102: Patient-Controlled Analgesia

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PROCEDURE 102

Patient-Controlled Analgesia

Lorie Ann Meek

PURPOSE:

Intravenous patient-controlled analgesia empowers patients to manage their pain by allowing them to administer smaller analgesic doses more frequently. Nurses are responsible for ensuring appropriate patient selection, maintaining the intravenous delivery system, and ensuring that patients are able to safely meet their own needs for pain management through frequent assessment and patient education.

PREREQUISITE NURSING KNOWLEDGE

• Pain is an unpleasant sensory and emotional experience that arises from actual or potential tissue damage or is described in terms of such damage.¹ According to the National Institutes of Health, more Americans are affected by pain than by diabetes, heart disease, and cancer combined.²⁸

• The most common reason for unrelieved pain in hospitals is the failure of staff to routinely and adequately assess pain and pain relief.¹

• Additional perceived barriers to adequate pain management are poor pain assessment, patient reluctance to report pain and take analgesics, and physician reluctance to prescribe opioids.¹ Tables 102-1 and 102-2 list guidelines for dosing and considerations for selection of opioids.

Table 102-1

Guidelines for Patient-Controlled Intravenous Opioid Administration for Opioid-Naive Adults and Children with Acute Pain

^*Typical concentrations are listed in parentheses.

(Miaskowski C, Blair M, Chou R, et al: Principles of analgesic use in the treatment of acute pain and cancer pain, ed 6, Glenview, IL, 2008, American Pain Society, 42).

Table 102-2

Patient Controlled Analgesia: Considerations in Opioid Selection

(Institute for Safe Medication Practices: Patient-controlled analgesia: making it safer for patients, Horsham, PA, 2006, Institute for Safe Medication Practices.)

• Unrelieved postoperative pain may result in clinical and psychologic changes, an increase in morbidity and mortality, an increase in costs, and a decrease in quality of life. Negative clinical outcomes related to ineffective pain management for patients after surgery include deep vein thrombosis, pulmonary embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound healing, impairment of the immune system, insomnia, and negative emotions.²⁵ Unrelieved pain may delay recovery and prolong hospital stays.¹^,³

• The Agency for Healthcare Research and Quality (AHRQ) urges healthcare professionals to accept the patient’s self-report as “the single most reliable indicator of the existence and intensity” of pain.¹

• Studies and meta-analyses have shown an increase in patient satisfaction with pain management and an improvement in pain control.⁵^,¹⁸^,²³^,³⁴^,³⁸ Intravenous (IV) patient-controlled analgesia (PCA) may be used for both acute and chronic pain.²⁶

• Intravenous PCA can be an effective method of pain relief for pediatric and adult patients.¹⁴^,¹⁸^,³⁴^,³⁸ Table 102-1 lists dosing guidelines.

• Intravenous PCA can be administered as a continuous (basal) infusion along with patient-initiated boluses or as intermittent patient-initiated boluses exclusively.

• Patient assessment at frequent, regular intervals (at least every 4 hours) should include an evaluation of the patient’s vital signs, sedation level with a valid and reliable scale, pain level with a valid and reliable scale, and common opioid side effects, such as pruritus, nausea,⁹^,¹² constipation, and urinary retention.¹³ Table 102-2 lists side effects associated with PCA opioids. Patients need more frequent assessments during the first 24 hours after initiation of IV PCA and during the night.¹⁰^,¹¹^,¹⁴^,¹⁹ Systematic evaluation of agitation and pain can lead to a reduction in pain levels and agitation.⁹

• PCA pump settings should be confirmed at regular intervals.¹⁰^,¹¹^,¹⁹ See Box 102-1 for common terms used when administering patient-controlled analgesia. Adverse events during IV PCA may include respiratory depression and hypoxemia. Opioid anatagonists should be readily available.

• Adjunctive medications can be used to improve pain management ⁷^,¹⁴^,¹⁵^,²⁷^,³⁹ or to improve opioid side effects.⁷^,¹⁵^,²³^,²⁴

• The Joint Commission does not support PCA by proxy (someone other than the patient pushing the PCA button) on the recommendation of the Institute of Safe Medication Practices (ISMP). According to ISMP, patients have experienced oversedation, increased respiratory depression, and death from PCA by proxy.¹¹^,¹⁹^,²¹

• PCA by authorized user (typically nurse or designated family member of patient) is a potential alternative to PCA by proxy. Healthcare institutions that use PCA by authorized user need to have the following in place before this practice is initiated.²^,¹¹^,¹⁹^,²¹^,²²^,³⁷^,⁴¹

