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Marks and Sachar: Undertreatment of medical

in-patients with narcotic analgesics.Ann. Int.

Med. 78:173-81.1973

73% of hospitalized patients showed

inadequate pain relief.

GOAL: Minimal effective analgesicconcentration.

(MEAC)


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Why ppl dont get adequate pain

relief:

Underestimated dosing range Overestimated duration of action

Exaggerated respiratory depression

Exaggerated addictions

Opioid concentrations exceed MEAC

only 35% of the time during any 4-hour

dosing intervalWHY?


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History

1968 Sechzar 1971 Keeri-Szanto

1976 Evans

1979 Tamsen

1982 Bennett


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PCA Defined

Any analgesic given by any route ofadministration; on immediate patient

demand in plentiful quantities

PCA pump-fail safe mechanism (so pt doesnt overdose)


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Routes of Administration

Epidural Subcutaneous

IV


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Modes of Administration

Demand dosing When pt feels pain they hit button and they get

opioid IV

Infusion-based systems Constant rate infusion + demand dosing

Get low background amount of opioid but if they

have breakthru (more) pain they can get moreopioid by hitting button


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PCA Terminology

Bolus (Loading Dose)

The cumulative amount of opioid used to initially make thepatient analgesic.

Demand Dose (PCA Dose)

Quantity of analgesic given to the patient by self-administration on the perception of need for additional

analgesia.

Delay Time (Lockout Interval)

The time interval during which the patient cannot initiateanother dose.


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PCA Terminology

Limit (1hr/4hr) Basal Rate (Background Infusion

Rate)


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Limit (1hr/4hr)

The maximum amount of medicationa patient can receive during a 1hr/4hr

time period.


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Basal Rate (Background Infusion

Rate)

The amount of medication infused/hour continuously by the PCA unit.


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The Ideal PCA Drug

Rapid onset Highly efficacious

Intermediate duration of action

Minimal tolerance & side effects

Ex. Morphine, dilatin, phentenol, demerol, etc.

*Cant discharge pt on PCA pump, you must get them off of it first withorals then discharge them


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Adult PCA Morphine

Recommendations

Bolus: 1-4mg Demand Dose: .5-2.5mg

Delay time: 6-12 minutes

4hr Limit: up to 35mg Basal Rate: 0-2mg/hr

Dont memorize doses


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Adult PCA Demerol

Recommendations

Bolus: 10-25mg Demand Dose: 5-20mg

Delay Time: 6-12 minutes

4hr Limit: up to 300mg Basal Rate: 5-20mg/hr

Dont memorize doses


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Patient Education

Explain the device Do not expect complete pain relief

Use as soon as you feel pain (nip it in butt)

Use the device prophylactically Minimize while awake; maximize prior to sleep


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Safety

Drug-related

There is no greater incidence of opioid-related side effects using PCA

vs. other routes of administration.

Mechanical-related

Mechanical-related problems are rare. Siphoningis the major

mechanical problem.

Morphine leaking and getting pts own infusion rate

Can lead to overdose

In 1987, the incidence of siphoning was 1.45 per 100,000.

User-related

The majority of PCA problems are user-related. No device is tamper-

proof.

Thus far, I hve found only one fatality associated with the use of PCA

(JAMA; 1988)


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Advantages of PCA

Rapid onset of analgesia Predictable clinical response

Less demand on nursing staff

Quicker discharge But make sure they are converted to

orals for pain not PCA since you cannot

discharge pts on PCA


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In Conclusion

Safe Cost-effective

Patient Compliant


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What Is It? IntraVenous

Regional

Anesthesia

LOCAL ANESTHETICS:

IVRA

1908 August Bier

AKA: Bier Block

Lost popularity untilthe 60s

Used in UE & LE

surgery

CLINICAL CORRELATIONSLECTURE


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IVRA

ADVANTAGES

Simple

Reliable

Rapid Return To Function Cost Effective

CONCERNS

Duration Of Surgery

Tourniquet Time

(dont put on fibular head b/

c compress common fibular

N)

LA (local anesthetic)

Toxicity


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Technique

Locals utilized include:

Lidocaine (most common, but shortest acting

drug)

Short procedure: using lidocaine okay. .3, .5,1cc etc.Dilute lidocaine with sterile saline helps.

Bupivacaine

Risk of cardiac arrest

Ropivacaine

Derivative of bupivacaine

Less chance of cardiac arrest/depression

Prilocaine


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Technique

IV contralateral limb

Butterfly in injured limb; in foot for venous access

Prepare LA (local anesthetic)

Two tourniquets applied distal to fibular head

Exsanguinate the limb

Inflate proximal tourniquet

Inject LA through your access

If tourniquet pain, inflate distal TQ, then release proximalTQ

How long?

If short procedure, then LA may not have bound to enough tissueand lead to cardiac depression, etc.

If too long, damage from TQ and pain. Perhaps compartmentsyndrome

Adj t T IVRA


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Adjuncts To IVRA

Opiods

Muscle Relaxants

NSAIDs

Clonidine

Potassium

Alkalizing Agents

Opiods and mm. relaxants are the more commonly utilized,and have been the more studied

Opiods include morphine, fentanyl, meperidine, andsufentanil

Muscle relaxants include pancuronium, atracurium,

mivacurium , and cisatracurium

Use adjuncts so you can use less local (leads away from toxicity


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Some Conclusions

Which LA is best?

Are adjuncts useful?

WHICH LA IS BEST?How quicly to they lose sensation

Lido, bupiv, prilo equal to onsetWhen do they get sensation back? Longer acting anesthetics lead to longer

time before sensing backLidocain and robivucaine are equal in preventing TQ pain

Post-op anelgesis in PACU: Longer acting anesthetic. Robivicaine (longer

acting)ARE ADJUNCTS USEFUL?

Dont need as much LA, but may take longer to get anelgesia before starting

procedure.LA by itself does job. No necessarily need other adjuncts.

ROPIVICAINE IS BEST OF ALL LA.

Fi ll S C li ti


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Finally, Some Complications

Seizures

Cardiac Arrest & Death

Incomplete Anesthesia Injection Pain

Tourniquet Pain

-(60MIN is magic number, most LA bound to tissue and lesspain)

Compartment Syndrome

Neuro Damage

Dysphoria, Dizziness, Facial Tingling

Mistakenly Deflating Cuff

Injecting Wrong Drug

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