PATIENT

CONTROLLED
ANALGESIA
Presenter: Dr Aishwarya Raj
Moderator: Dr Meena Vijayaraghavan
◦ Patient-Controlled Analgesia (PCA) has been utilized to optimize pain relief since
1971, with the first commercially available PCA pump appearing in 1976.

◦ Goal- to efficiently deliver pain relief at a patient's preferred dose and schedule by
allowing them to administer a predetermined bolus dose of medication on-demand
at the press of a button.

◦ PCA is used to treat acute, chronic, postoperative, and labor pain.

◦ Administered intravenously, epidurally, through a peripheral nerve catheter, or
transdermally.

◦ Drugs commonly administered are opioids and local anesthetics, but dissociatives
or other analgesics are also options.

◦ More effective at pain control than non-patient opioid injections and results in
higher patient satisfaction
INDICATIONS
1. For acute pain

-Useful in the acute pain setting where there is inadequate pain control from the
initial opioid administration in the emergency department, and continued opioid
dosing has been proven to improve patient outcomes.

-Common examples are vaso-occlusive pain crisis, trauma, pancreatitis, or

burns.
2. Patients with chronic illnesses who are suffering from lower levels of constant
chronic pain
- The most common examples are metastatic cancer, phantom limb
syndrome, and complex regional pain syndrome.

3.­Patients in labor pain

- The pain associated with contractions, especially when exacerbated by induction
agents such as oxytocin, can be adequately reduced and controlled by the patient.
4. Post-surgical patients, especially those with indwelling nerve or epidural
catheters
-Ability of a post-surgical patient to titrate and administer their own pain
medication allows for superior pain control to scheduled nursing dosing.
CONTRAINDICATIONS
Absolute contraindications:
• The patient is unable to understand the concept behind PCA
• Systemic infection, or infections at the preferred site of PCA placement
• Allergic reactions to the selected medication
• Burns or trauma on the area of PCA placement
• Preexisting neural deficits in the area of a planned indwelling nerve catheter
• Increased ICP for epidural catheter placement
Relative contraindications:
• Chronic renal failure
• The patient is on antithrombotic therapy
• The patient has a documented bleeding disorder
• Sleep apnea
EQUIPMENT
A. Routes:
◦ The route for PCA administration can be through an intravenous catheter, epidural
catheter, indwelling nerve catheter, or an iontophoretic transdermal system.

B. Pumps:
◦ Locking device, medication chamber, programming screen, and patient button.
◦ A provider will insert a syringe of medication into the pump and program the
pump to the prescribed initial loading dose, PCA dose, lockout interval,
continuous infusion rate, and one and four-hour limits. For intravenous PCA, the
medication line then gets connected to a fluid infusion line.
1. Disposable PCA devices:
◦ Typically deliver 0.5 ml with each patient demand, take about 6 min for the
patient-control module to refill from a reservoir, and deliver no more than 0.5 ml
every 6 min, should the demand button be depressed continuously.

◦ Efficacy and side effects may be comparable with the electronic devices.

◦ However, as the device delivers a Fixed volume with each demand, the amount of
drug delivered in each bolus can only be altered by changing the concentration of
drug in the reservoir.

◦ In addition, the opioid in the reservoir is much more easily accessible than that in
locked electronic infusion devices.
2. Electronic PCA devices
◦ Allow more flexibility in the timing and amount of dose delivered.
◦ They can also be programmed to deliver a constant background infusion.
◦ They are designed to be `tamper proof', so that access to the drug without
using the key is impossible, at least unless the pump is damaged in the attempt
C. Medications:
◦ Opioids : used alone for intravenous PCA or in conjunction with local anesthetics
for epidural catheter PCA.
i) Pure Mu opioid receptor agonists (morphine, fentanyl, hydromorphone,
meperidine, sufentanil, alfentanil, and remifentanil)
ii) Mu opioid receptor agonist-antagonists (butorphanol, nalbuphine, pentazocine)
iii) partial Mu opioid receptor agonists (buprenorphine, dezocine)

- Morphine remains the gold standard medication for intravenous PCA.

