dr. Muh. Takdir - Patient Controlled Analgesia

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

1. 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

2. INTRODUCTION First developed as a research tool First introduce in UK, 1976 The continuing popularity of PCA

3. 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

4. Principle Concept Good pain relief? Wait! Yes No

5. Cutting the time waiting Patient has Pain Sedation Analgesia Absorption from Injection Site Injection Given Prepare Injection Calls Nurse Nurse Responds “Screening” Sign out of Medications PCA X

6. EFFICACY OF PCA Intravenous opioid PCA provides better analgesia than conventional parenteral opioid regimens ( Level I evidence ) Patient preference for iv PCA is higher when compared with conventional regimens ( Level I evidence ) 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, 3 rd edition, ANZCA, 2010

7. Indication for PCA Major operations and NPO Contraindication to Epidural Analgesia Marked incident pain Cancer Pain Strongly motivated and appropriately educated for use PCA

8. PAIN Vs ANALGESIC

9. Why Opioid Intravenous PCA ? Opioid analgesics are the cornerstone of treatment for postoperative pain FK / FD opioids suitable for PCA Opioid phenomenon : analgesia occur at lower dose than does sedation Intravenous 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

10. OPIOID : Titrated to reach MEAC and maintain constant plasma concentration Grass, JA., Anesth Analg 2005;101:S44–S61

11. 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 care Meissner B. et al . Hospital Pharmacy, 2009, Volume 44,pp 312–324

12. FACTOR AFFECTING SAFETY Macintyre P.E., British Journal of Anesthesia, 2001, 87(1) PCA SAFETY PATIENT FACTORS EQUIPMENT FACTORS MEDICAL AND NURSING STAFF

13. 1. PATIENT FACTORS PATIENT’S AGE PSYCHOLOGICAL CHARACTERISTICS CONCURRENT DISORDERS OPIOID-TOLERANT PATIENTS INAPPROPRIATE USE OF PCA Macintyre P.E., British Journal of Anesthesia, 2001, 87(1)

14. 2. EQUIPMENT FACTORS DISPOSABLE PCA DEVICES Vs ELECTRONIC PCA DEVICES Efficacy and side effect may be comparable Disposable delivers a fixed volume Electronic more flexible in timing and dose Recommended 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

15. 3. MEDICAL AND NURSING STAFF FACTORS OPERATORS ERROR Incorrect programming Incorrect checking procedures THE LEVEL OF KNOWLEDGE NURSING AND MEDICAL STAFF

16. Nurses, can be a significant barrier to errors Learn to use the PCA pumps in facility and maintain proficiency Accept only PCA orders written Ability to enter a prescription into a PCA pump regularly Develop a list of patients who are good PCA candidates Another nurse independently check when initiate PCA Good monitoring D’Arcy Ivonne , www.Nursing2008.com |

17. Nurse training

18. THE PCA PRESCRIPTIONS by Anesthesiologist Bolus dose Lockout interval Loading dose Background infusion Dose limit

19. PCA order example Drug : Fentanyl Solution Normal Saline Concentration 10 microgram/ml Bolus dose 10 microgram Lockout 6 minutes Drug : Morphine Sulphate Solution Normal Saline Concentration 1mg/ml Bolus dose 1 mg Lockout 8 minutes Background nil

20. 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.

21. Opioid analgesics used in IV PCA opioids 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 – 0.1 hydromorphone 0.2 0.1 – 0.5 5 - 10 0.2 – 0.5 meperidine 10 5-15 5-12 5-40 morphine 1 0.5 - 3 5-12 1-10 oxymorphone 0.25 0.2-0.4 8-10 0.1-1.0 Little evidence suggest major differences of efficacy and side effects between opioids

22. PCA form

23. Some suggestion for safety ( ISMP ) Institute for Safe Medication Practice Assess vulnerability to serious errors Limit concentrations Distinguish custom concentrations Clarify the label Match the Medical Record to the label Employ an independent double-check ISMP. Misprogramming PCA concentration leads to dosing errors. August 28, 2008 issue. www.ismp.org/d/SpecialFollowUp.pdf

24. Physician-Patient Alliance for Health & Safety

25. 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

26. THANK YOU VERY MUCH FOR YOUR KIND ATTENTION