PCA -PCA - Patient Controlled Patient Controlled

AnalgesiaAnalgesia

גורביץ בוריסגורביץ בוריס

חטיבת הרדמהחטיבת הרדמה

מרכז רפואי סורוקהמרכז רפואי סורוקה

In traditional pain management protocolsIn traditional pain management protocols, opioids are administered as , opioids are administered as fixed doses at fixed dose intervals or as a fixed-rate infusion; however, fixed doses at fixed dose intervals or as a fixed-rate infusion; however, this approach is less than ideal for managing pain. this approach is less than ideal for managing pain.

Patient-controlled analgesia (PCA)Patient-controlled analgesia (PCA) is a well tolerated and effective is a well tolerated and effective method of pain control, especially in the postoperative period.method of pain control, especially in the postoperative period.

PCA offers flexibility in dose size and dose interval in individual PCA offers flexibility in dose size and dose interval in individual patients.patients.

Patient satisfaction is high with PCA and pain relief is generally better Patient satisfaction is high with PCA and pain relief is generally better than with conventional therapy, particularly where there is appropriate than with conventional therapy, particularly where there is appropriate patient selection and education.patient selection and education.

Although it was initially thought that less opioid would be used with Although it was initially thought that less opioid would be used with PCA and that the length of hospital stay would be reduced, this has PCA and that the length of hospital stay would be reduced, this has not been confirmed.not been confirmed.

PATIENT CONTROLLED PATIENT CONTROLLED ANALGESIAANALGESIA

Form of systemic opioid therapyForm of systemic opioid therapy

Self administered frequent small Self administered frequent small doses - more closely matches doses - more closely matches the need of the patientthe need of the patient

PCA device : microprocessor-PCA device : microprocessor-controlled pumpcontrolled pump

Programming the dose, Programming the dose, intervals, max. dose per intervals, max. dose per

set time and basal rateset time and basal rate

BODY GUARDINFUSION PUMP

BASIC VARIABLES BASIC VARIABLES OF OF PCAPCA

LOADING DOSE - LOADING DOSE - מנת העמסהמנת העמסה

DEMAND DOSE - DEMAND DOSE - מנת דחקמנת דחק LOCKOUT INTERVAL - LOCKOUT INTERVAL - זמן נעילהזמן נעילה BACKGROUND INFUSION RATEBACKGROUND INFUSION RATE 1 -AND 4 -HOUR LIMITS1 -AND 4 -HOUR LIMITS

MORPHINEMORPHINE

CONCENTRATION - 1 MG / MLCONCENTRATION - 1 MG / ML CONTINUOUS INFUSION RATE -1 MG /MLCONTINUOUS INFUSION RATE -1 MG /ML LOCKOUT PERIOD - 10-15 MIN.LOCKOUT PERIOD - 10-15 MIN. BOLUS - 1 MLBOLUS - 1 ML

0

20

40

60

80

100

120

0 1 2 3 4 5 6 7 8

intramuscular

PCA

PCA or IMPCA or IM? ?

Select the patientSelect the patient

Not too old, too confused, too young …Not too old, too confused, too young … Mild to moderate painMild to moderate pain Short duration of painShort duration of pain Early postop. period - ?Early postop. period - ? Patient with PCAPatient with PCA not need pain treatment ?not need pain treatment ? Same side effects like systematically opioidsSame side effects like systematically opioids

PCAPCA

MORPHINE 1 MG / MLMORPHINE 1 MG / ML

FENTANYL 10 FENTANYL 10 G/ML G/ML

HYDROMORPHONE 0.2 MG/ML HYDROMORPHONE 0.2 MG/ML

PETHIDINE 5 -10 MG/MLPETHIDINE 5 -10 MG/ML

FeatureMorphinePethidine (meperidine)Fentanyl

Usual PCA regimen (demand dose; lockout time):a

   IV1mg; 5minb10-20mgb;NA 20-40µg; 1-10minb

   IM5mg; 20min--

   SC1mg; 10min--

   EDNA;NA-5µg; 2min

   IN--25µg; 6minc

Time of relative onset (min):

   single IV bolus662

   single IM dose2017NA

tmax (min):

   single IV bolus19134

   single IM dose4830NA

Duration of effect (min):

   single IV bolus96207

   single IM dose11039NA

Approximate clinically equivalent IV bolus dose (mg)101000.1

Clearance (L/min)110.6

IM absorption half-life (min)7.710NA

PCA - PCA - INSTRUCTIONSINSTRUCTIONS

NO SYSTEMIC NARCOTICSNO SYSTEMIC NARCOTICS OR OTHER CNS OR OTHER CNS DEPRESSANTS TO BE GIVEN EXCEPT AS DEPRESSANTS TO BE GIVEN EXCEPT AS ORDERED BY THE ACUTE PAIN SERVICE.ORDERED BY THE ACUTE PAIN SERVICE.

