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YOUR PATIENT

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A 15-year-old male is scheduled for an elective colectomy secondary to ulcerative colitis. The family has refused an epidural for postoperative pain management.

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PREOPERATIVE CONSIDERATIONS

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  • Intravenous patient-controlled analgesia (IV PCA) is a method of analgesia administration involving a computer-programmable pump activated by the patient to receive small doses of opioid within defined limits. Titration of the opioid dose should be done after appropriate patient assessment. The settings of the PCA may include a demand dose with a specified lockout interval and a clinician bolus dose at a specified time interval to a maximum dose allowable at a specified frequency, as shown in Table 89.1. A continuous infusion may be prescribed if the patient is unable to push a demand dose button independently or if there is unremitting pain. Cognitively normal children over 8 years old are typically deemed appropriate for a demand dose PCA unless there are other medical or developmental issues.

  • IV PCA allows for patients to feel more in control of their pain management.

  • Children less than 1 year of age and those with serious medical conditions may have altered pharmacokinetics.

  • Be careful with premature infants and infants in general, patients with decreased cardiac output or relative hypoxia (decreased respiratory reserve), patients with a history of central or obstructive sleep apnea, patients who are at risk for increased intracranial pressure, patients with renal or liver insufficiency, patients who are morbidly obese, and patients who have a history of opioid tolerance or dependence or who have a history of hypersensitivity to opioids.

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Table Graphic Jump Location
TABLE 89-1

INTRAVENOUS PATIENT CONTROLLED ANALGESIA INITIAL OPIOID INFUSION ORDERS

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POSTOPERATIVE CONSIDERATIONS

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  • In general, equianalgesic doses of opioid produce similar degrees of respiratory depression, except in premature infants or in patients who have disordered breathing secondary to central or obstructive apnea.

  • Sedation typically precedes respiratory depression.

  • Patients who are receiving methadone or those with obstructive ...

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