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Pain facts 7. Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab . DCA, Dip. Software statistics PhD ( physio ) Mahatma Gandhi medical college and research institute , puducherry – India . Patient controlled analgesia . The patient controls his own analgesia

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pain facts 7

Pain facts 7

Dr. S. Parthasarathy

MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics

PhD (physio)

Mahatma Gandhi medical college and research institute , puducherry – India

patient controlled analgesia
Patient controlled analgesia
  • The patient controls his own analgesia
  • the use of a sophisticated microprocessor-controlled infusion pump that delivers

a preprogrammed dose of opioid when the patient pushes a demand button

patient controlled analgesia1
Patient controlled analgesia
  • Any analgesic given by any route of delivery (i.e., oral, subcutaneous, epidural, peripheral nerve catheter) can be considered PCA if administered on immediate patient demand in sufficient quantities.
  • But routine is IV opioids
background
Background
  • The traditional approach of IM opioids

given pro re nata (prn) results in at least 50% of patients experiencing inadequate pain relief after surgery.

  • Sechzer - the true pioneer of PCA evaluated the analgesic response to small IV doses of opioid given on patient demand by a nurse in 1968 and then by machine in 1971
we don t want action after distress
We don’t want action after distress
  • Painnursedilutes prepares drug

Analgesia Blood absor IM

conc.

PCA

indications
Indications
  • Acute post op pain
  • Trauma
  • Cancer
  • Labour
  • Burns
  • Sickle cell crisis
  • Sedation
advantages
Advantages
  • Better analgesia with same sedation
  • Better pulmonary results and less complications
  • Length of hospital stay
  • POCD is less
  • Patient satisfaction
relative contraindications
Relative contraindications
  • Sepsis
  • Fluid electrolyte disturbance
  • Hepatic or renal disease ( severe disease )
  • Sleep apnoea
  • Severe COPD
pca system
PCA system
  • Programmable electronic devices
  • Flexibility ,
  • Display and memory, cost
  • Disposable fixed programme devices
  • Nonweight , hydrostatic pressure based
  • No alarms, rudimentary but cheap
how to use
How to use
  • Methods
  • Demand dose ,
  • DD + basal infusion ,
  • DD + tail
  • Adjustable infusions
variables
Variables
  • Loading dose
  • Demand dose
  • Lock out interval
  • Basal infusion
  • 1 or 4 hourly maximum
  • Variables + drug = prescription
loading dose
Loading dose
  • We should understand that PCA is a maintenance therapy
  • It needs loading dose.
loading dose1
Loading dose
  • HIGH LOADING DOSE
  • OPIOID BASED ANAESTHESIA
  • Correlated with less analgesic requirements
  • Morphine – 3 -5 fentanyl 50 mic
  • Pethidine – 25 tramadol 100
basal infusion
Basal infusion
  • Less fluctuation ,increased pt. satisfaction
  • Sleep more medication
  • Per hour doses
  • Morphine – 1 fentanyl 10 mic
  • Pethidine – 25 tramadol 12
demand dose
Demand dose
  • The amount of drug injected as soon as the patient presses the button
  • Burp or tweek sound
  • dose is too small, they stop making demands
  • become frustrated with PCA, resulting in poor pain relief
  • Upto 5-6 doses / hour
demand dose1
Demand dose
  • Demand dose is too large, plasma drug concentration may eventually reach toxic levels- side effects ensue
  • Optimal dose
  • Morphine - 1 mg
  • Pethidine – 10 mg
  • Fentanyl – 10 mic
lock out interval
Lock out interval
  • Patient cant go on to press 10 times in half hour – get toxic doses
  • The time delay before the patient cannot go to the next dose
  • Onset of action of the drug
  • Fentanyl and morphine
  • Relative onset and duration ??
classical times
Classical times
  • Morphine – 8 min
  • Pethidine – 8 min
  • Fentanyl - 6 minutes
  • Short dose and lock out
  • Large dose and lock out
  • Fentanyl -- ?
lock out
Lock out ??
  • Brain to blood
  • Blood to brain
  • Redistribution
demand dose or lock out
Demand dose or lock out
  • Attempts
  • Sound
  • May deliver or not
  • Adjusted infusion
nothing like this
Nothing like this
  • One size fits all
  • Set and forget
  • The doses are only approximate

Patient weight prevents toxicity but efficacy ?

total dose
Total dose
  • 1 hour
  • 4 hours
assumptions
Assumptions
  • Side effects are produced at higher brain concentrations than the analgesic effect
  • Pain intensities are rarely constant
  • Pain relief is ideal in MEAC only
ideal opioid
Ideal opioid
  • Rapid onset
  • Medium duration
  • Less side effects
  • No ceiling to analgesia
  • Morphine -- pethidine – fentanyl
morphine
Morphine - ?
  • Renal insuffiency
  • Bilirubin
  • Preeclampsia
  • Smooth muscle spasm
pethidine
Pethidine
  • Seizures
  • Sickle cell crisis nor meperidine increased
  • Papillary necrosis in renal dysfunction
fentanyl
Fentanyl
  • Ideal for renal and hepatic dysfunction cases
  • But short duration should be in mind
  • Other drugs – hydromorphone, pentazocine and buprenorphine are used
monitoring
Monitoring
  • Staff
  • ABG
  • Respiration
  • Sedation score
  • But pulse oximetry is accepted as the monitor for PCA
side effects
Side effects
  • Operator error
  • Patient error
  • Equipment malfunction
side effects of opioids
Side effects of opioids
  • Nausea and vomiting
  • No difference
  • 30 % Vs 25% - PCA Vs IM
  • Use of anti emetics – similar
respiratory depression
Respiratory depression
  • PCA is more – wrong
  • Lot of studies – 0.5 – 0.9 % Vs
  • Old age , COPD, equipment failure, concomitant opioid admin by other routes, wrong doses
colonic pseudoobstruction
Colonic pseudoobstruction
  • Abd, distension
  • Nausea
  • Vomiting,
  • Flatus
  • Yes but 6/154 in a study of PCA -- not threatening
others
Others
  • Sedation - 20 %
  • Dizziness - 13 %
  • Pruritus - 20 %
  • In a study with PCA with hydromorphone
pca adjuncts
PCA adjuncts
  • Promethazine –
  • Droperidol
  • Metoclopramide
  • TDS scopolomine
  • Naloxone
  • NSAIDs
  • Clonidine
  • Paracetomol
  • Nerve blocks
other methods pcea
Other methods - PCEA

loading – basal – demand- lock out

  • Morph. 2 0.5 0.2 30
  • Peth. 30 10 10 20
  • Fentanyl 50 30 10 15
subcutaneous clysis
Subcutaneous (clysis)
  • 0.2 mg Loading with 0.2 mg demand SC 15 min. lock out of hydromorphone
  • Obesity
  • Edema
  • Vasculitis
  • But if no proper IV access – OK
rare routes
Rare routes
  • Intramuscular PCA
  • Paediatric PCA
  • Intraspinal PCA
  • Ventricular implantable PCA
  • Oral PCA
  • PCA with ketoroloc, midazolam has been done
slide40
Mr. X
  • Mr X bought a scooter
  • He did not know driving
  • He was struggling
  • One friend came near to say don’t worry, it will normalize in three months
  • Mr. X put the scooter into the shed to try it after three months
to understand pca
To understand PCA
  • USE it
  • Make it available in your institutes
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