patient controlled analgesia: return to nursing program
DESCRIPTION
This presentation outlines how nurses can use Patient Controlled Analgesia (PCA) to benefit patients/clients. This presentation covers: 1. Indications and contraindications of PCA use 2. The advantages of PCA and 3. The pharmacological principles of pain management This presentation was compiled by Gulzar Malik, an experienced and qualified Nursing Educator at IHNA. For more information about our return to nursing programs, please call 1800 22 52 83.TRANSCRIPT
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Patient Controlled Analgesia
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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
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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
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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
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PCA
Patient Controlled Analgesia (PCA): A method of administering IV analgesia where by the patient initiates boluses of analgesic agents via a delivery system.
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Indications for use
• Moderate to Severe Pain that requires multiple doses of IV analgesia
• Acute Pain
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Contraindications
• Patients who are cognitively impaired
• Patients with limited understanding, confusion or disorientation
• Patients who are physically unable to push the button
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Advantages
• Patient autonomy• Improved patient satisfaction• Reduces nursing workload• Allows accurate evaluation of
analgesia
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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
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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.
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Pharmacological Principles of Pain
Management• Analgesic Corridor
Adapted from Macintyre and Ready (2001)
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Settings
The PCA machine can be programmed to deliver:• Patient Demands only• Patient Demands and a Continuous
background infusion • A Continuous infusion only
(occasionally)
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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
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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
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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
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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
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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
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Pre programmed protocols:– Acute Morphine– High Risk Morphine – Pethidine– Acute Fentanyl– Tramadol– Chronic Morphine– Chronic Fentanyl (PCA & Infusion) – Ketamine
Drug Concentrations
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Patient Assessment and Monitoring
Baseline observations including pain score and level of sedation should be performed and documented prior to the commencement of PCA.
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• 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
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• 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
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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
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Pain Assessment
• Accurate pain assessment is a fundamental
factor in providing effective pain management • Assessment should be both at rest and on
movement
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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
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Side effects and Complications of
Opioid use
Respiratory• Apnoea• Respiratory Depression
Central Nervous System• Sedation (Primary indicator for
impending respiratory depression)
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Gastrointestinal• Nausea and Vomiting• Decreased gut motility (constipation)
Genitourinary• Urinary Retention
Dermatological • Pruritus
Side effects and Complications of
Opioid use
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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
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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
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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
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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
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Multi-modal Analgesia
Administration of additional analgesia is recommended for patients using PCA
Advantages: • Improves effectiveness of acute pain
management• May be Opioid sparing
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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
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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
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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
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