Patient controlled analgesia(pca)

PCA pump

1. Patient Controlled Analgesia(PCA) Dr. Priti Patil Department of Anaesthesiology Fortis Hospital , Mulund ,Mumbai.

2. Definition : Patient Controlled Analgesia is an effective method of pain relief that gives the patient a sense of control over their pain. History: First developed as a research tool. First pump ,”Cardiff Palliator ” was introduced in UK in 1976. Thus continuing the popularity of PCA.

3. Indications of PCA Major operations and NPO Marked incident pain Cancer Pain Strongly motivated and appropriately educated for use PCA

4. Why do we need PCA ? Patient has Pain Sedation Analgesia Absorption from Injection Site Injection Given Prepare Injection Calls Nurse Nurse Responds “Screening” Sign out of Medications PCA X

5. Mechanism of PCA Good pain relief? Wait! Yes No

6. PAIN Vs ANALGESIC

7. Postoperative Pain Treatment Multi m odal Therapy Local anesthetics (LA) infiltration Acetaminophen Anti-inflammatory agents, COX-2 inhibitor LA via peripheral nerve catheters Local anesthetics Opioids  2 -Agonists NMDA antagonists COX-2 Inhibitors Opioids  2 -Agonists Acetaminophen N -methyl- d -aspartate (NMDA) antagonists Slide courtesy of Raymond Sinatra, MD and modified for educational purposes

8. Routes: PCA can be given through different routes and with different drug compositions. Intravenous Epidural Peripheral Nerve Catheter T ransdermal

9. Multimodal therapy Key Practice Guidelines Recommendations American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology . 2012;116(2):248-273. Anesthesiologists who manage perioperative pain should, after thoughtfully considering the risks and benefits for the individual patient, use therapeutic options such as: Epidural or intrathecal opioids Systemic opioid patient-controlled analgesia (PCA) Regional techniques

10. Basics of a PCA For all modes of PCA the basic variables are Initial loading dose( to titrate upto MEAC) Demand dose (on activation of demand dose) Lockout interval (to prevent overdose) Background infusion (constant rate of infusion) 1-h and 4-h limits (to program the device to limit the patient)

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

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

13. 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

14. Side Effects Intravenous PCA (opioid based) Nausea and Vomiting Pruritus Sedation and confusion Epidural PCA Motor Blockade

15. Macintyre P.E., British Journal of Anesthesia, 2001, 87(1) PCA SAFETY PATIENT FACTORS EQUIPMENT FACTORS MEDICAL AND NURSING STAFF Factors Affecting Safety of PCA

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

17. 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

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

19. 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 |

20. 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

21. Physician-Patient Alliance for Health & Safety

22. Nurse controlled Analgesia It allows the nurse to give a small dose of the analgesic to the pediatric patients. Parents must be given educated about the PCA either via a handout or verbally . They must be informed that – The Nurse would frequently come to assess the child’s pain score. Only the nurse is allowed to press the button on the pump. Parents must be well informed of the potential side effects of the drugs used in the PCA , so they can be watchful.

23. Patient Controlled Analgesia is neither “ one size fits all “ nor a “ set and forget “ therapy.

24. THANK YOU