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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


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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