PATIENT-CONTROLLED ANALGESIA:
A REVIEW OF EFFECTIVENESS OF THERAPY AND
AN EVALUATION OF CURRENTLY AVAILABLE DEVICES
Robert P. Rapp, Brack A. Bivins, Robert A. Littrell, and Thomas S. Foster
ABSTRACf: Patient-controlled analgesia (PCA) is a major advance in
the management of pain in postoperative and cancer patients. The
success of PCA has resulted in a proliferation of marketed devices to
administer small bolus doses of parenteral pain-control drugs at fixed
intervalscontrolled by the patient with the push of a button. Because
patientsdemonstrate marked individual variation in pain medication
requirements, PCA devices should be able to accommodate rapidly
changing requirementsfor drugs with a minimum amount of effort on
behalf of health care personnel. Crude electronicdevices were
developedin the late 1960sand the early 1970sand usually consisted
of a syringe pump connected to some sort of timing device. Most
modem PCA devices marketed in the past five years are much more
sophisticated devices that are microprocessorbased and some newer
devices even generate hard copy for a permanent record of drug
administration. Although many such devices are available(includinga
totallydisposable PCA device), few have undergone extensiveclinical
evaluation. A review of the literature shows many devices are
available for use without a single publicationto document the safety
and utility of the device in the routine patient care situation. Use of
the PCA method of pain control will grow, and all hospital-based
healthcare personnel should become familiar with their use and
limitations.
D1CP 1989;23:899-904.
PATIENT-CONTROLLED ANALGESIA (PCA) is recognized as a
major advance in the management of pain for a wide variety
of clinical problems. I PCA employs an infusion pump inte-
grated with a timing device that allows patients to self-
administer small doses of narcotics intravenously. Using a
PCA device, a patient may self-administer an analgesic
when pain is perceived and experience a virtually immedi-
ate analgesic effect. The dose and frequency for the anal-
gesic are controlled to prescribed limits by the settings of
the device. In a large number of clinical studies, PCA has
been shown to be a safe, effective, and economical means
of managing pain. 2
As the concept of PCA has been validated, there has
been a proliferaton of marketed devices. The data in sup-
port of these devices are highly variable. The purpose of
ROBERT P. RAPP, !'harm.D., is a Professor and the Chairman, Divisionof Pharmacy
Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
40536:BRACK A. BIVINS, M.D.• is the Director. Divisionof Traumaand Emergency
Surgery. Henry Ford Medical Center, Detroit. MI; ROBERT A. LITTRELL,
!'harm.D.• isa PainManagementPharmacist,University Hospital,Departmentof Phar-
macy Central Supply, Lexington. KY; and 11I0MAS S. FOSTER, !'harm.D., is a
Imfessor and the Director, Caller for Pharmaceutical Science and ThchnoIogy. CoUege of
Pharmacy. University of Kentucky, Lexington, KY.ReprInts: RobertP. Rapp,!'harm.D.
DICP, The AnnaLs of Pharmacotherapy • 1989November, VoLume 23 •
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this article is to review the data in support of the effective-
ness of PCA and to evaluate the currently available PCA
devices.
Pain and Traditional Narcaic Administration
The principal impetus for the development of PCA has
been the failure of traditional techniques, primarily the pro
intramuscular administraton of narcotic analgesics, to ade-
quately manage pain. The effective management of pain
has long been a major clinical challenge despite the avail-
ability and use of potent narcotic analgesics. Patients dem-
onstrate marked variability in analgesic requirements,
dosing intervals, and tolerance to adverse effects. In the
acute setting, traditional pro intramuscular narcotics have
been inappropriately dosed a large proportion of the
time.r" Marks and Sachar found that 73 percent of inpa-
tients receiving an average of 90 mg/d of im meperidine had
severe or moderate distress." Similarly, Cohen found 75
percent of postoperative patients treated with standard im
narcotics to be in marked or moderate distress. 5 Such stud-
ies also have found that with traditional pro medication
administration techniques patients are often underdosed at
times of peak pain and overdosed to sedation when pain is
less severe. 3-5
Many factors contribute to the inadequacy of postopera-
tive analgesia. The treatment of postoperative pain has
most frequently used an every four to six hour schedule of
im medications given at the discretion of the nursing staff
on a pro basis.v' This process involves the pain cycle
(Figure I) as described by Graves et al." and includes
problems such as: (I) the potential for significant delays
between the perception of pain and the administration of
pain medication, (2) the high variability in absorption with
im analgesics and a narrow effective range of serum levels,
(3) the minimum serum concentration of drug to achieve
analgesia is exceeded for only 35 percent of the dosing
interval, and (4) peak concentrations of analgesic may vary
as much as fivefold in patients given the same im doses at
the same dosing interval.