NO OTHER INFUSIONSNO OTHER INFUSIONS OR MEDICINE MAY BE OR MEDICINE MAY BE GIVEN THROUGH THE PCA CONNECTED - IV GIVEN THROUGH THE PCA CONNECTED - IV

ACCESS ROUTE.ACCESS ROUTE.

PCA NOT TO BE DISCONTINUED EXCEPT BY PCA NOT TO BE DISCONTINUED EXCEPT BY ACUTE PAIN SERVICEACUTE PAIN SERVICE

Patient-controlled analgesia Patient-controlled analgesia updateupdate

Clinical bottom line

Patient-controlled analgesia with opioid produces modest improvement in pain relief compared to the same opioid given conventionally. Patients preferred it, and there were no more or fewer adverse events reported.

B Walder et al. Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain. Acta Anaesthesiologica Scandinavica 2001 45: 795-804.

Painful conditions and techniques for which Painful conditions and techniques for which patientpatient--controlled analgesia has been usedcontrolled analgesia has been used

Postoperative painPostoperative pain Cancer painCancer pain Painful medical conditionsPainful medical conditions: : sicklesickle--cell crisiscell crisis acute pancreatitisacute pancreatitis LabourLabour Oocyte pickup for assisted reproduction Oocyte pickup for assisted reproduction

techniquestechniques

Analgesic requirements variableAnalgesic requirements variable

There are a number of reasons why patientsThere are a number of reasons why patients differ in their opioid requirements:differ in their opioid requirements:

differing degree of painful stimulusdiffering degree of painful stimulus

variability in opioid kinetics in the bloodvariability in opioid kinetics in the blood

variability in the kinetics of CNS uptake of opioidsvariability in the kinetics of CNS uptake of opioids

variability in the number and distribution of opioidvariability in the number and distribution of opioid receptors within the CNSreceptors within the CNS

differences in patients' perception of and attitude to their paindifferences in patients' perception of and attitude to their pain

accuracy of the infusion device.accuracy of the infusion device.

Device may be simple or complexDevice may be simple or complex

A PCA device : a pump with reservoir of drug, and a handset that A PCA device : a pump with reservoir of drug, and a handset that administers a dose of drug when activated by the patient.administers a dose of drug when activated by the patient.

This may be a This may be a microprocessor-controlled systemmicroprocessor-controlled system, able to implement , able to implement complex instructions programmed by the prescriber and keep a record complex instructions programmed by the prescriber and keep a record of the patient-device interactions, or it may be a of the patient-device interactions, or it may be a simple disposable pumpsimple disposable pump powered by mechanical means such as a spring or an elastomeric drug powered by mechanical means such as a spring or an elastomeric drug reservoir.reservoir.

A `smart pump',A `smart pump', where an infusion is given at a rate proportional to the where an infusion is given at a rate proportional to the number of demands made by the patient, has been suggested but only number of demands made by the patient, has been suggested but only a small number of patients have used the system to date. a small number of patients have used the system to date. Such systems Such systems take some of the control away from the patient.take some of the control away from the patient.

As As patient control is considered to be fundamentalpatient control is considered to be fundamental to the safety of PCA, to the safety of PCA, the safety of all systems that give the patient opioid additional to that the safety of all systems that give the patient opioid additional to that requested needs to be carefully evaluated.requested needs to be carefully evaluated.

General principlesGeneral principles No benefit from complex dosage regimensNo benefit from complex dosage regimens

. . . . . . or from background infusionsor from background infusions

The clinician decides which drug to use and the size of each The clinician decides which drug to use and the size of each dose, while the patient determines the timing of the dosesdose, while the patient determines the timing of the doses

Lockout interval must be appropriateLockout interval must be appropriate

Determining appropriate demand dose size Determining appropriate demand dose size

Loading with analgesic Loading with analgesic

Loading doseLoading dose

The loading dose accelerates attainment of an effective blood level of the opioid at the initiation of therapy.

Since there is marked inter-patient variability in the amount of analgesic required for pain relief, the loading doses must be titrated to effect.

Many studies have demonstrated a five-fold variability in the quality of IV opioid required to produce equivalent analgesia after surgery.

