Patient Controlled Analgesia : How to applied safely to patient ?

A.M.TAKDIR MUSBA

DEPARTMENT OF ANESTHESIOLOGY, INTENSIVE CARE AND PAIN MANAGEMENT FACULTY OF MEDICINE, HASANUDDIN UNIVERSITY MAKASSAR-INONESIA

INTRODUCTIONFirst developed as a research toolFirst introduce in UK, 1976The continuing popularity of PCA

Basic Principle“ when I feel pain, I press a

button”PCA involve the on demand,

intermittent self – administration of a predetermined dose of analgesic ( usually an opioid ) by a patient

Intravenous, Epidural, s.c., Intranasal

P atien t exp erien c es e ffec t o f d ru g

D ru g works

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P atien t exp erien c es p a in

Principle Concept

Good pain relief?

Wait!

Yes No

Cutting the time waitingPatient has Pain

Sedation

Analgesia

Absorption fromInjection Site

Injection Given

Prepare Injection

Calls Nurse

Nurse Responds

“Screening”

Sign out ofMedications

PCA

X

EFFICACY OF PCA1. Intravenous opioid PCA provides better

analgesia than conventional parenteral opioid regimens (Level I evidence )

2. Patient preference for iv PCA is higher when compared with conventional regimens (Level I evidence )

3. There is little evidence that one opioid via PCA is superior to another with regards to analgesic or adverse effects in general (Level II evidence)

Acute Pain Management: Scientific Evidence, 3rd edition, ANZCA, 2010

Indication for PCAMajor operations and NPOContraindication to Epidural

AnalgesiaMarked incident painCancer Pain Strongly motivated and

appropriately educated for use PCA

PAIN Vs ANALGESIC

Why Opioid Intravenous PCA ?

Opioid analgesics are the cornerstone of treatment for postoperative pain

FK / FD opioids suitable for PCAOpioid phenomenon : analgesia occur at

lower dose than does sedationIntravenous patient controlled analgesia

(IV PCA) is a preferred route of administration ◦established efficacy◦sense of empowerment given the patient◦quick delivery and subsequent onset of pain relief

OPIOID : Titrated to reach MEAC and maintain constant plasma concentration

Grass, JA., Anesth Analg 2005;101:S44–S61

PCA “ Not just a pump “PCA has many advantages But …. Narrow therapeutic index of

opioids Potential for human error serious safety issues that

increase treatment costs and limit use, while also compromising quality of careMeissner B. et al . Hospital Pharmacy, 2009, Volume 44,pp 312–324

FACTOR AFFECTING SAFETY

Macintyre P.E., British Journal of Anesthesia, 2001, 87(1)

PCA SAFETY

PATIENT FACTORS

EQUIPMENT FACTORS

MEDICAL AND NURSING STAFF

1. PATIENT FACTORSPATIENT’S AGEPSYCHOLOGICAL

CHARACTERISTICSCONCURRENT DISORDERSOPIOID-TOLERANT PATIENTSINAPPROPRIATE USE OF PCA

Macintyre P.E., British Journal of Anesthesia, 2001, 87(1)

2. EQUIPMENT FACTORSDISPOSABLE PCA DEVICES Vs

ELECTRONIC PCA DEVICES◦Efficacy and side effect may be

comparable◦Disposable delivers a fixed volume ◦Electronic more flexible in timing and

doseRecommended that one type /

one model of PCA pump is used throughout the organization to reduce PCA medication errors

Macintyre P.E., British Journal of Anesthesia, 2001, 87(1) San Diego Patient Safety Taskforce ,PCA Guidelines of Care, 2008

3. MEDICAL AND NURSING STAFF FACTORS

OPERATORS ERROR◦Incorrect programming ◦Incorrect checking procedures

THE LEVEL OF KNOWLEDGE NURSING AND MEDICAL STAFF

Nurses, can be a significantbarrier to errors

Learn to use the PCA pumps in facility and maintain proficiency

Accept only PCA orders writtenAbility to enter a prescription into a PCA

pump regularlyDevelop a list of patients who are good

PCA candidatesAnother nurse independently check

when initiate PCAGood monitoring

D’Arcy Ivonne, www.Nursing2008.com |

Nurse training

THE PCA PRESCRIPTIONS by Anesthesiologist

Bolus dose Lockout intervalLoading doseBackground infusionDose limit

PCA order example Drug : FentanylSolution Normal SalineConcentration 10 microgram/mlBolus dose 10 microgramLockout 6 minutes

• Drug : Morphine Sulphate• Solution Normal Saline• Concentration 1mg/ml • Bolus dose 1 mg• Lockout 8 minutes• Background nil

One of the standard from San Diego Patient Safety Taskforce : PCA Guidelines of Care

Weber LM; Ghafoor VL; Phelps P. Implementation of standard order sets for patient-controlled analgesia. Am J Health Syst Pharm. 2008 Jun 15; Vol. 65 (12),pp.1184-91.Pasero C, IV opioid range orders for acute pain management. AJN. February2007. Vol. 107, No. 2, pp.52-59.Gammaitoni AR, Fine P, Alvarez N, McPherson ML, Bergmark S. Clinical application of opioid equianalgesic data. The Clinical Journal of Pain 2003. 19: pp.286–297. Lippincott Williams & Wilkins, Inc., Philadelphia.

Opioid analgesics used in IV PCAopioids Drug conc.

( mg/ml )Bolus dose( mg )

Lockout interval ( min )

Background infusion rate ( mg/hr ) *

fentanyl 0.01 0.01-0.02 5-10 0.02 – 0.1hydromorphone

0.2 0.1 – 0.5 5 - 10 0.2 – 0.5

meperidine 10 5-15 5-12 5-40morphine 1 0.5 - 3 5-12 1-10oxymorphone 0.25 0.2-0.4 8-10 0.1-1.0

Little evidence suggest major differences of efficacy and side effects between opioids

PCA form

Some suggestion for safety ( ISMP ) Institute for Safe Medication PracticeAssess vulnerability to serious

errorsLimit concentrationsDistinguish custom

concentrationsClarify the labelMatch the Medical Record to the

labelEmploy an independent double-

checkISMP. Misprogramming PCA concentration leads to dosing errors. August 28, 2008 issue. www.ismp.org/d/SpecialFollowUp.pdf

Physician-Patient Alliance for Health & Safety

TAKE HOME MESSAGE PCA is neither “ one size fits all “

or a “ set and forget “ therapy

An Anesthesiologist style ………. no fixed dose of drug fits all

patient make patient analgesia and take care

Etches RC. Surg Clin North Am. 1999, 79: 272-73

THANK YOU VERY MUCH FOR YOUR KIND ATTENTION