PAIN MANAGEMENT LECTURE:

Patient-Controlled Analgesia

Darrell R. Latva, D.P.M.

 Marks and Sachar: Undertreatment of medical

in-patients with narcotic analgesics. Ann. Int.
Med. 78:173-81.1973
73% of hospitalized patients showed
inadequate pain relief.
GOAL: Minimal effective analgesic
concentration.
(MEAC)

 Opioid concentrations exceed MEAC

only 35% of the time during any 4-hour
dosing intervalWHY?
Why ppl dont get adequate pain
relief:
Underestimated dosing range
Overestimated duration of action
Exaggerated respiratory depression
Exaggerated addictions

History

1968
1971
1976
1979
1982

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Sechzar
Keeri-Szanto
Evans
Tamsen
Bennett

PCA Defined
Any analgesic given by any route of
administration; on immediate patient
demand in plentiful quantities
PCA pump-fail safe mechanism (so pt doesnt overdose)

Classes of Analgesics
Benzodiazepines
Local Anesthetics
OPIOIDS

Routes of Administration
Epidural
Subcutaneous
IV

Modes of Administration
Demand dosing
When pt feels pain they hit button and they get
opioid IV

Infusion-based systems
Constant rate infusion + demand dosing
Get low background amount of opioid but if they
have breakthru (more) pain they can get more
opioid by hitting button

PCA Terminology
Bolus (Loading Dose)
The cumulative amount of opioid used to initially make the
patient analgesic.

Demand Dose (PCA Dose)

Quantity of analgesic given to the patient by selfadministration on the perception of need for additional
analgesia.

Delay Time (Lockout Interval)

The time interval during which the patient cannot initiate
another dose.

PCA Terminology
Limit (1hr/4hr)
Basal Rate (Background Infusion
Rate)

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Limit (1hr/4hr)
The maximum amount of medication
a patient can receive during a 1hr/4hr
time period.

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Basal Rate (Background Infusion

Rate)
The amount of medication infused/
hour continuously by the PCA unit.

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The Ideal PCA Drug

Rapid onset
Highly efficacious
Intermediate duration of action
Minimal tolerance & side effects

Ex. Morphine, dilatin, phentenol, demerol, etc.

*Cant discharge pt on PCA pump, you must get them off of it first with
orals then discharge them

Adult PCA Morphine

Recommendations

Bolus: 1-4mg
Demand Dose: .5-2.5mg
Delay time: 6-12 minutes
4hr Limit: up to 35mg
Basal Rate: 0-2mg/hr

Dont memorize doses

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Adult PCA Demerol

Recommendations

Bolus: 10-25mg
Demand Dose: 5-20mg
Delay Time: 6-12 minutes
4hr Limit: up to 300mg
Basal Rate: 5-20mg/hr

Dont memorize doses

Patient Education
Explain the device
Do not expect complete pain relief
Use as soon as you feel pain (nip it in butt)

Use the device prophylactically

Minimize while awake; maximize prior to sleep

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Safety
Drug-related
There is no greater incidence of opioid-related side effects using PCA
vs. other routes of administration.
Mechanical-related
Mechanical-related problems are rare. Siphoning is the major
mechanical problem.
Morphine leaking and getting pts own infusion rate
Can lead to overdose
In 1987, the incidence of siphoning was 1.45 per 100,000.
User-related
The majority of PCA problems are user-related. No device is tamperproof.
Thus far, I hve found only one fatality associated with the use of PCA
(JAMA; 1988)

Advantages of PCA

Rapid onset of analgesia

Predictable clinical response
Less demand on nursing staff
Quicker discharge
But make sure they are converted to
orals for pain not PCA since you cannot
discharge pts on PCA

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In Conclusion
Safe
Cost-effective
Patient Compliant

LOCAL ANESTHETICS:

IVRA
What Is It?
IntraVenous
Regional
Anesthesia
1908 August Bier
AKA: Bier Block
Lost popularity until
the 60s
Used in UE & LE
surgery

CLINICAL CORRELATIONS
LECTURE

IVRA
CONCERNS
ADVANTAGES
Simple
Duration Of Surgery
Reliable
Tourniquet Time
Rapid Return To Function
(dont put on fibular head b/
c compress common fibular
Cost Effective
N)

LA (local anesthetic)
Toxicity

Technique
Locals utilized include:

Lidocaine (most common, but shortest acting

drug)
Short procedure: using lidocaine okay. .3, .5,1cc etc.
Dilute lidocaine with sterile saline helps.

Bupivacaine
Risk of cardiac arrest

Ropivacaine
Derivative of bupivacaine
Less chance of cardiac arrest/depression

Prilocaine

Technique

IV contralateral limb
Butterfly in injured limb; in foot for venous access
Prepare LA (local anesthetic)
Two tourniquets applied distal to fibular head
Exsanguinate the limb
Inflate proximal tourniquet
Inject LA through your access
If tourniquet pain, inflate distal TQ, then release proximal
TQ
How long?
If short procedure, then LA may not have bound to enough tissue
and lead to cardiac depression, etc.
If too long, damage from TQ and pain. Perhaps compartment
syndrome

Adjuncts To IVRA

Opiods
Muscle Relaxants
NSAIDs
Clonidine
Potassium
Alkalizing Agents

Opiods and mm. relaxants are the more commonly utilized,

and have been the more studied
Opiods include morphine, fentanyl, meperidine, and
sufentanil
Muscle relaxants include pancuronium, atracurium,
mivacurium , and cisatracurium
Use adjuncts so you can use less local (leads away from toxicity

Some Conclusions

Which LA is best?
Are adjuncts useful?
WHICH LA IS BEST?
How quicly to they lose sensation
Lido, bupiv, prilo equal to onset
When do they get sensation back? Longer acting anesthetics lead to longer
time before sensing back
Lidocain and robivucaine are equal in preventing TQ pain
Post-op anelgesis in PACU: Longer acting anesthetic. Robivicaine (longer
acting)
ARE ADJUNCTS USEFUL?
Dont need as much LA, but may take longer to get anelgesia before starting
procedure.
LA by itself does job. No necessarily need other adjuncts.
ROPIVICAINE IS BEST OF ALL LA.

Finally, Some Complications

Seizures
Cardiac Arrest & Death
Incomplete Anesthesia
Injection Pain
Tourniquet Pain
-(60MIN is magic number, most LA bound to tissue and less
pain)
Compartment Syndrome
Neuro Damage
Dysphoria, Dizziness, Facial Tingling
Mistakenly Deflating Cuff
Injecting Wrong Drug