The loading dose should be repeated every 5 -10 minutes so that the effect of the dose is felt before the next dose is administered.

Loading doseLoading dose

The size of the loading dose is influenced by: The size of the loading dose is influenced by:

Lean body weightLean body weight

(Male: 50+2.3 x Ht.(in.)-60; Female: 45.5 +2.3 x Ht(in.)-60) (Male: 50+2.3 x Ht.(in.)-60; Female: 45.5 +2.3 x Ht(in.)-60)

Age (>65 years dose decreased by 25%) Age (>65 years dose decreased by 25%)

Physical status (dose decreased by 25-50% in debilitated patients) Physical status (dose decreased by 25-50% in debilitated patients)

Opioid tolerance (increase the dose 25-50%) Opioid tolerance (increase the dose 25-50%)

If the initial 3 to 4 loading doses are ineffective, the loading dose can be If the initial 3 to 4 loading doses are ineffective, the loading dose can be increased by 25-50% after an appropriate assessment of the patient's increased by 25-50% after an appropriate assessment of the patient's pain level and the side effects of the opioid (primarily sedation). pain level and the side effects of the opioid (primarily sedation).

Problems with PCAProblems with PCA

The risk of serious adverse events associated The risk of serious adverse events associated

with PCA is low. with PCA is low.

The risk is increased when the patient's degree of control over The risk is increased when the patient's degree of control over drug administration is reduced, such as when a background drug administration is reduced, such as when a background infusion is added.infusion is added.

There are a number of reports every year of patients put at risk There are a number of reports every year of patients put at risk by mistakes made by staff when initiating PCA.by mistakes made by staff when initiating PCA.

Risk of respiratory depressionRisk of respiratory depression

•• background infusions background infusions

•• PCA use in the elderlyPCA use in the elderly •• concomitant sedative medications concomitant sedative medications

•• a large demand dose with a short lockout a large demand dose with a short lockout interval.interval.

Sedation and Respiratory Depression

The first action should be to administer oxygen, followed by the addition or adjustment of drug !

If sedation score = 3 and respiratory rate = 10: Administer oxygen and halve the size of the PCA dose

If sedation score = 3 and respiratory rate <10: STOP PCA, obtain Naloxone 0.4 mg/10cc 0.9% NS and inject 1-2 cc q. 1-2 minutes until patient is back to his or her normal baseline (titrate to effect) and offer nonopioid analgesic

For children who are somnolent, difficult to arouse, or have a RR less than the age-appropriate baseline as noted on pediatric order sheet, STOP PCA and call primary service. Naxolone dose for reversal of respiratory depression with pediatric patients is 2 -5 mcg/kg, repeated q. 2 - 3 minutes (titrate to effect).

Take precautions against Take precautions against medication errorsmedication errors! !

Problems do arise from staff errors. Problems do arise from staff errors. Continuous staff training is advised, and staff should be Continuous staff training is advised, and staff should be

present whenever the PCA programme is changed.present whenever the PCA programme is changed.

PCA manufacturers have responded to these concerns PCA manufacturers have responded to these concerns by producing systems that can be customised to by producing systems that can be customised to default default to the settings that are generally usedto the settings that are generally used at any particular at any particular hospital thus minimising staff programming errors.hospital thus minimising staff programming errors.

Accidental overdoses have been reported, usually Accidental overdoses have been reported, usually where the where the patients or visitors mistook the PCA push patients or visitors mistook the PCA push buttonbutton for the nurse call button, or where the patient's for the nurse call button, or where the patient's spouse took controlspouse took control of the PCA handset. of the PCA handset.

AssessmentAssessment The timing for assessment of the efficacy of pain relief is The timing for assessment of the efficacy of pain relief is

dependent upon the situation.dependent upon the situation.

If the patient is in severe pain requiring upward titration of If the patient is in severe pain requiring upward titration of analgesics, pain assessment should be completed analgesics, pain assessment should be completed frequently (e.g., every 15 minutes). frequently (e.g., every 15 minutes).

In general, pain should be assessed approximately 15-30 In general, pain should be assessed approximately 15-30 minutes after administering parenteral medication and 60 minutes after administering parenteral medication and 60 minutes after administering oral medication.minutes after administering oral medication.

During the initial 24-hour postoperative period, pain During the initial 24-hour postoperative period, pain should be assessed at least every 2 to 4 hours.should be assessed at least every 2 to 4 hours. If pain is If pain is well controlled, the pain intensity should be assessed well controlled, the pain intensity should be assessed routinely with vital signs.routinely with vital signs.

