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Management of moderate to severe pain when inadequate analgesia would result from oral pain medications or intermittent intravenous opioid boluses.

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Typically started after initial opioid titration to comfort in the PACU.

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  • Patients who do not have the cognitive ability to understand how to use a patient-controlled analgesia (PCA) device
  • Patients physically incapable of activating the PCA demand function

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The PCA device may be programmed to deliver a demand dose with or without a basal rate. PCA order must include the following elements:

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  • Selected opioid and its concentration (often, this will be institutionally standardized)
  • Demand (bolus) dose
  • Lockout time interval of the demand dose in minutes

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Optional parameters include:

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  • Loading dose (administered when initiating the PCA)
  • Basal (continuous) infusion hourly rate
  • Clinician dose (extra doses that can be administered by the RN in case of breakthrough pain; this should prompt a call to the pain service, but will ensure timely treatment)

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Patient-Controlled Analgesia (PCA) Recommendations for the Average Adult
DrugBolusLockout interval (min)Optional basal rate (opioid-naïve patient)
Morphine0.5–3 mg5–200–1 mg/h
Fentanyl (Sublimaze)10–25 μg5–200–10 μg/h
Hydromorphone (Dilaudid)0.05–0.3 mg5–200–0.2 mg/h
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Loading dose is encouraged on PCA initiation (and during significant PCA dose increases) to give the patient prompt analgesia. Omitting the loading dose can cause the patient to be undertreated, to over-rely on the demand doses in an attempt to get prompt analgesia, and to declare the PCA modality ineffective.

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Use of a basal infusion is controversial:

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  • Not shown to improve pain outcomes
  • Associated with higher incidence of side effects and respiratory depression
  • May be needed in patients who are on high dose of daily opioids and those who have significant opioid physiological dependence

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Increasing the demand dose is preferable to a basal infusion rate.

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Patient and family education prior to the start of PCA are critical. Discuss how much pain can be expected despite optimal PCA use.

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Discuss dangers of someone other than the patient pressing the button for a bolus dose (especially for pediatric patients).

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  • Higher patient satisfaction—personal control aspect of PCA and rapid onset of pain relief
  • Improved postoperative analgesia when compared with PRN analgesic regimens
  • Improvements in postoperative morbidity such as postoperative pulmonary function and earlier postoperative mobilization
  • Better continuous incremental titration compared with intermittent PRN analgesic dosing
  • Not more cost effective
  • No decrease in LOS

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Nausea and vomiting, pruritus, ileus, sedation, and confusion. More pruritus with morphine. If unresponsive to treatment, change to another opioid (hydromorphone or fentanyl).

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Consider use of a multimodal analgesic regimen to reduce opioid requirements and opioid-induced side effects.

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Figure 158-1. Management of IV PCA
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