PATIENT CONTROLLED

ANALGESIA

DEPARTMENT OF ANAESTHESIA
AND PAIN MANAGEMENT

ACUTE PAIN SERVICE

 INTRODUCTION

CONCEPTS ABOUT PAIN

Over 100,000 operations are performed each year here at the Royal
Melbourne Hospital.

Figures worldwide indicate that 50 to 75% of patients get inadequate

postoperative analgesia. This is just for postoperative pain. There are also
the patients with burns, multiple trauma, renal colic, myocardial infarctions or
shingles, etc. A survey at the Royal Adelaide Hospital found 22% of patients
have inadequate pain relief for at least 12 hours and 12% still have severe
pain 60 hours post-operatively.

There are many reasons why pain is treated badly. Apart from an inadequate
knowledge of both the drugs and techniques used in the management of
acute pain, there are a number of myths that surround pain and its treatment.
Myths such as:

‘Pain is good/not harmful for you’

‘The patient will become addicted’
‘Risk of respiratory depression with opioids is high’
‘Maximum doses are morphine 10-15mg, pethidine 100mg, omnopon
20mg’
‘Opioids must not be given more often than 4 hourly’
‘PRN means give as little as possible and as infrequently as possible’
‘Opioid dose is proportional to patient weight’.

WHAT DOES PAIN MEAN TO YOU ?

The official definition is that of the IASP, which is the International Association
for the Study of Pain.

‘An unpleasant sensory and emotional experience associated with

actual or potential tissue damage or described in terms of such
damage.’

In other words, pain is a very individual thing and many factors interact to
produce what the patient then describes as pain. There is an easier,
alternative working definition of pain, and that is:-

‘Pain is what the patient says it is, occurring whenever he/she says it does’
(McCaffery 1989)
This does not mean that patients are not in pain unless they complain of pain.
For many reasons some patients will not want to bother staff and others may
be reticent about admitting to pain. All patients should be asked whether they
have any pain and offered pain relief regularly and frequently. Pain is what
the patient says hurts when asked. Social and psychological problems should
not be ignored but treat them separately. Do not use them to interpret how
much pain you think the patient has.

It was once believed that pain was not harmful. In fact, unrelieved severe
acute pain can lead to the following complications:

RS Splinting, decreased tidal volume, decreased functional

residual capacity and other lung volumes, decreased
cough, sputum retention, infection, atelectasis,
decreased PO2, increased PCO2

CVS Tachycardia, hypertension, increased peripheral

vascular resistance, increased cardiac work, increased
O2 consumption, myocardial ischaemia or infarction,
DVT, pulmonary emboli.

GIT Reduced motility and gastric stasis.

GUT Urinary retention.

ENDOCRINE Increases in aldosterone, ADH, cortisol and

catecholamines resulting in NA+ and H2O retention and
hyperglycaemia.

CNS Anxiety and sleeplessness.

Good pain relief may lead to fewer complications post-operatively and

possibly a shorter hospital stay.

New knowledge and improved techniques have lead to major changes in the
management of acute pain. Successful management of pain and use of
specialised techniques to control pain require that nursing staff receive
appropriate education about, and fully understand, each technique prior to its
introduction into the ward.

Specialised techniques used at the Royal Melbourne Hospital will be reviewed

by an consultant anaesthetist, anaesthetic registrar and nurse each morning
and then by an anaesthetic registrar each evening. With a 24-hour on call
service available.
 ACUTE PAIN SERVICE

HISTORY

Opium has been used as a panacea throughout human history, for both its
analgesic and psychological effects. Opium is obtained from the milky
exudate of the unripe seed capsule of the poppy, Papaver somniferum.
Opium contains about 25 different alkaloids. Only two of these have any
analgesic action - morphine (10% by weight of opium) and codeine (0.5%).
These are called opiates. All drugs, naturally occurring and synthetic, that has
morphine like actions are referred to as opioids. The term narcotic is
nowadays more confined to a legal sense for drugs capable of producing
dependence.

The psychological effects of opium may have been known as far back as
4000BC, when the ancient Sumerians called the poppy the ‘joy plant’. The
first documented reference to poppy juice is found in the writings of
Theophrastus in the third century BC. In the early 1500’s, Paracelsus
compounded ‘laudanum’ from opium and by the middle of the sixteen-century,
the uses of opium that are still valid today were well understood in Europe. In
1860, Thomas Sydenham wrote “Among the remedies that it has pleased
Almighty God to give man to relieve his suffering, none is so universal and
efficacious as opium”. In 1803 a German pharmacist named Serturner
isolated an opium alkaloid that he called morphine, after Morpheus, the Greek
God of sleep.