Research has emphasized the importance of pain man-
agement." For example, the fear of pain may lead to
delays in seeking care. In the postoperative period inade-
quately controlled pain may lead to decreased ambulation
and poor pulmonary toilet. Other problems with pain man-
899
agement center on the attitudes of medical personnel. The
antiquated notion that to suffer pain is in some way benefi-
cial should not be part of any medical or nursing plan in the
1980s. Similarly, the fear of narcotic addiction, proven to
be unfounded in the management of acute pain, should not
govern analgesic regimens. Angell stated that "in no other
area of medicine has such an extravagant concern for side
effects so drastically limited treatment. "10 In modern clini-
cal practice the adequate control of pain should be a goal
achieved through communication and cooperation among
all health professionals. 11
The PeA Concept
Given the problems associated with traditional im nar-
cotic administration, a system such as PCA, which allows
for individual variation in analgesic requirements, should
be accepted by both medical personnel and patients. The
concept of small, bolus doses of narcotics as an analgesic
technique has been present for over 25 years. In 1963 Roe
demonstrated that small iv doses of analgesics gave more
effective pain relief than im doses. Unfortunately, the man-
ually administered iv bolus system had several negative
aspects, including a very short duration of pain relief with
small doses and an unacceptably high incidence of seda-
tion, respiratory depression, nausea, and vomiting with
higher doses." Using a manual administration system
monitored by a "nurse observer," Sechzer noted in 1968
that small doses of iv analgesics were effective. However,
he also found that patient variations in dose requirements
were cyclic and inconsistent. 13 Even if these early systems
had been completely acceptable clinically, the nursing time
required by the manual infusion techniques would be pro-
hibitive in today's financially controlled hospital environ-
ment and would be further limited by the nursing shortage
affecting most areas of the U.S.
The early studies of intermittent bolus dosing of anal-
gesics hinted at the potential of PCA. The rapid progress in
microprocessor electronics in hospital infusion control
equipment of the 1970s allowed the medical electronics
industry to design specific devices for administration of
small iv doses of analgesics. With these devices incorporat-
ing safeguards against overinfusion, excess sedation, and
respiratory depression, analgesic administration could be
controlled in most cases by the patient. 14
The first electronic PCA devices were developed in the
late 1960s and early 1970s. These devices were rather crude
by today's standards and consisted of a syringe pump con-
nected to a timing device. The patient activated the syringe
pump by depressing a hand-held button connected to a
timing and lockout device.9.1s-18
Today, there are a number of electronic PCA devices on
the market as well as a recently introduced nonelectronic
device that uses manually applied power rather than electri-
cal line power to deliver the bolus of medication. Table I
lists the major characteristics of PCA devices presently
available in the U.S. Many of these devices have additional
capability including the administration of bolus loading
dose, the infusion of a baseline dose of drug together with a
demand bolus dose, storage of patient data for various time
periods, and the generation of hard copy of patient data for
nursing records in addition to small prn bolus doses."
There also are a number of research/clinical projects that
have evaluated the use of home PCA devices designed
900 • DICP, The Annals of Pharmacotherapy •
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~ patient has pain
sedation
~
call nurse
relief of pain
r \
nurse responds
f
absorption from site
l
nurse screens
J
"
injection given sign out medication
prepare injection
Figure I. Conventional pain therapy cycle.
especially for patients with terminal cancer pain that require
increasing doses of analgesics. 19,20
Therapeutic EjJicQ£Y
In a prospective, randomized trial, Bennett et al. com-
pared PCA morphine sulfate with morphine sulfate 8-12
mg im q4-6h prn. Patients in the PCA group maintained a
state of adequate analgesia without sedation compared with
the im group, who exhibited more sedation between 6 a.m.
and 10 p.m. The PCA group showed greater sedation dur-
ing regular sleeping hours. Patients and nursing staff were
more satisfied with PCA-administered morphine. Only in
the PCA group were patients able to meet the wide varia-
tion seen in the amount of morphine required." Numerous
studies have verified the high level of patient satisfaction
seen in PCA-administered analgesics.P-" A comparative
trial of nursing-controlled continuous infusion morphine
(i.e., the nurse increased the infusion rate when the patient
complained of pain and decreased the rate when the patient
seemed to be sedated) versus regularly scheduled im mor-
phine given q4h demonstrated an improvement in postop-
erative pulmonary function in the continuous infusion
group." Other investigators have shown better pulmo-
nary function in patients using PCA compared with stan-
dard im prn regimens." Two studies have shown that, in
spite of better analgesia in the patients receiving PCA, the
total dose of morphine required is less than that in patients
receiving im drugs. 27 ,28 Other studies, however, have not
demonstrated similar findings but still find a high level of
patient satisfaction when PCA is used. 24,29 Graves et al.
