Chapter 29 Patient-Controlled Analgesia Flashcards Preview

Essentials of Pain Medicine > Chapter 29 Patient-Controlled Analgesia > Flashcards

Flashcards in Chapter 29 Patient-Controlled Analgesia Deck (39):
1

basic variables of PCA

initial loading dose, demand (bolus) dose, lockout interval,
basal continuous infusions, and 1- to 4-hr
maximal dose limits

2

demand dose

the amount of
analgesic the patient receives after activation of the pump

3

Optimization of efficacy and safety depends on

the selection of a demand dose large enough to provide sufficient analgesia but small enough to minimize side effects

4

lockout interval

the time during which there will be no
drug delivery, even if the patient pushes the demand button

5

use of a lockout interval that is less than
the time to peak effect of the drug may result in

inadvertent overdosage due to stacking of analgesic doses. However,
lockout intervals between 5 and 10 min appear optimal regardless of the opioid used

6

Reasons Patient-controlled analgesia is extremely popular

Patients like the security of knowing they can
achieve pain relief quickly and easily without involving a nurse, not having to wait for pain relief, and not having intramuscular (IM) or subcutaneous injections . Because of the ease with which each demand dose can be given, small boluses can be given frequently.

7

PCA may avoid subtherapeutic opioid concentration troughs, which can be
associated with

unpleasant recovery secondary to guarding,
poor chest expansion, and reluctance to mobilize

8

PCA may also help avoid excessive peak plasma concentrations,
with associated

respiratory depression and sedation

9

What makes a patient is a good candidate for PCA?

patients must be
cooperative, must comprehend the concept, and must be able to push the PCA button

10

PCA may not be appropriate for

very young children, or for patients with certain menta or physical limitations

11

Nurse-controlled analgesia (NCA)

may be used if the patient’s age, developmental level, or
muscle strength interact with the ability to use the PCA device. NCA is a safe and effective method of analgesic
administration in the pediatric intensive care unit (ICU) setting.

12

most frequent negative perceptions relate to PCA

inadequate analgesia and/or presence of side effects, but some patients also report not trusting the PCA pump, or
fearing overdose or addiction

13

Oversedation with PCA can occur as a result of

repeated excessive use (patient misunderstanding of the analgesic goal), mistaking the PCA handset for the nurse call button, and family, visitor, or unauthorized nurse-activated demand
boluses

14

Operator errors can cause oversedation
via

programming of incorrect bolus dose size, incorrect concentrations, incorrect background infusions, and/or unintended background infusions

15

first choice for IV PCA

Opioids that are pure m-receptor agonists

16

ideal opioid for IV PCA

would have a rapid onset of action, high efficacy, and intermediate
duration of action without significant accumulation
of drug or metabolites over time

17

opioid-based IV PCA types

Morphine, hydromorphone,
and fentanyl

18

why is meperidine may not be a good first choice for IV PCA?

meperidine metabolites can accumulate

19

Drug/ Bolus (mg) / Lockout Interval (min)

Fentanyl: 0.015–0.05/ 3–10 min
Hydromorphone: 0.1–0.5/ 5–15 min
Meperidine: 5–15/ 5–15 min
Morphine: 0.5–3/ 5–20 min
Oxymorphone: 0.2–0.8 /5–15 min
Remifentanil (labor) 0.5mcg/kg/ 2 min
Sufentanil 0.003-0.015/ 3–10 min

20

Continuous infusions of PCA pose increased risk for

respiratory depression

21

Benefit of Continuous
opioid infusion in association with PCA

may provide a
more constant plasma opioid levels and improve analgesia.

22

ketamine

(an N-methyl-d-aspartate [NMDA] receptor antagonist) to IV PCA solutions may improve analgesian in some

23

Clonidine

an a2-adrenergic agonist with analgesic
properties. Addition of clonidine to morphine PCA significantly
reduced nausea and vomiting

24

two common alternative
routes of NONINTRAVENOUS PCAs

patient-controlled epidural analgesia and
patient-controlled peripheral nerve catheter analgesia

25

PCEA compared
with IV PCA.

providing better
pain control, epidural analgesia also has the potential benefits
of decreased morbidity such as fewer cardiopulmonary
complications, less thromboembolism, better mental status, earlier restoration of gastrointestinal function, enhanced functional exercise capacity and health-related quality of
life, and earlier discharge from the hospital.

26

potential risks associated with the placement of a catheter

epidural
hematoma, infection, or neurologic injury

27

Epidural analgesia with a local anesthetic combined with an opioid provides better
postoperative analgesia

than epidural or systemic opioids alone, and may improve postoperative outcome

28

Use of local anesthetic alone may result in

excessive motor blockade

29

complications of PCEA

hypotension and motor blockade.

30

PCEA with clonidine plus local anesthetic can provide

adequate analgesia without the usual opioid-related side effects such as nausea or pruritus

31

to reduce side effects and facilitate transition
to oral analgesia

the PCEA settings can be reduced gradually
rather than abruptly terminating the PCEA. This can be done, for example, by eliminating the basal rate 6 hr prior to stopping the PCEA

32

Many common nerve blocks for extended postoperative analgesia.

brachial plexus, sciatic, and femoral nerve blocks are amenable to having peripheral nerve catheters inserted

33

compared to bupivacaine, Ropivacaine may be associated with reduction
of

complete motor and sensory block,

34

Peripheral nerve catheter patient-controlled analgesia (PNC PCA) Common concentrations of local anesthetic

ropivacaine, 0.2% to 0.3%, and
bupivacaine, 0.12% to 0.25%.

35

During Labor, IV PCA (compared to intermittent IM dosing)

may provide better pain relief and reduce maternal sedation,
respiratory depression, and nausea. it reduces umbilical cord blood opioid levels (indicating less placental drug
transfer); in most cases IV PCA does not cause significant
fetal depression

36

PAIN CONTROL IN PEDIATRIC PATIENTS

children younger
than 4 years of age are not good candidates for PCA use. Children aged 4 to 6 years can use PCA pumps with the
encouragement of nursing staff and parents. Nonetheless, the success rate in this age-group is low. Children older
than 7 years of age often can use PCA independently

37

Pediatric PCA Dosing
Drug/ Bolus (mg/kg) Lockout (min)

Morphine: 10–20 /7–15 min
Hydromorphone: 5–15/ 15 min
Fentanyl: 0.1–0.2/ 7–15 min

38

Pediatric PCEA Dosing

Drug: Bupivacaine 0.06% + hydromorphone 10 mcg/ml
Basal Rate (ml/hr): 0.1–0.3 ml/kg/hr
Demand Dose: 0.1 mg/kg
Lockout (min): Minimum of 10 min
One-Hour Limit (ml): Max 5 0.4 ml/kg/hr

39

Pediatric Peripheral Nerve Catheter PCA Dosing

Drug: Ropivacaine 0.2%
Basal Rate (ml/hr) :0.1–0.2 ml/kg/hr
One-Hour Limit (ml): 0.2 ml/kg/hr

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