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Analgesia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
Patient-controlled analgesia is a
programmable delivery system by
which patients self-administer
predetermined doses of analgesic
medication at the push of a button
Demand dose
The demand dose is the amount of
analgesic the patient receives after
activation of the pump
Demand dose
Optimization of efficacy and safety
depends on the selection of a demand
dose large enough to provide sufficient
analgesia but small enough to
minimize side effects
Lockout interval
The lockout interval is the amount of
time following a successfully delivered
demand dose
during which the patient can
administer no further opioid even if the
system is activated
Lockout interval
Theoretically, use of a lockout interval
that is less than the time to peak effect
of the drug may result in inadvertent
overdosage due to stacking of analgesic
doses
However, lockout intervals between 5
and 10 min appear optimal regardless
of the opioid used
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
Hourly Limit
An hourly limit sets the maximum
amount of opioid that can be
administered in the given
time period
An hourly limit is automatically
determined
by the setting of a demand dose and
lockout interval
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
ADVANTAGES OF PCA
DISADVANTAGES OF PCA
IMPORTANCE OF
ACUTE PAIN SERVICE
TYPES OF PCAs
INTRAVENOUS PCAs
NONINTRAVENOUS PCAs
Patient-controlled epidural analgesia
Peripheral nerve catheter patient-controlled analgesia
Subcutaneous PCA (SC PCA)
Intranasal PCA (PCINA)
Transdermal PCA
Nei Ting
INTRAVENOUS PCAs
Morphine
hydromorphone
fentanyl
ketamine
Addition of ketamine [NMDA] to IV PCA
solutions may improve analgesia in
some, but not all, circumstances
NMDA receptors are associated with the
early development of opioid tolerance
ketamine can arouse psychomimetic
effects and impair cognition
Naloxone
Ultralow doses of naloxone (0.6 g added
to 1 mg PCA morphine) led to a lower
incidence of nausea (not vomiting) and
pruritus,
with no change in pain relief or morphine
use
But a 10-fold increase in dose (6 g added to
1 mg PCA morphine) resulted in increased
pain and higher morphine requirements
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
Clonidine
Clonidine is an a2-adrenergic agonist
with analgesic properties
Addition of clonidine to morphine PCA
significantly reduced nausea and
vomiting in a female population
undergoing lower abdominal surgery?
But in other studies was not proven
Patient-controlled
epidural analgesia
(PCEA)
PNC PCA
Infections and neurologic
complications, although rare, are
possible
In contrast with neuraxial blocks,
there is less
concern about interaction of
anticoagulants
and peripheral nerve blocks.
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
In PNC PCA
Opioids may increase side effects
without improving analgesia
Addition of clonidine to ropivacaine for
PNC PCA
does not improve analgesia
In PNC PCA
A low-dose continuous infusion
(combined
with a demand dose) reduces local
anesthetic consumption without
compromising analgesia, in
comparison with continuous infusion
alone
Subcutaneous PCA
Data on the effectiveness of SC PCA
compared with IV PCA are inconsistent
Intranasal PCA
The opioid most commonly studied for
use in PCINA is fentanyl
The bioavailability of fentanyl via the
intranasal route is 0.7
Therefore a PCINA bolus dose of 25 g
is equivalent to an IV PCA bolus dose
of 17.5 g
Transdermal PCA
An iontophoretic transdermal PCA
fentanyl system (Ionsys) is now
available
It uses a low intensity electric current
to drive the drug from the reservoir
through the skin and into the systemic
circulation
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
SPECIAL
CONDITIONS
LABOR PAIN
PAIN CONTROL
IN
PEDIATRIC
PATIENTS
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
PAIN CONTROL IN
CANCER PATIENTS
PCA Monitoring
GemStar Medication
CADD-Prizm
Alaris System