Policies that guide the practice, including the patient population

Definition of PCA by an authorized user

Education plan for the authorized user

Documentation of the authorized user and education given

• Patients with an increased risk for complications during IV PCA use include those with:

Age more than 65 years (greater incidence of desaturation)²⁹

Morbid obesity (greater incidence of desaturation)⁸^,²⁹^,³⁶

Sleep apnea or asthma ⁸^,¹¹^,²⁰^,³⁶

Concurrent medications that potentiate opiates (e.g., sedation)¹¹^,¹⁹

Impaired organ function ²⁵

• Careful patient selection is imperative for effective pain management. Patients who may be poor candidates for PCA include the following:

Anyone with cognitive abilities that prohibit understanding and following directions for IV PCA (e.g., infants, young children, patients with a decreased level of consciousness or with developmental disabilities)¹¹^,¹⁹

Anyone without the physical ability to push the PCA button that controls the dose administration ¹¹^,¹⁹

Anyone with a psychologic reason that prohibits using the PCA button for pain management (e.g., psychologic disability, refusal to operate the PCA administration button)¹¹^,¹⁹

• Patients can have as effective or better pain control with epidural analgesia than with IV PCA after various surgical procedures.⁶^,¹⁶^,³²^,³³^,⁴⁰

• A number of medication errors have been reported with IV PCA. Factors associated with errors include improper patient selection, inadequate monitoring, inadequate patient education, medication product mix-ups, programming errors, PCA by proxy, inadequate medical and nursing staff education, prescription errors, and PCA pump design flaws.¹¹^,¹⁷^,¹⁹

• PCA is available in various routes, including IV, epidural (patient-controlled epidural analgesia [PCEA]; see Procedure 101), subcutaneous, peripheral nerve catheter (see Procedure 103), oral, intranasal, and transdermal.¹⁴^,¹⁵^,²⁵^,²⁶^,³¹ The focus of this procedure is IV PCA.

EQUIPMENT

• PCA pump

• PCA tubing with antisiphon valve (may also include a plunger for insertion into PCA medication syringe barrel)

• IV pump

• IV tubing

• Prescribed medication (may be in a syringe, bag, or cassette)

• Alcohol wipes

• Non-sterile gloves

• ECG and blood pressure monitoring equipment

• Pulse oximetry equipment

• Normal saline solution or other compatible IV fluid

Additional equipment as needed includes:

• Emergency medications, including naloxone

• Bag-valve-mask device and oxygen

• End-title carbon dioxide monitoring equipment

PATIENT AND FAMILY EDUCATION

• Review an appropriate pain rating scale with the patient. The healthcare provider and patient need to establish a mutually agreeable pain level goal. Rationale: Review ensures that the patient understands the pain rating scale and enables the nurse to obtain a baseline assessment. Establishing a pain level goal allows the healthcare provider to know an acceptable goal for pain management.

• Review the principles of PCA use with the patient and family members.³¹ If a basal rate has been prescribed, inform the patient that pain medication will be infusing at all times. Explain that if the pain is not relieved with the steady dose, extra medicine can be delivered. Be sure the patient understands what the lockout interval is. If the patient’s pain needs are not met, the dosage can and will be changed to meet those needs. Rationale: This review may reduce anxiety and preconceptions about PCA use.

• Intravenous PCA is designed for the patient to administer the pain medication. In most circumstances, the patient should be the only one to deliver the demand dose. The ISMP and The Joint Commission do not support PCA by proxy because of adverse events, such as oversedation, respiratory depression, cardiopulmonary arrest, and deaths that have occurred with PCA by proxy.¹¹^,¹⁹^,²⁰^,²¹ Rationale: The patient should remain alert enough to administer his or her own dose. A safeguard to oversedation is that a patient cannot administer additional medication doses if sedated.

• Instruct the patient and family members to report common side effects, such as oversedation, pruritus, nausea or vomiting, constipation, or urinary retention. Rationale: Side effects are identified by the patient and family.

PATIENT ASSESSMENT AND PREPARATION

Patient Assessment

• Assess the patient’s ability to properly use IV PCA as a method for pain management. Rationale: The patient will not achieve adequate pain management if unable to use the PCA.

• Assess the patient’s pain and document the intensity, location, and characteristics.²^,³^,²⁷ Rationale: A baseline assessment permits an accurate evaluation of the efficacy of the PCA.

• Assess the patient’s level of consciousness with use of a sedation scale.²⁸^,⁴¹ Rationale: Sedation generally precedes respiratory depression; a patient who is less alert should be closely monitored if PCA is prescribed.