demonstrated a diurnal morphine dosing rhythm in mor-
bidly obese patients undergoing gastric bypass. Peak mor-
phine use occurred at 9 a.m. and was lowest at 3 p.m. This
difference was statistically significant and was postulated to
be related to the diurnal variation in adrenocorticotropic
hormone and pituitary secretion of beta-endorphins. Adap-
tation of drug dosing to drug diurnal requirements could be
accomplished only with the PCA system of administra-
tion."
The risk of clinically significant adverse effects associ-
ated with PCA appears to be quite low. Initial fears of
respiratory depression with commonly used doses of ago-
nist narcotic analgesics have been shown to be unfounded.
Patients undergoing many different types of major surgery
have had consistently normal arterial blood gases with
PCA use in the postoperative period.t'-" Respiratory
1989 November, Volume 23
 Patient-Controlled Analgesia

mechanics have also been shown to remain normal in clini-
cal trials with PCA.33.34
PCA also may offer some advantages in terms of com-
plications of narcotic adverse effects." Narcotics can pro-
duce a variety of adverse effects including nausea,
sedation, respiratory depression, and pruritus. Narcotic
addiction and/or withdrawal in patients being treated for
acute pain develops rarely and does not appear to be a
clinically significant problem.
One narcotic adverse effect that appears to be related to
administration technique is pruritus, which is particularly
bothersome in patients receiving epidural narcotics. In a
randomized trial comparing epidural PCA and im mor-
phine, Eisenach et al. found that 85 percent of patients
treated with epidural morphine complained of pruritus and
40 percent required treatment with systemic medications
for relief of symptoms. Pruritus was significantly less in
both the PCA and im morphine groups.v Another com-
parative trial has shown similar results. 37
The main concerns with patient safety with PCA appear
to be associated with operator error." White reported two
cases in which overdoses of PCA-administered narcotics
occurred. The first case involved a programming error and
the second involved the inadvertent administration of a
bolus dose of sufentaniI. 38 Errors of this type are best
avoided by conducting rigorous nursing inservice educa-
tion programs and by insuring that personnel follow written
hospital procedures in all phases of set up. One report of a
patient's death from what may have been a pump malfunc-
tion has been published." The patient's family and
friends must be instructed not to "push the button" for the
patient. In our experience, family interference (albeit well
intentioned) with the pain control cycle has resulted in
additional narcotic administration to a comfortable or
sleeping patient. This may obviously cause adverse effects
with PCA therapy. Routine cleaning and sound mainte-
nance of the PCA control device are necessary to ensure
that mechanical malfunctions are minimal as with any
patient care microprocessor-based equipment. Since PCA
systems usually are connected to a peripheral catheter,
problems associated with the catheter will influence the
success of pain management. The outpatient use of PCA by
the subcutaneous route has been reported; this would over-
come the problems associated with maintaining an indwell-
ing venous catheter. 40
PeA Devices
Many PCA devices are now commercially available and
use a variety of different technologies to store and adminis-
ter small bolus doses of the drug. Most devices use a
syringe system with a "screw driven" motor to depress the
plunger of the syringe. The motor is interfaced with the

Table 1. Characteristics of PCA Devices Available in the U.S.