Recreational use of opium was common in the eighteenth and nineteenth

centuries and its availability was not restricted until the early years of this
century. The invention of the hypodermic needle and glass syringe in 1853,
and the parenteral use of morphine, tended to produce a more severe variety
of compulsive drug use, and in the 1860’s the concept of addiction emerged.
The recognition of this serious liability of morphine stimulated a search for
potent analgesics that would not lead to addiction - the search has not ended.
 OPIODS USED TODAY !

 Morphine. Today, morphine still remains the standard against which new
analgesics are measured. Although newer analgesics possess special
qualities, none is clinically superior in relieving pain. Improved
management of acute pain has come about, not through the development
of new drugs, but through a better understanding of the older drugs and the
introduction of new techniques for their administration.
The main metabolites of morphine are a 3-glucuronide which has very
little, if any, analgesic action, and a 6-glucuronide which is at least as
potent an analgesic as morphine. Both metabolites are excreted through
the kidneys, so if there is renal impairment (which can occur in the elderly,
as well as in overt renal failure) there can be a dangerous build up of the
active metabolite and CNS depression or sedation.

 Pethidine. Pethidine was first synthesised just prior to WW11 by a

German industrial chemist during the search for an alternative to atropine.
As well as an analgesic action, pethidine does have some atropine-like
actions and patients may complain of a dry mouth or tachycardia. Severe
cardiovascular depression may occur in larger (anaesthetic) doses.
The main metabolite of pethidine is norpethidine. This is an analgesic in
its own right with a long half-life of 14 to 21 hours. High blood levels can
cause irritability, twitching and even frank convulsions. Patients receiving
large doses (especially oral) or those with renal impairment are particularly
at risk.

 Papaveretum (Omnopon). Also contains alkaloids of the opium poppy, but

the percentage of morphine by weight is 50%. 20mg papaveretum = 13mg
morphine.

 Codeine. 5 to 10% of codeine is metabolised to morphine and this is

probably how codeine works. The metabolic step is under genetic control
and up to 10% of Caucasians are poor metabolisers. This may be why
codeine does not work as well as expected in some patients.

 Heroin. Heroin is diamorphine. It is metabolised to morphine and

acetylmorphine. A superior efficacy compared to morphine has not been
substantiated.

QUESTION
The metabolites of morphine are M3 Glucuronide and M6 Glucuronide.
These cause
1. Sedation and analgesia
2. Convulsions and irritability
3. Twitching
4. Renal impairment

ANSWER
No 1. Metabolites of Morphine can cause sedation and analgesia,
metabolites of Pethidine, Norpethidine causes convulsion, twitching and
irritability.
 PHARMACOLOGY OF OPIOIDS

Opioid receptors and endogenous opioids

Up until the mid 1970’s there was very little understanding about the
mechanism of action of opioid drugs. In the last 15 to 20 years, not only have
receptor sites for these drugs been identified but it was also discovered that
the body was capable of producing its own opioid drugs - the endogenous
opioids. In 1973 opioid receptors were identified in the central and peripheral
nervous systems. Two years later, in 1975, endogenous opioids were
isolated. The endogenous opioids include endorphins, enkephalins and
dynorphins. They are found in the brain, spinal cord, GI tract and plasma.

Endorphins and enkephalins are released in response to stimuli, such as pain

or stress, but their true functions have not yet been fully defined.

The release of endogenous opioids may be partly responsible for the placebo
response. Any procedure which the patient undergoes with the intention of
relieving pain (technique and/or drug) will relieve pain in a proportion
(approximately one third) of patients. The greater the confidence expressed
by medical and nursing staff about the technique or drug, the more dramatic
the procedure, the greater will be the proportion of placebo responders.

All opioids, endogenous and exogenous (morphine, pethidine, fentanyl, etc.)

act at the opioid receptors and affect the transmission of pain signals to the
brain as well as producing the side effects associated with opioid analgesia.
Their effect can be blocked by naloxone.

To date, five receptor types have been identified - mu, delta, kappa, sigma
and epsilon. The opioids we use for pain management, like pethidine and
morphine, act primarily at the mu receptors and therefore all can cause
respiratory depression, nausea and vomiting, constipation, etc. It is now
thought that there are mu 1 and mu 2 receptors - the mu 1 (high affinity site)
resulting in analgesia and the mu 2 (low affinity site) being mainly responsible
for the respiratory depression and bradycardia. A search is underway for a
drug that acts only on the mu 1 receptor.

