Patient Controlled Analgesia

Aka: Patient Controlled Analgesia, PCA Pump, PCA Pump Settings

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II. 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

III. Contraindications

  1. Inadequate capacity or mental status to understand pump use
  2. High risk for respiratory depression (e.g. severe Sleep Apnea)

IV. 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

V. 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)

VI. 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

VII. 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

VIII. 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

IX. 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

X. 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

XI. 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

XII. 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

XIII. Management: Step 5: Convert from Morphine to other Opioid

  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)

XIV. 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

XV. 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]

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Related Studies

Ontology: Patient-Controlled Analgesia (C0078944)

Definition (NCI) A method of intravenous narcotic analgesic delivery that uses a pump or similar delivery system that allows the patient, or in the absence of the patient's ability to do so the patient's nurse or family members, to administer predetermined doses of analgesic as needed to maintain adequate pain control. This method allows the patient and/or family to have increased autonomy. Further, research has shown improved pain control and reductions in narcotics necessary to maintain pain control to be associated with this delivery method.
Definition (NCI_NCI-GLOSS) A method of pain relief in which the patient controls the amount of pain medicine that is used. When pain relief is needed, the person can receive a preset dose of pain medicine by pressing a button on a computerized pump that is connected to a small tube in the body.
Definition (MSH) Relief of PAIN, without loss of CONSCIOUSNESS, through ANALGESIC AGENTS administered by the patients. It has been used successfully to control POSTOPERATIVE PAIN, during OBSTETRIC LABOR, after BURNS, and in TERMINAL CARE. The choice of agent, dose, and lockout interval greatly influence effectiveness. The potential for overdose can be minimized by combining small bolus doses with a mandatory interval between successive doses (lockout interval).
Concepts Therapeutic or Preventive Procedure (T061)
MSH D016058
SnomedCT 241716000
English Analgesia, Patient Controlled, Analgesia, Patient-Controlled, PCA - Pt controlled analgesia, analgesia controlled patient, patient controlled analgesia, Patient Controlled Analgesia, Patient-controlled analgesia, patient-controlled analgesia, Patient controlled analgesia, PCA - Patient controlled analgesia, Patient controlled analgesia (procedure), PCA, IV PCA, Intravenous Patient-Controlled Analgesia, Patient-Controlled Analgesia
Swedish Smärtlindring, patientstyrd
Finnish Potilaan säätelemä kivunlievitys
Russian ANALGEZIIA, KONTROLIRUEMAIA BOL'NYM, АНАЛГЕЗИЯ, КОНТРОЛИРУЕМАЯ БОЛЬНЫМ
Japanese 自己鎮痛法, 無痛法-自己, 自己無痛法, 鎮痛法-自己
French Analgésie auto-contrôlée, Analgésie contrôlée par le patient, AAC (Analgésie Autocontrôlée), ACP (Analgésie Contrôlée par le Patient), Analgésie autocontrôlée
Polish Podawanie środków przeciwbólowych samodzielnie przez pacjenta, Analgezja kontrolowana przez pacjenta, Znieczulenie kontrolowane przez pacjenta
Czech pacientem kontrolovaná analgezie, pacientem řízená analgezie, samoobslužná anestezie, analgézie řízená pacientem
Norwegian Pasientstyrt smertelindring, Pasientstyrt analgesi, Pasientkontrollert smertebehandling
Spanish analgesia controlada por el paciente (procedimiento), analgesia controlada por el paciente, Analgesia Controlada por el Paciente
German Analgesie, patientengesteuerte, Patientengesteuerte Analgesie
Italian Analgesia controllata dal paziente
Dutch Analgesie, patiëntgecontroleerde, Analgesie, patiëntgestuurde, Patiëntgecontroleerde analgesie
Portuguese Analgesia Controlada pelo Paciente
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Intravenous analgesia unit (C0181331)

Definition (UMD) Infusion pumps that are designed to deliver a predetermined amount of analgesic drug on demand, i.e., when requested Infusion pumps designed to deliver a predetermined amount of analgesic drug on demand (i.e., when requested by the patient) as well as delivering continuous pain control. To prevent tampering or diversion, PCA pumps typically offer a method of securing the controls and medication container, which is connected to a proprietary administration set. The administration set tubing is connected to an intravenous catheter or other infusion device (e.g., epidural catheter, subcutaneous injection/infusion port). Typically, PCA pumps are programmed to deliver in any one of the following modes: demand dose, demand dose plus continuous infusion, or continuous infusion only; the pumps can also be programmed to deliver one-time doses (i.e., bolus or loading doses). PCA pumps are designed with specific safeguards that restrict the amount of drug that can be requested and delivered over a specific period of time (e.g., 1 mg of drug every 6 minutes for a total of 10 mg per hour). PCA pumps allow narcotic analgesics (e.g., morphine, meperidine, hydromorphone) and fentanyl to be administered as needed by the patient while keeping the amount within the prescribed limits and preventing unauthorized access to the medication. The software inherent in the PCA pump is typically capable of storing cumulative data regarding number of doses delivered, date/time of each dose delivered, number of requests received, and total volume of drug delivered. PCA pumps are intended for patient control of pain by permitting self-administration of analgesics (i.e., patient-controlled analgesic pumps) within pre-established limits; they are typically mounted on poles or used on tabletops but dedicated ambulatory pumps are also available.
Definition (SPN) An infusion pump is a device used in a health care facility to pump fluids into a patient in a controlled manner. The device may use a piston pump, a roller pump, or a peristaltic pump and may be powered electrically or mechanically. The device may also operate using a constant force to propel the fluid through a narrow tube which determines the flow rate. The device may include means to detect a fault condition, such as air in, or blockage of, the infusion line and to activate an alarm.
Concepts Medical Device (T074)
SnomedCT 73571002
HL7 PCA
English PUMP, INFUSION, PCA, PCA Pumps, Patient-Controlled Analgesia Units, Infusion Pumps, Demand Analgesia, Intravenous analgesia unit, device, pca pumps, pca pump, Infusion Pumps, Patient-Controlled Analgesic, Intrathecal Analgesia Units, Epidural Analgesia Units, Infusion Pumps, Analgesic, Patient-Controlled, Analgesic Infusion Pumps, Patient-Controlled, Analgesia Units, Intravenous, Intravenous analgesia unit, Patient controlled analgesic infusion pump, Intravenous analgesia unit, device (physical object), PCA Pump
Spanish bomba de infusión analgésica controlada por el paciente, unidad para analgesia intravenosa (objeto físico), unidad para analgesia intravenosa
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: narcotics patient controlled anesthesia (PCA) settings (C2224190)

Concepts Therapeutic or Preventive Procedure (T061)
English narcotics PCA settings, narcotics patient controlled anesthesia (PCA) settings, narcotics patient controlled anesthesia (PCA) settings (medication)
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Analgesic Medications

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