Skip to Main Content

Chapter 89: INTRAVENOUS PATIENT-CONTROLLED ANALGESIA

Mary E. Tresgallo, DNP, MPH, FNP-BC

YOUR PATIENT

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.

PREOPERATIVE CONSIDERATIONS

  • 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.

TABLE 89-1

INTRAVENOUS PATIENT CONTROLLED ANALGESIA INITIAL OPIOID INFUSION ORDERS

View Table||Download (.pdf)
TABLE 89-1

INTRAVENOUS PATIENT CONTROLLED ANALGESIA INITIAL OPIOID INFUSION ORDERS
Drug (and concentrations) Continuous Basal Infusion,* μg/kg/h (range, μg/kg/h) Demand Dose, μg/kg (range, μg/kg) Demand Dose Lockout Interval, Minutes (range) Number of Demand Doses/Hour (range) †Clinician Bolus Dose (μg/kg) †Clinician Bolus Dose Lockout Interval, Minutes (range)
Morphine 10 (10-15) 15 (10-30) 10 (6-20) 6 (1-10) 15 (15-30) 20 (15-30)
Hydromorphone 3 (2-3) 3 (2-6) 10 (6-20) 6 (1-10) 3 (3-6) 20 (15-30)
Fentanyl 0.1 (0.1-0.25) 0.1 (0.05-0.25) 15 (10-20) 4 (1-6) 0.1 (0.05-0.25) 20 (20-30)

*A basal infusion is not always used. It may increase the risk of excessive sedation or respiratory depression.

†The clinician bolus dose (μg/kg) can be administered at the specified lockout interval (minutes) to a maximum dose of 3 doses every 4 hours as needed for break-through pain.

Guidelines are to be followed in an acute care setting; dosages must be individualized for each patient.

POSTOPERATIVE CONSIDERATIONS

  • 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 ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MH Privacy Center Close