The effects of action of the mu receptor are:

Miosis, respiratory depression, bradycardia, mood changes and
analgesia.

OPIOID DOSE

What is the correct dose of opioid for an adult? (There are some differences
in the paediatric population).

The right dose is ENOUGH!

The right dose is BASED INITIALLY ON PATIENT AGE AND
ADJUSTED BY TITRATION.

Each patient has a fairly constant range of blood levels within which they will
get pain relief. It can be thought of as an ‘Analgesic Corridor’ (see Figure 1).
Below this level they feel pain, above this level they still have analgesia but
start to get side effects. This corridor may be at low blood levels or high blood
levels but is stays relatively constant for each patient. Between patients there
is a 5-fold variation in blood level of opioid needed for analgesia. Taking into
account pharmacokinetic variables this means that there is at least an 8 to 10
fold variation in dose requirement between patients. Whatever opioid is
chosen and whatever technique is used to administer it, the aim is to give
enough to provide each patient with a blood level, which falls inside their
analgesic corridor.
Analgesia Drug Concentration

Side Effects
Analgesia
Pain

Time (hours)

Figure one: Analgesia Corridor

The most common parameter that is taken into account when the dose of
opioid to be prescribed is chosen has always been patient weight. When the
correlations between opioid requirement and age or weight were examined,
the results were as follows:

o There is no close correlation between WEIGHT of patient and

DOSE of opioid.
o There is a GOOD CORRELATION between AGE of patient and
DOSE of opioid.

This means that the choice of initial dose should be based on patient age, but
that the 8 to 10 fold variation in dose requirement between patients means
that titration of subsequent doses will still be needed.

QUESTION
The amount of Morphine required by patient
1. Decreases with age
2. Depends more on weight than age
ANSWER
No 1. The amount of Morphine required by any patient decreases with
age and therefore is a more accurate correlation when determination the
initial dose required.
The table shows the equivalent doses of the commonly used opioids when
compared to 10mg intramuscular morphine. Note that if you switch a patient
to oral opioids you will need to prescribe a bigger dose, especially for those
opioids that have a large ‘first pass effect’, i.e. a large percentage of the drug
is metabolised as it passes through the liver (after absorption from the
gastrointestinal tract) into the systemic circulation.

Opioid IM (mg) Oral (mg) Half-life (hrs)

Morphine 10 30-60 1.5-4
Pethidine 75 400 2-6
Methadone 10 20 22-25
Codeine 130 200 3-4
Oxycodone 15 30 2-3

SIDE EFFECTS OF OPIOIDS

Most side effects are very similar, regardless of opioid used. They are
usually dose related and careful titration of the dose for each patient can
reduce the likelihood of side effects occurring. Excessive doses of any opioid
can lead to:

RS Respiratory depression
CNS Sedation, euphoria, miosis, nausea and vomiting, muscle
rigidity.
CVS Vasodilatation (direct or histamine release) with potential for
postural hypotension. Occasionally bradycardia (vagal) and
direct myocardial depression with high doses (e.g. doses
used with anaesthesia). Reduced myocardial O2
consumption.
GUT Urinary retention
GIT Delayed gastric emptying, constipation, spasm of sphincter
of Oddi
ITCHING Not necessarily histamine release but may be action on
opioid receptors. Itch from epidural opioids can be helped
with naloxone.

All opioids in equianalgesic doses cause the same degree of respiratory

depression. This is not always as a reduction in respiratory rate!! Some
patients, particularly the elderly, may get a reduction in tidal volume or
periods of intermittent airway obstruction. This leads to a rise in arterial
PCO2 levels, which cause sedation. Thus:

Sedation = respiratory depression until proven otherwise.

Apnoea may occur while the patient is still conscious - that is, rousable but
not breathing. Tell the patient to take a breath - i.e. although spontaneous
respiration has stopped, a voluntary breath may be possible. Patients who
are sleeping are more likely to get respiratory depression and CNS
depressant drugs, like diazepam and tempazepam, will also increase the
risk of respiratory depression and should not be used at all.

Constipation can also occur just because a patient is confined to bed and is
better prevented with something like Coloxyl, once they are drinking.
 Not all nausea and vomiting is due to opioids. The patient may have an
ileus or a nasogastric tube may be misplaced. If you think that the
nausea/vomiting is due to opioids, it is often dose related and a reduction in
dose may be more appropriate than a change to another drug acting on the
same receptors.

