Patient-Controlled Analgesia
Devices
INTRODUCTION
Patient-controlled analgesia (PCA) describes the conceptual
framework for on-demand, intermittent administration of opioid
and nonopioid analgesics under patient control.
The broader concept of PCA should neither be restricted to a
single route or mode of administration, nor should PCA imply a
mandatory need for a sophisticated or expensive infusion device.
INTRAVENOUS SYSTEMS
Opioid analgesics remain the mainstay for the treatment of moderate to severe postoperative
pain.
Traditionally, they are administered on an as-needed (PRN) basis via oral and intravenous
routes and, less often, intramuscularly.
To achieve optimal analgesic benefit, several pharmacokinetic principles must be appreciated.
(1) Therapeutic plasma levels and adequate central nervous system (CNS)
delivery must be achieved to assure sufficient occupancy and activation of
opiate receptors.
(2) Therapeutic concentrations for different opioid agonists exhibit wide
interpatient variability.
(3) For most opioids, the therapeutic window is relatively narrow; hence,
underdosing and overdosing can easily occur.
INTRAVENOUS SYSTEMS
The efficacy of IV-administered opioids is also dependent on individual
patient characteristics such as degree of pain perception, absorption from
the administration site, pharmacokinetics and pharmacodynamics, opioid
receptor polymorphisms, and psychologic variables
A patient interactive dose delivery system is usually better able to
accommodate for these variabilities. IV PCA allows patients to self titrate
drugs in proportion to the degree of perceived pain intensity, as well as
dosing adjustments in response to changes in the painful stimulus
A method to reduce PCA by proxy. Labels
are placed on the pump indicating that only
the patient may activate the PCA device.
The photograph shows labels used by the
pain service at Duke University Medical
Center. A new label provides instructions in
Spanish in addition to the English language
sticker (figure courtesy of Dr Brian
Ginsberg).
IV PCA is an analgesic delivery system that allows
patients to self-titrate analgesics in response to the
magnitude of their perceived pain stimulus.
It accommodates for interindividual differences in
analgesic pharmacokinetics and pharmacodynamics, as
well as psychosocial responses to discomfort. Such
therapy may facilitate ambulation because patients can
administer additional doses of analgesics to
compensate for an increasing intensity of incident pain.
Clinical Management
In a recent systematic review on the safety and efficacy of PCA for acute
postoperative pain, Walder et al12 analyzed the data from 288 randomized
controlled trials, comparing opioids administered by IV PCA with
conventional opioid analgesia (intravenous, subcutaneous, and
intramuscular) in postoperative patients. This review presented data
suggesting that, IV PCA therapy provided superior postoperative pain
control.
However, the amount of opioids consumedwas no different with the two
methods, and the incidence of opioid-related adverse reactions (ie,
respiratory depression, hypoxia, nausea and vomiting, sedation, urinary
retention) was similarwith both therapies.
Mu opioid receptor agonists are the mainstays of acute postoperative pain
management and have been successfully administered via IV PCA. They
provide powerful, dose-dependent analgesic effects.However, annoying and,
occasionally intolerable, side effects may result in a “clinical analgesic
ceiling.”
This ceiling may limit further dosing and the achievement of adequate pain
relief. The agonists are equally effective at equianalgesic doses (eg, 10mg of
morphine = 1mg of oxymorphone, = 2 mg of hydromorphone = 100 mg of
meperidine.)
Commercially Available IV-PCA Infusion Devices
NEURAXIAL AND PATIENT
CONTROLLED
Background
ANALGESIA SYSTEMS
Neuraxial drug administration describes a technique of delivering medication into the vicinity of
the spinal cord. Two primary methods of neuraxial drug administration include the epidural
technique and the subarachnoid (intrathecal) technique.
Subarachnoid analgesia is achieved by injecting a bolus dose of drug directly into the
subarachnoid space. The drug is then dispersed in the cerebrospinal fluid (CSF), a medium that is
in direct contact with neural structures of the spinal cord.
Epidural analgesia describes the bolus injection or continous infusion of medications via an
indwelling catheter positioned in the epidural space.
Epidural dosing depends on diffusion of drug through the duramater to produce an effect on
spinal nerve roots or spinal cord.36
NEURAXIAL AND PATIENT CONTROLLED
ANALGESIA SYSTEMS
Design Theory
The proposed theory for the effectiveness of PCEA, also termed epidural patient controlled
analgesia (EPCA) for acute pain management, embodies many of the described assumptions
underlying the efficacy and versatility of IV PCA.
PCEA systems are also designed to take advantage of spinal cord pain processing as well as the
unique pharmacokinetics of opioids and local anesthetics within the neuraxis.
Most PCEA pumps share similar design and technology as pumps designed for IV PCA.
In this regard, many of the devices designed for IV PCA can be used for PCEA and vice versa.
NEURAXIAL AND PATIENT CONTROLLED
ANALGESIA SYSTEMS
Safety
Intravenous PCA and EPCA therapy share similar hazards and potential
for programming errors and device/catheter malfunction.
Epidural infusion devices are predisposed to preparation and
administration errors, including incorrect drug or drug concentrations
and rates of infusion.
That may lead not only to overdose, but also to the risk of
neurotoxicity. For example, bags prepared for IV infusion may be
confused and substituted for epidural solutions with potentially serious
complications
Terima kasih
