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Pain at the Pump

Dan Johnson, MD, regional department chief for palliative care for Kaiser-Permanente in Colorado, says the level of experience with the PCA is highly variable among physicians he works with. “Some know how to use the PCA and actually do it quite well. Many others are not adequately trained,” he says. “When I test residents with a few questions, they customarily do very poorly. Some of the answers I see make me nervous.”

Dr. Johnson offers a refresher on the PCA for hospitalists in the Denver area who attend an annual palliative care retreat. Those who come regularly seem to retain the information he offers. “If I were in a hospital that had not rolled out PCA standing orders, I’d make sure that there were educational units provided for hospitalists,” he says. “I’d also investigate how to develop standing orders for the hospital.” TH

Larry Beresford is a frequent contributor to The Hospitalist.

References

  1. Hudcova J, McNicol E, Quah C, et al. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2006;4.
  2. Ballantyne JC, Carr DB, Chalmers TC. Postoperative patient-controlled analgesia: Meta-analyses of initial randomized controlled trials. J Clin Anesth. 1993 May/June;5(3):182-193.
  3. D’Arcy Y. New pain management options: Delivery systems and techniques. Nursing. 2007 February; 37(2):26-27.
  4. Pasero C, McCaffery M. Safe use of a continuous infusion with IV PCA. J PeriAnesthesia Nursing. 2004 Feb;19(1):42-45.
  5. Joint Commission. Patient-controlled analgesia by proxy. Available at www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm. Last accessed July 12, 2007.
  6. Wuhrman E, Cooney MF, Dunwoody CJ, et al. Authorized and unauthorized (“PCA by Proxy”) dosing of analgesic infusion pumps: Position statement with clinical practice recommendations. Pain Manag Nurs. 2007 Mar;8(1):4-11.
  7. Prommer E. Fast Fact and Concept #92, Patient controlled analgesia in palliative care. End-of-Life/ Palliative Education Resource Center, Medical College of Wisconsin, Milwaukee:www.eperc.mcw.edu/ff_index.htm.
  8. Owen H, Plummer JL, Armstrong I, et al. Variables of patient-controlled analgesia. 1. Bolus size. Anaesthesia.1989 Jan.;44(1):7-10.
  9. Vicente KJ, Kada-Bekhaled K, Hillel G, et al. Programming errors contribute to death from patient-controlled analgesia. Can J Anesth. 2003;50:328-332.

How to Titrate the PCA

Teaching guidelines developed by Jean Youngwerth, MD, hospitalist and associate director of the palliative care fellowship program at the University of Colorado Health Sciences Center in Denver. Dr. Youngwerth says she has not found good published guidelines for PCA titration and uses the following guidelines when she teaches residents about pain management and PCAs.

  • Opioid naïve: No basal rate to start; and
  • Chronic opioid use: Use basal rate at equianalgesic dose of chronic opioid.

Parameters:

  • Calculate basal rate (equianalgesic dose of current opioid);
  • Incremental dose: 50%-100% of basal rate;
  • Lockout time: eight to 10 minutes (six-minute lockout for fentanyl);
  • Loading dose: Twice the incremental dose (or 10% of 24-hour dose);
  • Can change incremental dose at least every 30-60 minutes (use for acute pain control; rapid titration). For mild to moderate pain, increase dose by 25%-50%; for moderate to severe pain, increase dose by 50%-100%; and
  • Can change basal rate every eight hours or greater (do not increase by more than 100% at a time).

Dr. Youngwerth emphasizes that these guidelines have not been formally approved by the hospital or implemented as standard practice. They are offered as general information to aid others in developing hospital PCA policies. These rough guidelines should not be construed as medical advice, and clinicians should always take into account patient-specific factors.

Guidelines for PCA use specifically for palliative care patients can be found at the End-of-Life/Palliative Education Resource Center of the Medical College of Wisconsin, in “Fast Fact and Concept #92, Patient controlled analgesia in palliative care”: www.eperc.mcw. edu/fastFact/ff_92.htm.—LB

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