Confusion is often blamed on opioids but in therapeutic doses, opioids are

rarely a direct cause of confusion. However, confusion can result from
hypoxia, and respiratory depression from opioids is only one cause of
hypoxia. Hypoxia can have rapid and irreversible, catastrophic effects,
therefore should be ruled out in all cases. Sleep deprivation, particularly in
the elderly, and sepsis are some of the other causes of confusion.

QUESTION
Which is NOT a feature of respiratory depression seen with opiates?
1. Low respiratory rate
2. Sedation
3. Apnoeic episodes
4. Hypoxia
5. High PH
6. High Pa C02
ANSWER
No 5. Respiratory depression leads to retention of carbon dioxide,
respiratory acidosis and a fall in PH

QUESTION
Opioids may cause

Respiratory depression TRUE/FALSE TRUE

Activation of the sympathetic response TRUE/FALSE FALSE
Insomnia TRUE/FALSE FALSE
Tachyopnea TRUE/FALSE FALSE
Miosis TRUE/FALSE TRUE
Sedation TRUE/FALSE TRUE
Bradycardia TRUE/FALSE TRUE
Diarrhoea TRUE/FALSE FALSE

ADDICTION

Available evidence would suggest that where opioids are used in the medical
treatment of acute pain or chronic cancer pain, addiction is a very, very rare
event. If for some reason it is suspected, or prior abuse is suspected, the
acute pain should be treated and advice sought from agencies such as the
addiction medicine

Addiction is NOT the same as tolerance - if opioids are needed for a longish
period of time, higher doses may be needed to get the same degree of
analgesia. This is quite normal. Similarly, if a patient is on long-term opioid
treatment, suddenly stopping them or suddenly reducing the dose (as
happens if a patient is changed to epidural morphine) could lead to
withdrawal. Again, this is to be expected on physiological grounds and merely
requires a tapering of the dose.
 ASSESSING SIDE EFFECT OF OPIOID ANALGESIA

The most serious and dangerous side effect of opioids is respiratory

depression and this can be assessed by observing respiratory rate and the
sedation score.

SEDATION SCORE

0 Awake, alert
1 Mild sedation, easy to rouse
1S Asleep, easy to rouse
2 Moderate sedation, unable to remain
awake
3 Difficult to rouse

A sedation score of 2 is the maximum that should be allowed to occur. At this

level you would not administer any more opioid and would turn OFF an opioid
infusion and or remove the PCA button.

By knowing ‘how much is enough’, ‘how much is too much’ and that a wide
interpatient variability requires careful titration of dose, it is quite possible to
get very good analgesia with most conventional methods.
NALOXONE (NARCAN)

Dose 0.1 to 0.8mg IV (titrated in 0.1mg doses)

Duration 30 to 90 minutes

Action Opioid receptor antagonist

Complications Hypertension, tachycardia, pulmonary oedema,

arrhythmias, cardiac arrest.

Note that the half-life of naloxone is shorter than the opioid drugs so repeat
doses may be required. If for any reason there is no venous access available,
the naloxone can be given by subcutaneous or intramuscular injection. It will
take longer to work but it is better than nothing. A bolus of 0.4mg should be
given instead of the 0.1mg increments suggested for intravenous use.

The cardiovascular effects mentioned above are very rare and will not occur if
naloxone is titrated as described.

Bigger doses of naloxone are needed if used to reverse respiratory

depression from epidural opioids. It is for this reason that small increments of
naloxone can be used to treat any itching or urinary retention that occurs with
epidural opioid analgesia, without reversing the analgesia.

QUESTION
Which statement best describes NALOXONE ?
1. Reverse the effects of Midazolam
2. Has a longer half life than Morphine and Pethidine
3. Reverse the effects of opioids and should be given as 0.1
mg increments IV.

ANSWER
No 3. Naloxone reverses opioids, it may need to be repeated due to its
shorter half life than opioids and should be given incrementally after an
adequate airway, ventilation and oxygenation are established.
 ASSESSING ADEQUACY OF ANALGESIA

A verbal numerical rating pain score (0 to10) can be used to assess

analgesia. However, it is not always necessary or safe to aim for scores of 0.
Many patients are quite happy and comfortable with scores of 4 or 5 as long
as they know they will not have to wait too long for another dose if the pain
gets worse. This is highlighted in patients who use the PCA machine and are
in control of their own analgesia. They are often quite comfortable with low
pain scores and do not seek to reduce them further.