LOCKOUT
PREALLED SECURITY INTERVAL
DEVICE NAME FUNCTIONS BOLUS SYRINGE SYSTEM RANGE

Abbott Lifecare PeA volume yes; key 5-99 min

Infusor 1821 30 mL
Abbott Lifecare PeNcontinuous mg yes; key 5-99 min
Infusor 4100 PeNcontinuous 30 mL
Bard PeA mg or no; yes 3-240 min
Ambulatory continuous volume 100 or
PeA PeNcontinuous 250 mL
reservoir
Baxter PeA PeA fixed use with optional 6 min
System* volume Baxter pole fixed
Infusor; mount
not prefilled
Becton Dickinson PeA mg yes; key 5-99 min
PeA Infusor continuous IMS prefilled
PeNcontinuous 30 mL
Graseby PeA PeA mg no; key 3-40 min
System continuous B.D. disp
PeNcontinuous 60 mL
Harvard PeA PeNcontinuous volume yes; key 3-60 min
Pump 6464-00 I PeNcontinuous 50 mL
MiniMedPeA PeA volume no; case 0-799 min
Device-404-S continuous 3 mLdisp locks
PeNcontinuous syringe
Pancretec PeA mg or no; key I min-
Provider-5ooo continuous volume use with 50- 200 h
PeNcontinuous 3000 mL iv
bag
Pharmacia PeA mg no; key 5-199 min
Deltec-Model continuous use with
5200 PXC PeNcontinuous medication
cassette
Stratofuse PeA volume yes; key 5-60 min
PeA PSM-9000 continuous IMS prefilled
PeNcontinuous 30 mL
*Includes Baxter Infusor (5 mUh) and patient-control module.

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1989 November, Volume 23 • 901
microprocessor for programming and for safety alarms.
Pumps manufactured by Abbott, Bard, Becton Dickinson,
Graseby, Strato, and MiniMed use this technology. Other
devices connect directly to standard iv plastic containers
(Pancretec) or use disposable cassettes (Pharmacia, Deltec
BARD Ambulatory). Baxter markets a disposable PCA
mechanical device known as the patient-control module,
which must be used with the Baxter Infusor, a 50-mL
elastomer balloon enclosed in a rigid frame. The safety and
utility of each marketed device should be verified through
appropriate clinical trials and by vigorous in vitro evalua-
tion such as conducted by the nonprofit agency, the Emer-
gency Care Research Institute (ECRI). A recent issue of
Health Devices. published by ECRI, evaluates the available
PCA devices in the U.S.14 This report is an extremely
valuable reference for hospitals interested in beginning a
PCA program.
Clinical Documentation ofPCA Devices
ABBOTI' LABORATORIES LIFECARE PeA INFUSOR
The Abbott PCA Infusor was one of the first micro-
processor-based infusion control devices to gain clinical
acceptance in the U.S. and has the largest published clinical
use experience. This device is preset on physicians' orders
for dose volume (volume per patient-activated infusion in
milliliters) and lockout interval (minutes between doses).
Any combination that totals more than 20 mLth is not
allowed. The dose and lockout setting are displayed on the
face of the device. An alarm sounds if an attempt is made to
tamper with the cover that locks and secures the controls,
the analgesic vial, or the drive mechanism. A visual display
indicates the total volume delivered since last cleared and
set. Touch switches activate display of the number of com-
pleted patient dose requests and the maximum preset four-
hour volume. The device can be operated on battery power
or AC current. To initiate an infusion, the patient activates a
hand-held button similar to a standard nurse call button.
This device uses a dedicated glass syringe that can be
purchased prefilled or empty. The cartridge or syringe of
drug and all switches are located behind a panel door that
locks. The lock also prevents removal of the unit from the iv
pole. Clinical documentation of the use and safety of the
Abbott device has been fairly extensive.
Citron et al. used the Abbott device in patients with
severe pain from terminal cancer. At the completion of the
study, all eight patients expressed satisfaction with the unit
and five patients preferred the PCA mode of therapy over
conventional narcotic therapy." Harrison et al. used the
Abbott PCA device in a comparative trial of PCA, epi-
dural, and im morphine. Pain relief was superior in the
PCA group of patients compared with the im group. Addi-
tionally, patient's PCA satisfaction was better and adverse
effects less when compared with the epidural group. 31
Another evaluation of the Abbott PCA Infusor was done by
Baumann et al. in 18 postoperative or trauma patients. Pain
relief was excellent and the investigators found the device
was easily integrated into the clinical environment with
only minimal nursing training and supervision required. 41
Several other clinical trials have been published.Pr" in-
cluding a multicenter trial of 102 patients demonstrating the
clinical documentation of the Abbott device."
Abbott Laboratories has recently introduced the Lifecare
PCA 4100 Infusor. This unit uses the same prefilled
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syringes but offers the continuous infusion mode or the
continuous infusion plus bolus dose mode of operation in
addition to the standard PCA mode. The unit is pro-
grammed in milligrams and concentration is entered in
mg/mL instead of volume, a feature throught to be desir-
able by the Health Devices group." An additional feature
of the new Abbott device includes computer-prompted pro-
gramming and a system that double-checks the dose and
infusion rate. This new unit will probably replace the older
Abbott device over the next several years.