Modify treatment to achieve Modify treatment to achieve effective pain control with effective pain control with

minimal harm and side effects.minimal harm and side effects.

Nausea/VomitingNausea/Vomiting

•• Evaluation of postoperative nausea is to ensure stable vital Evaluation of postoperative nausea is to ensure stable vital signs and adequate control of painsigns and adequate control of pain. .

•• Unfortunately, opioids stimulate nausea and may require Unfortunately, opioids stimulate nausea and may require treatment (Cohen et al., 1992; Wang, 1996; gan et al., 1998; treatment (Cohen et al., 1992; Wang, 1996; gan et al., 1998; Chung et al., 1999) or alteration of pain therapy to allow the Chung et al., 1999) or alteration of pain therapy to allow the patient to be nausea free with pain controlpatient to be nausea free with pain control. .

•• Because of high incidence of nausea, prophylactic antiemetic Because of high incidence of nausea, prophylactic antiemetic therapy is often given (Chen et al., 1996; Pitkanen et al., 1997; therapy is often given (Chen et al., 1996; Pitkanen et al., 1997; Helmy, 1999; Gan et al., 1997Helmy, 1999; Gan et al., 1997((

•• The choice of antinausea agent is driven by patient factors and The choice of antinausea agent is driven by patient factors and prior antinausea therapy. For example, if a dopamine antagonist prior antinausea therapy. For example, if a dopamine antagonist was given for nausea earlier, the addition of a serotonin was given for nausea earlier, the addition of a serotonin antagonist may be more helpful than a second dopamine antagonist may be more helpful than a second dopamine antagonistantagonist..

Lethargy/Sedation/Respiratory Lethargy/Sedation/Respiratory DepressionDepression

Evaluation is paramount to treatment of sedation. Evaluation is paramount to treatment of sedation.

Respiratory depression secondary to opiates is preceded by Respiratory depression secondary to opiates is preceded by lethargy and sedation; treatment is the same for this side effect. lethargy and sedation; treatment is the same for this side effect.

After causes of sedation other than analgesics have been After causes of sedation other than analgesics have been addressed, adjusting the selected pain therapy is required addressed, adjusting the selected pain therapy is required (Kenady et al., 1992; Eriksson-Mjoberg et al., 1997; Passchier et (Kenady et al., 1992; Eriksson-Mjoberg et al., 1997; Passchier et al., 1993). al., 1993).

If significant overdose of analgesics is suspected, use of reversal If significant overdose of analgesics is suspected, use of reversal agents is indicated (naloxone 0.4 mg intramuscular/intravenous). If agents is indicated (naloxone 0.4 mg intramuscular/intravenous). If respiratory depression persists, this dose may need to be repeated respiratory depression persists, this dose may need to be repeated

and other causes considered.and other causes considered.

Itching/PruritisItching/Pruritis

Once allergic reactions have been ruled out, Once allergic reactions have been ruled out, treatment of pruritis in the presence of appropriate treatment of pruritis in the presence of appropriate opioid therapy is with antihistamines and opioid opioid therapy is with antihistamines and opioid antagonists (Cohen et al., 1992; Gan et al., 1997). antagonists (Cohen et al., 1992; Gan et al., 1997).

With regional analgesia techniques, it may be With regional analgesia techniques, it may be possible to eliminate the opioid component.possible to eliminate the opioid component.

Numbness/WeaknessNumbness/Weakness

Numbness is not associated with analgesics other than local Numbness is not associated with analgesics other than local anesthetics and the cause should be sought. anesthetics and the cause should be sought.

Numbness in the affected area in the presence of regional Numbness in the affected area in the presence of regional analgesia should be evaluated (possible subarachnoid hematoma, analgesia should be evaluated (possible subarachnoid hematoma, abscess) and the dose adjusted. abscess) and the dose adjusted.

Weakness can be seen with analgesics usually in conjunction with Weakness can be seen with analgesics usually in conjunction with other signs of relative overdose. other signs of relative overdose.

Weakness seen with regional techniques should be minimized to Weakness seen with regional techniques should be minimized to allow for ambulation with assistance if desired.allow for ambulation with assistance if desired.

Myoclonus/SeizuresMyoclonus/Seizures

Seizure-like activity in the postoperative setting should Seizure-like activity in the postoperative setting should be evaluated and treated.be evaluated and treated.

Some opioids, meperidine in particular, are associated Some opioids, meperidine in particular, are associated

with seizures and myoclonus. with seizures and myoclonus.