The patient should be asked to rate their pain on a score of 0 to 10 where:

0 = ‘ no pain’ and 10 = ‘the worst pain imaginable’.

PAIN ASSESSMENT TOOLS (Pain Score 0 – 10)

SUBJECTIVE PAIN SCORES

1. Visual Analogue Scale Ruler

☺ ☹
0 (No Pain) 10 (Worst pain
imagineable)

2. Verbal Numeric Rating Scale

0 1 2 3 4 5 6 7 8 9 10

No pain Moderate pain Worst pain ever

3. Faces Pain Scale (see Acute Pain Service Guidelines – Policy and
Procedure Manual)

4. Behavioural Rating Scale (see Acute Pain Service Guidelines – Policy

and Procedure Manual)

OBJECTIVE PAIN ASSESSMENT TOOL

FUNCTIONAL ACTIVITY SCORE (FAS)

A No limitation Activity is unrestricted by pain

B Mild limitations Activity is mild to moderately restricted by pain
C Severe The ability to perform the activity is severely
limitation limited by pain
 ROUTES OF OPIOID ADMINISTRATION

1. INTRAMUSCULAR

Peak absorption of opioids following injection is usually within 30 minutes.

Analgesia Drug Concentration

Side Effects
Analgesia
Pain

Time (hours)

FIGURE 3 Intramuscular injection

Figure 3 shows what can happen if morphine or pethidine is given at 4 hourly

intervals. To get an injection to last the 4 hours, the bolus dose may need to
be of a size that will produce some side effects initially. This is commonly
reported by patients who may say that they are ‘allergic to morphine’ when, in
fact, they become nauseated and vomited soon after the injection as their
blood level peaked above their ‘analgesic corridor’. It is better to order the
doses at lesser intervals (e.g. 3 or even 2 hourly PRN) and ensure that PRN
means ‘offered frequently’ and not wait for the patient to ask. A ‘little less
more often’ can result in blood levels staying within the ‘analgesic corridor’.

Interestingly, the concept for the ‘4 hourly dose’ regimen seems to date back
to a clinical study done in the 1950’s, when the time between the injection of
opioid and the return of severe pain was found to be 4 hours!

2. SUBCUTANEOUS (USUALLY MORPHINE)

Subcutaneous morphine injection is the injection of morphine into the fatty

layer just beneath the skin - the subcutaneous tissue. The rate of uptake of
morphine into the circulation from this site is similar to the uptake following an
intramuscular injection. An indwelling narrow gauge butterfly needle or small
IV cannula can be left in position, commonly just below the clavicle or the
upper outer aspect of the arm, lower abdomen and injections administered
through the needle, avoiding the need for repeated skin punctures.

3. ORAL

Once the patient is able to drink properly, oral opioids can be very effective for
the management of acute pain, providing the difference between oral and
parental doses is understood. Onset of action is a little slower and duration of
action a little longer than intramuscular/subcutaneous injections of opioid.
Oxycodone (5 mg tablets) is a potent oral opioid and should be given at
regular 3-4 hourly intervals. The dose of oxycodone, as for all routes, should
be individualised for each patient.

4. INTERMITTENT INTRAVENOUS BOLUS DOSES.

Analgesia Drug Concentration

Side Effects
Analgesia
Pain

Time (hours)

FIGURE 4 Intravenous bolus

Not a particularly effective way of administering opioids as the injections need

to be given at least hourly (if not more often) if good analgesia is to be
obtained without side effects. (Figure 4).

5. INTRAVENOUS INFUSIONS
Analgesia Drug Concentration

Side Effects
Analgesia
Pain

Time (hours)

FIGURE 5 INTRAVENOUS INFUSION ALONE

If an infusion is ordered at a constant rate, it takes 5 half-lives of a drug to

reach steady state. The half-life of morphine is 1.5 to 4 hours, so it may take
up to 20 hours to reach a steady state plateau, and it is this plateau that you
want to be in the ‘analgesic corridor’. (Figure 5).
 Analgesia Drug Concentration

Side Effects
Analgesia
Pain

Time (hours)

FIGURE 6 Intravenous Infusion , loading dose plus bolus dose.