BARD HARVARD PeA INFUSOR
This unit uses either standard 60-mL disposable syringes
or 50-mL prefilled glass syringes. The syringe is placed in
a slot secured by a locked plastic cover. All programming is
done in volumetric units, and all three modes of operation
can be selected (i.e., PCA, PCA/continuous, or continuous
infusion only). Owen et al. conducted a laboratory and
clinical comparison of the Bard PCA Infusor and the On
Demand Analgesia Computer (ODAC-Janssen Scientific).
Both devices performed satisfactorily in the comparative
trial. 46
Wermeling et al. used the Bard Instrument in 25
postoperative patients, the majority of whom underwent
total abdominal hysterectomy. Pain control was managed
with butorphanol. The device performed in a satisfactory
manner in all 25 patients, but 4 had insufficient pain relief
with butorphanol and were switched to PCA morphine."
From an administrative and drug-control standpoint, the
use of drugs such as butorphanol, which do not fall under
the Drug Enforcement Administration Schedule II cate-
gory, is desirable. Paperwork by nursing and pharmacy
personnel would be reduced, as would the theoretical pos-
sibility of illegal drug diversion. However, the utility of
agonist/antagonist drugs in relieving the most serious
postoperative pain remains to be proven by future compara-
tive trials with PCA morphine sulfate. An additional case
study using the Bard PCA Infusor to give PCA high-dose
morphine to a burn patient has been published."
BAXTER PeA INFUSOR WITH PATIENT-CONTROL MODULE
The Baxter unit consists of two separate entities that
must be used together to perform PCA. The infusor is an
elastomer balloon device that is breech-filled with up to 50
mL of the narcotic solution (usually morphine sulfate 2
mg/mL). The 5 mLth infusor delivers 0.5 mL every six
minutes. Constant mechanical pressure is generated by the
elastomer balloon and an outflow restrictor. The set from
the infusor is connected to the patient control module
(PCM) which contains a 0.5-mL bladder. The bladder,
therefore, fills in six minutes. When the bladder is filled the
infusor no longer flows. Depression of the button on the
PCM results in discharge into the iv line. Also, the flow rate
is constant at 0.5 mLt6 min, no more than 5 mL of solution
can be delivered in a one-hour period regardless of how
often the patient depresses the button. Because the flow rate
control is governed by the restrictor, changes in the tem-
perature of the solution or in viscosity can alter the accuracy
of the flow rate. Also, the rate of infusion is fixed so
changes in dose per injection require preparation of a new
infusor with a concentraton equivalent to twice the new
dose per injection. Drug use by the patient is estimated by
visual examination of the volume left in the device. Also, a
1989 November. Volume 23

history of patient attempts versus actual injections is
unavailable. A separate plastic case that can secure the
infusor to the bed rail can be purchased. The entire device is
disposable.
Wermeling et al. evaluated the Baxter device in 50
postoperative patients. Pain relief was satisfactory in about
90 percent of patients although the drug concentration had
to be changed in 18.8 percent of patients (10 of 53) to obtain
pain relief." Since a new infusor must be prepared by the
pharmacy when a dose change is required, this must be
considered in evaluating the Baxter PCA system against the
electronic devices. For example, a 24-hour pharmacy
admixture service may be a necessary feature to handle
dosing changes when the disposable system is considered.
Gallion et aI. provided PCA with the disposable device to
20 patients undergoing abdominal hysterectomy. The
device was effective in controlling pain and well accepted
by the patients. so
GRASEBY PeAS PUMP
The Graseby PCA System (PCAS) is the modern ver-
sion of one of the first PCA prototype devices known as the
Cardiff Palliator. Although not known well in the U.S.,
extensive clinical documentation has been published in the
United Kingdom and New Zealand. 17 ,18,Sl-S3 The Graseby
unit will accept a 6O-mL disposable syringe and is pro-
grammed in milligrams. No prefilled syringes are avail-
able. To achieve security for the narcotic syringe container
a separate syringe hood must be acquired; otherwise, the
syringe is not tamperproof.
OTHER DEVICES
There are at least six other PCA devices currently being
marketed, including Becton Dickinson PCA Infusor, Strato
Stratofuse PCA, Pancretec Provider 5000, Pharmacia
Deltec CADD-PCA Pump, MiniMed PCA Pump, and the
Bard Ambulatory PCA Pump. Unfortunately, for these six
PCA devices, no clinical documentation of their safety and
effectiveness is available. However, information about
these devices is available in the ECRI report" and a recent
review of high technology infusion devices is also an addi-
tional source of information. 54
Summary
PCA appears to be, at present, the best way to meet the
variable needs of patients experiencing moderate to severe
pain. Traditional im pain management does not achieve the
success shown with PCA and, in many cases, the patient is
either underdosed or oversedated. The PCA concept allows
the patient to be an active participant in pain management.