While very high doses of local anesthetics can cause While very high doses of local anesthetics can cause seizures, this is unlikely in the postoperative setting seizures, this is unlikely in the postoperative setting unless a large amount is actually given.unless a large amount is actually given.

HallucinationsHallucinations

Hallucinations in the postoperative patient can Hallucinations in the postoperative patient can be due to a variety of causes including be due to a variety of causes including change in surroundings, sleep deprivation and change in surroundings, sleep deprivation and intraoperative medications (H2 blockers, intraoperative medications (H2 blockers, anticholinergics, opiates). anticholinergics, opiates).

Evaluations of hallucinations are often Evaluations of hallucinations are often decided by "trial and error" techniques.decided by "trial and error" techniques.

DysphoriaDysphoria

Postoperative dysphoria is unsettling to the Postoperative dysphoria is unsettling to the patient and family and difficult to evaluate. patient and family and difficult to evaluate. Sometimes reassurance can be all that is Sometimes reassurance can be all that is needed, but it may also require changing of needed, but it may also require changing of pain management techniques. pain management techniques.

It is more common with mixed opioid It is more common with mixed opioid agonists/antagonists and antidopaminergic agonists/antagonists and antidopaminergic medications.medications.

Urinary RetentionUrinary Retention

Urinary retention is a common side effect Urinary retention is a common side effect of pharmacologic pain management and is of pharmacologic pain management and is more common after neuraxial dministrationmore common after neuraxial dministration

HypotensionHypotension

Hypotension due to systemic analgesics is rare and is Hypotension due to systemic analgesics is rare and is likely due to hypovolemia and loss of sympathetic likely due to hypovolemia and loss of sympathetic drive with appropriate analgesia. drive with appropriate analgesia.

Hypotension from neuraxial opioids alone is unlikely. Hypotension from neuraxial opioids alone is unlikely.

Hypotension with regional analgesia techniques is Hypotension with regional analgesia techniques is common and treated by replenishing fluids and common and treated by replenishing fluids and altering the local anesthetic dose. altering the local anesthetic dose.

Short term therapy can be accomplished with Short term therapy can be accomplished with vasopressors until the above can be addressed.vasopressors until the above can be addressed.

MonitoringMonitoring! !

BPBPHRHRVASVASSedationSedation

ScoreScore

RespResp

RateRate

SpOSpO22MotorMotor

BlockBlock

InsertInsert

SiteSite

33 hh33 hh33 hh11 hh11 hh11 hh33 hh2424 hh

All PatientsAll Patients Patients on OpiatesPatients on Opiates EpiduralsEpidurals

מצבי חירוםמצבי חירום

ומעלה ומעלה33רמת ערנות רמת ערנות

-ממ"ק ממ"ק100100ל.ד. סיסטולי מתחת ל- ל.ד. סיסטולי מתחת ל

-בדקה בדקה1010קצב נשימות מתחת ל- קצב נשימות מתחת ל

-עם חמצן עם חמצן92%92%סטוראציה פחות מ- סטוראציה פחות מ

SEDATION SCALESEDATION SCALE--

דרגות ערנותדרגות ערנות

0 0 - - FULLY AWAKE FULLY AWAKE ער לגמריער לגמרי

11 - - MILD SEDATION MILD SEDATION ישן לסירוגיןישן לסירוגין

22 - SEDATED BUT AROUSABLE - SEDATED BUT AROUSABLE

רב הזמןרב הזמן ישנוני, מגיב לפקודות ישנוני, מגיב לפקודות

33 - DEEP SEDATION, NOT RESPONDING - DEEP SEDATION, NOT RESPONDING

ישן וקשה להעירוישן וקשה להעירו

44 - NOT RESPONDING - NOT RESPONDING לא ניתן להעירולא ניתן להעירו

אומדן כאב יזום ע"י המטפלאומדן כאב יזום ע"י המטפל טיפול סביב השעון טיפול סביב השעון שילוב תרופות שילוב תרופות מתן מתן RESCUERESCUE לכאב מתפרץ לכאב מתפרץשיטות טיפול מגוונות שיטות טיפול מגוונות ניטור שיטתי לזיהוי וטיפול בתופעות לוואי ניטור שיטתי לזיהוי וטיפול בתופעות לוואי טיפול בשיטות לא מכאיבות טיפול בשיטות לא מכאיבות

הבטחת שיכוך כאבים בבית הבטחת שיכוך כאבים בבית

עקרונות טיפול איכותי