An easier way is to get the blood level into the analgesic corridor BEFORE
starting the infusion (Figure 6). To do this we use bolus doses of a small
amount of the opioid. A loading dose means that increments are given until
the patient is comfortable, as long as the sedation score is less than 2 and the
respiratory rate does not drop to less then 8. The infusion can then be
started. If the rate of infusion is too low, pain will return as the blood level
falls. Bolus doses can again be used until the patient is comfortable and the
infusion continued at a higher rate.
Bolus doses can be used in a number of situations:
Loading dose
Before stepping to a higher infusion rate
‘Incident’ pain

6. RECTAL

This route has the benefit that the drug does not pass through the liver before
entry into the systemic circulation. Rectal absorption is often irregular and
incomplete, but can be used if oral ingestion is unreliable.

QUESTION
Which best describes the onset of action of Morphine according to
different routes of administration
1. Intravenous > Oral > Intramuscular > Subcutaneous
2. Intravenous > Subcutaneous = Oral > Intramuscular
3. Intravenous > Intramuscular > Subcutaneous > Oral
4. Intravenous > Subcutaneous = Intramuscular > Oral

ANSWER
No 4. The onset of action of Morphine via the subcutaneous and
intramuscular route is similar.
 PATIENT CONTROLLED ANALGESIA (PCA)

1. INTRODUCTION

Patient controlled analgesia is a method of opioid delivery (usually

intravenous but can be subcutaneous or epidural). A computerised syringe
pump is set to deliver bolus doses whenever the patient presses a button.
Certain parameters are prescribed and programmed into the machine, such
as the bolus size and minimum time to elapse before the patient receives
another bolus. Patient controlled analgesia (PCA) allows small amounts of an
opioid to be give intravenously at frequent intervals, keeping the blood levels
of the opioid within an effective range.

Patient Controlled Analgesia Systems (PCAS) have been successfully used

for the treatment of ‘acute’ pain, especially in the postoperative period in many
centres. The advantages include improved analgesia for patients compared
to conventional intravenous or intramuscular techniques by maintaining the
analgesic blood level within the small effective range for that particular patient.
This then reduces total drug doses and removes the large swings in blood
levels that account for side effects of nausea, sedation and vomiting and for
the pain returning. The PCA also removes observer interpretation of how
much analgesic each patient requires.
Analgesia Drug Concentration

Side Effects
Analgesia
Pain

Time (hours)
2. IMPLICATIONS

Safe use of this technique will have some implications for nurses involved in
the care of these patients.

Registered nurses will be taught to manage these systems during an in-

service training. Instruction will include:

 Pump management
Programming the pump, changing a setting. replacing syringes as they
empty.

 Documentation on the Acute Pain Analgesia and Observation Chart

Pain Assessment including Functional Activity Score
Sedation score
Respiratory rate
No. Bolus given
No. Total Demands
Total cumulative dose – Mg/microg
Side effects.

 Recognition and management of side effects specifically respiratory

depression.

Nursing staff will be asked to demonstrate their ability in these three areas at
the conclusion of the in-service to a designated clinical or nurse educator.
They will then be accredited to use the pumps. There must be 2 accredited
RNs in the ward on any one shift.

3. PROCEDURE

Definitions

P.C.A. - a computerised syringe pump capable of delivering pre-determined

doses of a drug providing time delays between doses as prescribed by the
anaesthetist.

PCA Bolus - The incremental dose of opioid is determined by the volume to

be infused and the drug concentration in the syringe, both of which are
prescribed by the anaesthetist. (e.g. 1 ml bolus of a solution morphine 1
mg/ml equals a 1 mg bolus).

Nurse Initiated Bolus – The dose the patient receives, equal to the PCA
dose when the patient is unable to push the button used in high dependency
areas or Intensive Care only.

Continuous/Background Infusion – A continuous infusion of opioid,

mg/microg per hour. Usually within the first 24 hours postoperatively when
requirement may be higher, in opioid tolerant patient or when patients awake
in pain. However, the risk of respiratory depression will be higher.

Lockout Interval - The period of time between the completion of a bolus and
the commencement time of the next bolus. The interval is prescribed by the
anaesthetist and will usually be 5 minutes. The patient cannot self-administer
another bolus during this period even if the button is depressed.

Guideline For Prescription

Syringe 50 ml Terumo 50 ml Terumo

Drug Morphine 50 mg Fentanyl 500 microcg

Diluent N/Saline N/Saline

Concentration 1 mg/ml 10 microg/ml

Loading Dose Zero Zero

PCA Bolus Dose 1 – 1.5 mg 10 - 20 microg

Lockout Interval 5 minutes 5 minutes

Dosage and Administration

 The dosage, administration and parameters for the PCA’S will be

determined and prescribed by the anaesthetist and recorded on the Acute
Analgesia and Observation Chart (IP12D). Ensure that no other opioids
are prescribed on the inpatient medication sheet (IP12).