PCA has gained widespread acceptance among physicians,
nurses, pharmacists, and administrators as an effective
approach to pain control in many clinical settings.
The future will bring a multitude of new, probably better,
more sophisticated devices as PCA gains increasing clini-
cal acceptance. It is hoped that this will lead to the optimal
management of pain in the clinical setting.s>
References
I. BENNETI RL, BAUMANN rr, BATENHORST RL, et aI. Morphinetitration
in postoperative laparatomypatientsusingpatient-eontrolled analgesia.
Curr Ther Res 1982;32:45-52.
DICP. The Annals of Pharmacotherapy
Downloaded from aop.sagepub.com at The University of Iowa Libraries on June 9, 2015
Patient-ControUedAnalgesia
2. MCKENNA TR, BRANIGAN TA,SORACKE AH. Phannacy-initiated intro-
duction of patient-controlled analgesiato a 400-bed communityhospi-
tal, Am J Hosp Pharm 1989;46:291-4.
3. SRIWATANAKUl K, WEIS OF, ALlOZA n, et aI. Analysis of narcotic
analgesic usage in the treatment of postoperative pain. .b\MA 1983;
250:926-9.
4. MARKS RM, SACHAR fJ. Undertreatment of medical inpatients with
narcotic analgesics. Ann Intern Med 1973;78:173-81.
5. COHEN FL. Postsurgical pain relief: patient's status and nurses' medica-
tion choices, Pain 1980;9:265-74.
6. UTTLINGJE, SMITH JM. Postoperative analgesia. Anaesthesia 1979;
34:320-32.
7. HUGCC Jr. Improvinganalgesictherapy. Anesthesiology 1980;53:441-3.
8. GRAVES DA, FOSTER TS, BATENHORST RL, et aI. Patient-controlled
analgesia. Ann Intern Med 1983;99:360-6.
9. EVANS 1M, ROSEN M, MACCARTHY J, HOGGMil. Apparatusfor patient-
controlledadministration of intravenous narcoticsduring labor. Lancet
1976;/:17-8.
10. ANGEll M. The quality of mercy. N Engl J Med 1982;306:98-9.
II. Panel cites need for improved pain-management. Clin Pharm 1986;
5:777-8.
12. ROE BB. Are postoperative narcotics necessary? Arch Surg 1963;
87:912-5.
13. SECHZER PH. Objective measurement of pain. Anesthesiology 1968;
29:209-10.
14. Patient-controlled analgesic infusion pumps. Health Devices 1988;
17:136-67.
15. SCHZER PH. Studies in pain with the analgesic-demand system. Anesth
Analg 1971;50:1-10.
16. KEERJ-SZANTO M. Apparatusfor demand analgesia. CanAnaesthSocJ
1971; 18:581-2.
17. HARMER M, SLATTERY OJ, ROSEN M, VICKERS MD. Comparison
between buprenorphine and pentazocine given iv on demand in the
control of postoperative pain. Br J Anaesth 1983;55:21-4.
18. GIBBS JM, JOHNSON HD, DAVIS FM. Patient administration of iv
buprenorphine for post-operative pain relief using the "Cardiff"
demand analgesia apparatus. Br J Anaesth 1982;54:278-84.
19. CITRON ML, JOHNSTON-EARLY A, BOYER M, et aI. Patient-eontrolled
analgesia for severe cancer pain. Arch Intern Med 1986;146:134-6.
20. TWYCROSS RG, FAIRFIELD S. Pain in far-advanced cancer. Pain 1982;
14:303-10.
21. BENNETI RL, BATENHORST RL, BIVINS BA, et aI. Patient-controlled
analgesia-a newconceptof postoperative pain relief. AnnSurg 1982;
195:700-5.
22. DAHLlB, DAUSAARD JJ,LARSEN HY, et aI. Patient-controlled analgesia:
a controlled trial. Acta Anesthesiol Scand 1987;3/:744-7.
23. ALBERT JM, TALBOTITM. Patient-controlled analgesiavs conventional
intramuscular analgesia following colon surgery. Dis Colon Rectum
1988;3/:83-6.
24. BOlLISH SJ, COLLINS ci, KlRKINS DM, BARTLETI RH. Efficacy of
patient-controlled versus conventional analgesia for post-operative
pain. Clin Pharm 1985;4:48-52.
