retaining analgesic effects

• Repeated doses of Naloxone may be required

Naloxone

• Ampoules:Naloxone comes in 400mcg/1ml ampoules

• Preparation: 1ml Naloxone diluted with 3ml N/Saline (to a total of 4mls)

• Concentration: 400mcg / 4ml100mcg / 1ml

• Dose: 100mcg every 2 mins until response

Multi-modal Analgesia

Administration of additional analgesia is recommended for patients using PCA

Advantages: • Improves effectiveness of acute pain

management• May be Opioid sparing

Analgesic drugs that may be used in conjunction with PCA are:• Paracetamol• Tramadol• Non Steroidal Anti Inflammatory Drug

(NSAID)• Ketamine• Oxycodone (controlled release)

Multi-modal Analgesia

Opioids:Whilst a PCA is in use, NO additional opioids or sedatives via any other route should be given without prior consultation with the Acute Pain Service

This also includes the administration of Panadeine.

Multi-modal Analgesia

References

• Macintyre, P.E. & Ready, L. B. (2001) Acute Pain Management, a Practical Guide. 2nd Edition. W.B. Saunders

• Nursing Education & Research. (2003) Acute Pain Management Operational Guidelines, Southern Health

• Southern Health - PCA Clinical Protocols• Victorian Quality Council (2007). Acute Pain

Management Measurement Toolkit. Department Of Human Services

IHNA offers qualifications in aged care, disability and nursing. Go to http://www.ihna.edu.au to kick start your health career.

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