 Two registered nurses will check the dosage and PCA parameters
programmed into the pump and record their signatures on the Acute Pain
Analgesia and Observation chart (IP19). The key required to programme
the PCA should be kept with the Drugs of Addiction keys. A spare will be
held by the PACU and replacement key can be obtained through Clinical
Nurse Advisor, Acute Pain Service.

 The administration tubing set will incorporate a ‘PCA extension set’, which
contains a non-reflux valve. A non-reflux valve must be incorporated in all
other IV infusions using the IV cannula in conjunction with the PCA.

 Having established the patency of the cannula, connect it to the infusion

line and commence the infusion.

 The lockout interval will usually be 5 minutes. The patient is able to initiate
and receive 11 bolus doses in any one-hour period. Notify the anaesthetist
when more than 100 – 200 microg Fentanyl or 10 - 15 mg morphine per
hour is administered for two consecutive hours.

 In the recovery period the nursing staff may initiate bolus demands as
deemed necessary within limits charted by the anaesthetist for up to 2
hours post anaesthetic.

 The yellow “PCA” sign must be displayed by the bedside, and all visitors
instructed that only the patient be permitted to initiate a bolus.
 Naloxone 0.4mg ampoule, a syringe, N/Saline 10ml and needle must be
available on the ward whilst the PCA is in use. Naloxone must be ordered
on the Acute Pain Analgesic and Observation chart (IP12D).

 Oxygen will be administered to all patients when prescribed an opioid, on

the Acute Pain Drug Analgesia and Observation Chart (IP12D).

 No other systemic opioids or sedatives are to be administered without

consulting (with the exception of 7SE, Head and Neck surgery patients) the
pain registrar as these may exaggerate respiratory depression).

 Central venous catheters may be used for PCA administration if they are
the only IV access and provided that a separate port from the TPN infusion
is used and that normal aseptic procedures are adhered to.

4. MONITORING AND DOCUMENTATION

 A recording of patient progress is to be made on the Acute Pain Analgesia

and Observation chart (IP12D).

 Pain relief is to be assessed with a Verbal Linear Analogue, Verbal

Numerical Rating Score, Pain Faces Score hourly for the first 12 hours and
then 2 hourly whilst the patent is awake. The scale is between zero and 10
where zero indicates no pain and 10 the worst pain imaginable. Values
over 4 for two consecutive recordings with a Functional Activity Score of C
where activity is severely limited by pain, is to be reported to the pain
anaesthesia registrar.

 A Functional Activity Score (FAS) is to be recorded hourly for 12 hours then

2 hourly. A FAS score of C, where a patients activity is severely limited due
to pain should be reported to the pain anaesthesia registrar.

 A sedation assessment is to be recorded hourly for 12 hours and then 2

hourly. Sedation levels of 2 (moderate, frequently drowsy, difficult to
rouse) and 3 (severe, difficult to arouse) should be reported to the pain
anaesthesia registrar and a level of 3 also requires administration of
naloxone 0.1mg IV increments as per protocol.

 Respiratory rate is to be recorded hourly for 12 hours and then 2 hourly If

the rate falls to 8 and the sedation score is 3 then naloxone 0.1mg IV
increments should be given as per protocol.

 If naloxone is given the pain anaesthetic registrar must be notified.

5. DOSAGE

RECORD

 The No. Bolus given - GOOD and No. Total demands – TOTAL should be
recorded on the Observation section of the Acute Pain Analgesia and
Observation Chart (IP12D).

 These should be recorded hourly for the first 12 hours and then 2 hourly.
 When the patient is self-administering, as each syringe is changed the
syringe number, date, time and initials of the two people checking the
pump settings prior to restarting the pump should be recorded.

 The total volume, dose administered and pump programme settings must
be checked from the syringe at the change of each shift.

6. SIGNS AND SYMPTOMS OF OPIOID OVERDOSE

 Respiratory Depression. Respiration rate is less than, or equal to, 8 per

minute and the sedation score is 2.

 The sedation score is 3.