25. NAYMAN 1. Measurementand control of postoperative pain. Ann R Coli
Surg EngI1979;6/:419-26.
26. BENNETI RL, BATENHORST RL, FOSTER TS, et aI. Postoperative pul-
monary function with patient controlled analgesia (abstract). Anesth
Analg 1982;6:171.
27. KEERJ-SZANTO M, HEAMAN S, Postoperative demand analgesia. Surg
GynecolObstet 1972;/34:647-51.
28. KLUMAN RL, LIPMAN AG, HAREBD, MACDONALD SD. A comparison
of morphineadministeredby patient-controlled analgesiaand regularly
scheduled intramuscularinjection in severe postoperative pain. J Pain
Symp Manag 1988;3:15-22.
29. BENNETRL, BATENHORST RL, GRAVES D, et aI. Drug use pattern in
patient-controlled analgesia (abstract). Anesthesiology 1982;
57(suppl):A-21O.
30. GRAVES DA, BATENHORST RL, BENNETI RL, et. aI. Morphinerequire-
ments using patient-controlled analgesia: influenceof diurnal variation
and morbid obesity. Clin Pharm 1983;2:49-53.
31. WHITEDC, PEARCH OJ, NORMAN 1. Postoperative analgesia-a com-
parison of intravenous on-demandfentanylwith epidural bupivacaine.
Br Med J 1979;2:166-7.
32. TAMSEN A, HARTVIG P, FAGERLUND C, et aI. Patient controlled anal-
• 1989 November. Volume 23 • 903
 gesia therapy-clinical experience. Acta Anaesth Scand 1982;74:
157-60.
33. ROSENBERT PH, HEINOR A,SCHEININ B.Comparison of intramuscular
analgesia, intercostal block, epidural morphine, and on-demand iv
fentanyl in the control of pain after upper abdominal surgery. Acta
Anaesthesiol Scand 1984;28:603-7.
34. WELeHEW EA. Ondemandanalgesia-a double-blind comparison ofon
demand intravenous fentanyl with regular intramuscular morphine.
Anaesthesia 1983;38:19-25.
35. WHITE PF. Use of patient-controlled analgesia for management of acute
pain. .b\MA 1988;259:243-7.
36. EISENACH JC,GRICE SC, DEWAN MD. Patient-controlled analgesia fol-
lowing cesareansection: a comparison withepidural andintramuscular
narcotics. Anesthesiology 1988;68:441-8.
37. HARRJSON OM, SINATRA R,MORGESE L,CHUNG JH. Epidural narcotics
and patient-controlled analgesia for post-cesarean section pain relief.
Anesthesiology 1988;34:454-7.
38. WHITE PF. Mishaps with patient-controlled analgesia. Anesthesiology
1987;66:81-3.
39. GREY Te, SWEENEY ES. Patient-controlled analgesia (letter). .b\MA
1988;259:2240.
40. KERR IG, LOVE M,DEANGEWS C, et aI. Continuous narcotic infusion
withpatient-controlled analgesia forchroniccancerpaininoutpatients.
Ann Intern Med 1988;108:544-7.
41. BAUMANN TJ, GUTSCHJ LM, BIVINS BA. The safety and efficacy of a
new patient-controlled analgesia device in hospitalized trauma and
surgerypatients. Henry Ford Hosp Med J 1986;34: 105-8.
42. REINES HD, BARBARASH RA. Patient-eontrolled analgesia for postoper-
ativepain. Postgrad Med 1986;(suppl):29-32.
43. HILL HF, SAEGER ic, CHAPMAN CR. Patient-controlled analgesia after
bone marrow transplantation for cancer. Postgrad Med 1986;
(suppl):33-40.
44. PATEL R, MCKENZIE R. Patient-controlled analgesia after cesarean sec-
tion. Postgrad Med 1986;(suppl):23-7.
45. VINIK HR, ANTON KE, BARBARASH RA, et aI. Patient-controlled anal-
gesia in hospitalized patients: a multicenter evaluation. PostgradMed
1986; (suppl):41-5.
46. OWEN H, GLAVIN RI, REEKlE RM, TREW AS. Patient-controlled anal-
gesia. Anesthesia 1986;4/:1230-5
47. WERMELING DP, FOSTER TS, FARRINGTON EA, et aI. Patient-controlled
analgesia usingbutorphanol forpostoperative painrelief: an open label
study. Acute Care 1986;12(suppl):31-9.
