PATIENT

CONTROLLED
ANALGESIA
DR NOOR US SABAH
INTRODUCTION
Pain
Analgesia
1980s
Basic principle:
 Is
that the patient can self administer small
doses of the drug at relatively frequent intervals
to provide optimal pain relief.
PHARMACOKINETICS
 GOAL
 Therapeutic window
 Large doses
 Large time intervals
 Small doses
 Small time intervals
 Sedation
PCA dosing strategies and
parameters
 LOADING DOSE:
A single large dose is given initially to
establish analgesia.it is used to bring
levels of the analgesic to the therapeutic
window
DEMAND DOSE
The amount of drug that is self
administered by the patient each
time he or she activates the PCA
delivery mechanism is known as
demand dose.
LOCKOUT INTERVAL:
The minimum amount of time
allowed between each demand
dose is called as lockout interval.
when the pt has self administered
a dose the system will not deliver
any dose till the lockout interval
has expired.
1- and 4- HOUR LIMITS
PCA systems can be set to limit
the total amount of drug given
in a 1- or 4- hour period.
BACKGROUND INFUSION RATE
Insome patients a small amount of
the analgesic is infused
continuously to maintain a low,
background level of analgesia.
Demand dose is super imposed
whenever the pt, feels inc. pain (ie
the breakthrough pain during cough
and change of position)
Background infusion during
sleep when pt is unable to
activate PCA or the pump.
ANALGESICS USED FOR PCA
CLASSIFICATION:
A. OPIOID ANALGESICS:
• Morphine
• Meperidine
• Tramadol
• Fentanyl
• Fentanyl derivatives:
• Alfentanyl, remifentanil
B.NONOPIOID ANALGESICS
1. Morphine+NSAIDS(ketorolac)
2. Morphine+anaesthetics(ketamine)
3. Morphine
+antipsychotics(droperidol)
4. Opioid receptor
antagonist(NALOXONE) +opioid
C.LOCAL ANAESTHETICS
Bupivacaine
Ropivacaine
• Labour
• Surgeries
• Local application
• Patient controlled Regional Analgesia
ROUTES OF ADMINISTERATION
 Intravenous
 Epidural
 Spinal
 Transdermal
 Regional PCA
ADMINISTERATION ROUTES
A. INTRAVENOUS PCA:
 inserting a needle into
peripheral vein and then
connecting the needle to a
catheter or I/V line. This is
connected to a PCA pump.
For first few days after surgery.
2.For longer periods
catheter is implanted surgically in a large
central vein with tip of catheter towards
right atrium of heart.
Catheter then tunneled thru s/c tissue nd
brought out through the skin to be
connected to access port, implanted s/c in
patients bod. Huber needle, silicone
rubber septum. for small doses and less
chances of infection and displacement
(removable for bathing and dress
changing)
B.EPIDURAL PCA:
 SPINAL or intrathecal administration
 In
between meninges arachnoid mater and pia
mater
 Inserting a small catheter so that tip of catheter
lies in space between at a specific spinal level
 Intrathecal…within a sheath
 Safer less risk of meninges damage
 1…Short term use --- only with surgical tape
 2…Longterm use---tunneled into sc tissue in pt,
abdominal wall and then brought out of skin
 Difficult
 Advantages
• Effective analgesia
• Small amount of drug
• Epidural morphine is 5to 10 times more
potent than intravenous directly to spinal
chord
• Early recovery
• Early rehabilitation
• Total knee arthroplasty
C..TRANSDERMAL PCA:
 Newest variation of PCA
 PCTA uses a delivery system consisting of
a small patch that is approx. the size of a
credit card. adhered to pt skin.
 Usually on arm or upper chest.
 Patchis impregnated with an opioid such
as FENTANYL
 Pt
can administer small doses of drug by
pushing a button located on the patch.
ADVANTAGES:
 Small amount of doses can be given
 Similarto iontophoresis techniques small amount of
electric current to facilitate transdermal delivery.
 Additional benefit of allowing the pt.to activate drug
delivery
 Meet specific needs
 As no needle is required ……noninvasive method
 Pt
can remain mobile as no IV line is connected to PCA
pump
 Superiorpain control as compared to other postoperative
analgesic techniques
D.REGIONAL PCA:
 Pt.
self-administer the analgesic directly into
a specific anatomical site, such as a
peripheral joint ,peripheral nerve or into a
wound.
 Localize
the drug to the site of
administration
 Adequate pain control with minimal effects
on other tissues or organs
 Localanaesthetics i.e bupivacaine or
ropivacaine
 Safe and effective pain control
 Accomplished by inserting a catheter
into the affected site and then attaching
it to some type of pump that enables the
pt to self administer small amounts of of
medications as needed.
 Acromial decompression surgery
 Peripheral nerves
sciatic
popliteal
 Surgeries
 Two main ways
 Single one shot dose
 Continuous infusion
E. PCA PUMPS:
 PUMPS allow the doc to set specific
parameters of drug delivery
 Demand dose
 Lockout interval etc.
Warning nd proper instructions to patient
and caregiver
Two types :
 External pumps  Internal or implants
A simple syringe pumps
driver  surgical
implantation
 Peristaltic beneath pt skin
tube
 Connected to a catheter
 Cassette system
leading to pts
 Disposable models bloodstream or
perispinal spaces
(epidural or intrathecal)
 Closed system
 Reservoir filled with med
ADVANTAGES:
 Equivalent or increased analgesic effects
 Lower incidence of side effects
 Acute pain following surgery
 Pain of cancers pts
 Chronic pain
 Easy to use
 Small frequent doses at infrequent intervals
 More pt satisfaction
 inc feeling of control over pain
 Early mobility after surgery
 Shorter hospital stay
 Feasibleto administer opioid analgesics
by slow iv infusion
 Decrease the need of health
proffessionals
 Morealert pt in rehabilitation and more
cooperative pt
SIDE EFFECTS/ PROBLEMS:
 A.OPERATOR ERRORS:
 Misprogramming PCA device
 Failure to clamp or unclamp tubing
 Improperly loading syringe or cartridge
 Inability to respond to safety alarms
 Misplacing PCA pumps key
B.PATIENTS ERRORS:
 Failure to understand PCA therapy
 Misunderstanding PCA pump device
 Intentional analgesic abuse
C.MECHANICAL PROBLEMS:
 Failure to deliver on demand
 Cracked drug vials or syringes
 Defective one way valve
 Faulty alarm system
 Malfunctions eg lock