7. GUIDELINES FOR THE TREATMENT OF OPIOID OVERDOSE.

 Commence oxygen therapy

 Check and clear patients airway

 Place in the lateral position

 Cease PCA including background opioid infusion

 Contact pain anaesthetic registrar on duty and/or call a MET CALL

 Naxolone is to be available on the ward. If the respiratory rate falls to 8, or

below 8, and the sedation score is 2 or greater, naxolone 0.1 mg
increments intravenously may be administered by the registered nurse after
notifying the nurse in charge. The anaesthetist must then be notified
immediately

8. PATIENT ADVICE ON THE PCA INFUSION PUMP

 Pre-operative instruction will be given to patients by an accredited RN. An

information sheet will also be supplied.
 Patient information includes:

Question: What is PCA?

PCA stands for Patient Controlled Analgesia

Question: What can PCA do for you?

The PCA pump allows you to give yourself pain medication when
you need it. You get your pain medication IMMEDIATELY, as
OFTEN as you need it and it acts RAPIDLY. You don’t have to ask
the nurse for injections.
Question: How does PCA work?
You have a hand button that you press when you have pain. When
you press the hand button the pump will give you a small dose of
pain medication into the drip in your arm. The medication starts to
work very quickly ..... within minutes.
Question: Is it safe?
It has been used for many years and the pump has many safety
features. If used correctly it is very effective and safe. Your doctor
prescribes just the right amount of medication and your nurses will
be regularly monitoring your condition. Provided that you only
press the button WHEN YOU FEEL PAIN it is virtually impossible
to overdose yourself.

Question: Each time I press the button do I get a dose of the drug?
No. This is to allow the drug time to work and to help prevent you
from receiving too much. The pump has a time when no matter
how many times you press the button you will not get any more of
the medication. This is called the lockout time.

Question: How often should I press the button?

You should press the button WHENEVER you have pain; also
before you do something that may cause pain, for example, before
the physiotherapist sees you or before you walk to the bathroom.

Early movement will hasten your recovery.

Question: How long will I have the PCA pump?

As long as you need it. Most patients need it for a couple of days
then move onto oral medication.

Question: What are the side effects?

You may feel sleepy at times. Just rest and push the button again
when you become uncomfortable. Another side effect is nausea so
please let your nurse know so that we can relieve this.

It is important to notify your nurse if you are uncomfortable or

experiencing pain, even if you are pressing the button, so that she
can improve your comfort.

9. COMMON PROBLEMS

Nausea/Vomiting
Check for cause:
Give antiemetic as prescribed
If Severe - contact pain anaesthesia registrar who may –
- reduce dose,
- increase dose duration
- add in an non opioid, analgesic adjunct
- change to a different opioid

Patient not comfortable

Repeat patient education
Troubleshoot pump, lines, IV access to ensure patient is
receiving analgesia
Eliminate the possibilities of a post operative complication for
increased pain level.
Look at the number of times the patient has pressed the
demand button each hour. Most patient will not press more the
 3 or 4 times an hour, and if this is occurring the size of the bolus
dose may be increased.
Contact the pain anaesthetic registrar.

10. CONTRAINDICATION TO PCA

Untrained nursing staff

Patient unable to understand instructions (confusion).

QUESTIONS
To institute a PCA, the following requirements are needed
1. 2 accredited RN’s on the ward per shift and an anti-reflux
valve is required to prevent the opioid from back tracking
up the hydration line.
2. An anti-reflux valve PCA set is attached to a triflow giving
set which then is attached to the IV cannula
3. A notice to warn visitors to stay away from the pump

ANSWER
No 1. The anti-reflux valve PCA set must be attached directly to the IV
cannula to prevent the opioid from back tracking up the hydration line.

QUESTION
Concentration of the opioid is expressed in
1. MLS
2. MG
3. GRAMS
4. ML per hour
5. ML per gram
6. MG/Microg per ml

ANSWER
No 6.

REFERENCE
Macintyre P. & Ready L Acute Pain Management – A Practical
Guide. London, Saunders, 1997.
Cooper I.M. Morphine for Postoperative Analgesia. A Comparison of
Intramuscular and Subcutaneous Routes of Administration. Anaesthesia and
Intensive
Care 1996; 24(5):574-578.
Munro A. J., Long G.F and Sleigh J. Nurse Administered Subcutaneous
Morphine
Is a satisfactory alternative to intravenous Patient Controlled Analgesia
Morphine
after Cardiac surgery. Anaesthesia and Analgesia 1998, 87(1) 11-5.
NHMRC – Acute Pain Management: scientific evidence. 2 nd Edition Canberra
Commonwealth Government, 2010 .
Royal Adelaide Hospital Pain Protocols.