48. WERMELING DP, RECORD KE, FOSTER TS. Patient-controlled high-dose
morphine therapy in a patientwithelectrical bums. Clin Pharm 1986;
5:832-5.
49. WERMELING DP, FOSTER TS, RAPP RP, KENADY DE. Evaluation of a
disposable, nonelectronic patient-eontrolled analgesic devicefor post-
operative pain. Clin Pharm 1987;6:307-14.
50. GALLION HH, WERMELING DP, FOSTER TS, et aI. Patient-controlled
analgesia in gynecologic oncology. Gynecol-Oncol 1987;27:247-53.
51. CHAKRAVARTY K,TUCKER W, ROSEN M,VICKERS MD. Comparison of
buprenorphine and pethidine givenintravenously on demandto relieve
postoperative pain. Br Med J 1979;2:895-7.
52. BOHAR M,ROSEN M,VICKERS MD. Self-administered nalbuphine, mor-
phine and pethidine. Anaesthesia 1985;40:529-32.
53. KAY B, KRISHMAN A. On-demand nalbuphine for postoperative pain
relief. Acta Anaesthesiol Belg 1986;37:33-6.
904 • DICP, The Annals of Pharmacotherapy •
Downloaded from aop.sagepub.com at The University of Iowa Libraries on June 9, 2015
54. KWAN JW. High-technology iv infusion devices. AmJ Hosp Pharm 1989;
46:320-35.
EXTRACfO
La analgesia controlada por el paciente (PeA) es una nuev~ ..
modalidad de tratamiento de dolor. Este metodo de analgesia utiliza
una bomba de infusi6n integrada a un dispositivo de tiempo que
permite al paciente administrarse dosis. ~ueii~ de narc6t~cos por
la via intravenosa logrando aSI analgesia inmediata. La dosis y la
frecuencia de administraci6n del medicamento estan controladas
por lfrnites ya prescritos. En este articulo se ~visa I~ inf~~aci6n
que respalda la efectividad de PeA y se evalua los dispositivos de
PeA disponibles en los Estados Unidos (E.U.). EI riesgo de efectos
adversos cllnicamente significativos asociados aI uso de PeA es
bajo. Ofrece la ventaja de mejor control tanto del dolor como de los
siguientes efectos adversos de los narc6ticos: nauseas, sedaci6n,
depresi6n respiratoria, y pruritus. Los ~isposit~vos de PeA, .
disponibles en E. U. incluyen desde unidades SImples ~o ele~~lcas
hasta microprocesadores electr6nicos. La documentacion chmca
para los dispositivos es buena para algunos y para otros es
inexistente. La analgesia controlada por el paciente ha demostrado
ser una forma segura, efectiva, y econ6mica de manejar el dolor.
LESBIA HERNANDEZ
RESUME
L'analgesie controlee par Ie patient (ACP) s'avere une rnodalite
d'administration interessante dans Ie traitement de la douleur chez
les patients cancereux ou en periode post-operatoire, Avec Ie succes
de I'ACP, on observe I'apparition sur Ie marche de nombreux
appareils servant a administrer de faibles bolus de ",Iedicame.nts
analgesiques a intervalles fixes, controles par Ie patient a I'aide
d'un bouton-poussoir. Puisqu'il existe une grande variabilite inter-
patients en ce qui concerne les besoins en medication analgesique,
les appareils utilises pour I'ACP doivent pouvoir s'ajuster
facilement et rapidement a des doses variables de medicament. Des
appareils electroniques simples sont apparus sur Ie marche vers la
fin des annees 1960. Avec Ie debut des annees 1970, on a developpe
des "pousse-seringues" relies a un dispositif de min.utage. I..:~
majorite des appareils mis en rnarche au cours des cmq dermeres
annees sont beaucoup plus sophistiques et fonctionnent a I'aide
d'un microprocesseur; certains appareils peuvent rneme produire un
document ecrit pouvant servir de registre d'administration du
medicament. Bien que plusieurs appareils soient presenternent
disponibles, tres peu d'entre eux ont subi une evaluation c1inique
approfondie. Une revue de la litterature revele que plusieurs
appareils sont mis en rnarche sans qu'un seul article n'ait ete publie
concernant la securite et l'utilite de ce nouveau dispositif dans Ie
traitement des patients. L'utilisation de I'ACP comme moyen de
controle de la douleur va continuer de se developper; c'est pourquoi
tous les professionnels de la sante doivent devenir plus familiers
avec son utilisation et ses Iimites.
CLAUDE MAILHOT
1989 November, Volume 23