◦ Local anesthetics are primarily used for epidural catheter and indwelling nerve
catheter PCA.

◦ Bupivacaine, levobupivacaine, and ropivacaine.

◦ Other medications like ketamine, naloxone, clonidine, magnesium, ketorolac,

lidocaine, and droperidol can be added to intravenous PCA in an attempt to
reduce side effects and improve pain control.
PREPARATION
◦ A pre-procedure cognitive assessment ensures the patient has the mental capacity
to participate in PCA and can understand the concepts of dosing, interval, lockout,
and expected pain relief.

◦ Whether the patient is opioid naive will determine the initial dosing, titration, and
expected pain relief and side effects.

◦ Periodic pain assessments using the numerical pain rating scale to create a baseline
before PCA begins and to track its efficacy throughout treatment.
◦ A sedation assessment should also take place before the procedure begins and
periodically throughout.

◦ A respiration assessment of the rate, depth, effort, and sound of breaths should be
performed to establish a patient baseline and to monitor the effects of the
medications during treatment.

◦ Before the administration of PCA through a peripheral nerve catheter or an

epidural catheter, a neurological exam assessing for pain sensation, light touch
sensation, and motor function over the targeted dermatomes and myotomes require
assessment
TECHNIQUE
◦ The initial loading dose can be titrated by a nurse to reach the minimum effective
concentration (MEC) of the desired medication.

◦ The bolus or demand dose is the dose of medication delivered each time the
patient presses the button.

◦ A lockout interval is the time after a demand dose in which a dose of medication
will not get administered even if the patient presses the button; this is done to
prevent overdosing.
◦ A continuous infusion rate can be used in the background of PCA dosing to
maintain the MEC of the medication independent of patient demands.

◦ One and four-hour limits put a cap on the maximum allowed amount of
medication to be administered within those time periods and are usually less than
the dose given if the patient were to press the dosing button at every possible
interval.
COMPLICATIONS
◦ Common side effects and complications of PCA relate to the inherent mechanism
of the procedure and the medications involved.

◦ Complications of PCA pumps include “run-away” pumps, failure to use anti-reflux

valves, incorrect syringe placement, PCA by proxy, and machine tampering.

◦ Runaway pumps are a result of a mechanical error in which a pump malfunctions

and delivers doses at incorrect intervals and amounts. This error can lead to a
potentially fatal overdose.
◦ Anti-reflux valves prevent the opioid medication from flowing up into the
intravenous fluid infusion line.

◦ Failure to use an anti-reflux valve can result in refluxed medication into the fluid
infusion line.

◦ This medication could then all be delivered to the patient at once if the intravenous
line is flushed, resulting in an overdose.
◦ If the syringe containing the medication is damaged or incorrectly placed into the
PCA machine, it could potentially empty by gravity and administer the entire
syringe of medication to the patient at once.

◦ To prevent this from happening, lines should be cross-clamped when changing the
syringe, and machines should be kept level to or below the intravenous catheter in
the patient. Some devices are even equipped with anti-siphon valves to prevent
this complication.
◦ PCA by proxy is when someone besides the patient is pressing the button to
administer a dose because they believe the patient is in pain and needs it.

◦ This phenomenon has been documented to lead to respiratory depression.

◦ To prevent tampering with PCA pumps, access to the medication and

programming portion of the pump should only be permitted by a health care
provider who has a key or code to the pump.

◦ Devices should be routinely checked to make sure there has been no

compromise to their locking mechanisms.
◦ Complications of epidural and indwelling nerve catheter PCA include infection,
catheter dislodgement, medication leakage, skin irritation, allergic reaction, and
short and long term nerve damage.

◦ Side effects of PCA administration can be related to the medications or the

delivery device used and include nausea and vomiting, constipation, urinary
retention, pruritus, respiratory depression, and local anesthetic toxicity
References:
◦ https://www.ncbi.nlm.nih.gov/books/NBK551610/#article-26754.s16
Pastino A, Lakra A. Patient-Controlled Analgesia. [Updated 2023 Jan 29]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2023

◦ Miller’s Anaesthesia 9th Edition