Patient Controlled Analgesia (PCA)
Created By: esiddel 06/27/2005 - 11:34 AM
CONNECTICUT CHILDREN’S MEDICAL CENTER
[Clinical Care Manual]
Title: Patient Controlled Analgesia
(PCA)
Date of Origination: April 1996
Approved By: Leonard Comeau,
MD
Signature(s):
Document Name: pca.doc
Date Last Revised: June 2005
Approval Date: September 2005
I.
Policy: It is the policy of Connecticut Children’s Medical Center
(CCMC) that Patient Controlled Analgesia (PCA) should be used
for the administration of analgesics to minimize pain. A
physician/licensed independent practitioner is responsible for
ordering and adjusting the medications as well as determining the
set limits through a PCA infusion. A registered nurse (RN) is
responsible for monitoring and maintaining a PCA infusion.
II.
II.
Purpose: To state the requirements of care and provide
dosing and assessment recommendations for the child who is
receiving PCA. PCA analgesia is used to allow the patient to
control the analgesic medication to minimize pain, within
physician determined pre-set limits.
III.
III.
Protocol:
A. A. Criteria/Standards:
1. 1. The physician and nursing staff providing care will
determine patient appropriateness for PCA. Such criteria
shall include, but is not limited to:
a. a. Age/cognitive ability (recommended minimum
age for use 7 years old)
b. b. Alertness
c. c. Physical ability (must be able to hold and push
the button)
d. d. Moderate to severe pain level with an
expected minimum duration of pain for 24-36
hours.
2. 2. Nurse-Controlled Analgesia may be used as an
alternative to PCA in patients whose age, clinical
condition, and/or motor or cognitive ability preclude use of
standard PCA. Refer to the “Nurse-Controlled Analgesia”
guidelines for specific instructions.
3. 3. Parent-Controlled Analgesia is inappropriate except
when the patient is receiving palliative care and is
experiencing rapidly escalating, severe pain. ParentControlled Analgesia will not be used at CCMC under any
other circumstances.
4. 4. Patients receiving continuous mode of IV opioids must
be on continuous monitoring for heart rate, respiratory rate,
and SaO2.
a. a.
Patients > one year of age may come off
monitor when the dose of the continuous mode
medication is unchanged for 24 hours.
b. b.
Patients receiving PCA mode-only do not
require this type of monitoring.
B. B. Nursing Responsibilities:
1. 1. The RN is responsible for pump set-up and
programming as ordered by the MD, as well as the tubing
changes and medication cartridge changes.
2. 2. When setting up pump, clear the prior patient’s history.
Do not clear history for subsequent syringe changes for the
same patient.
3. 3. Pain scores will be assessed after initiation, after any
change in pump setting, and ongoing using a standardized
pain rating scale to assess pain relief response to the PCA
medication at least every 8 hours.
4. 4. Assess vital signs and other parameters per unit
standard (at least every 4 hours), or as ordered by the
physician.
5. 5. When using PCA mode only, the infusion should be
“piggy-backed” into another IV fluid source to infuse at a
minimum rate of 3 ml/hour.
C. C. Initiation of PCA:
1. 1. PCA requires a physician order.
2. 2. The patient should be made comfortable before the
PCA pump is initiated. This may require several
intermittent analgesic doses at standard doses (morphine
0.05 to 0.1 mg/kg or equivalent) before the PCA pump is
set. The PCA pump allows for only a single loading dose to
be given at the start. PCA is most effective in maintaining
pain control.
D. D. Recommended Starting Doses (see Table):
1. 1. Due to limits of the PCA pump, round doses to nearest
0.1 mg or nearest 1 mcg.
2. 2. Four hour maximum cannot exceed 30 times drug
concentration (1 PCA cartridge).
Medication
Morphine (1mg/ml)
Loading Dose
Continuous Dose
PCA Dose
Lockout Interval
4 Hour Maximum
(initial)
Hydromorphone
(Dilaudid) (0.2 mg/ml)
Loading Dose
Continuous Dose
PCA Dose
Lockout Interval
4 Hour Maximum
Opioid Naïve Patients
Sickle Cell Crisis or
Chronic Opioid Use
Patients
0.05 – 0.1 mg/kg
0.015 – 0.025 mg/kg/hr
0.03 mg/kg
6-12 minutes
0.3 – 0.35 mg/kg
0.1 mg/kg
0.04-0.06 mg/kg/hr
0.02-0.03 mg/kg
6-8 minutes
0.48 – 0.72 mg/kg
0.01– 0.02 mg/kg
0.003– 0.005 mg/kg/hr
0.006 mg/kg
6-12 minutes
0.06 – 0.07 mg/kg
0.02 mg/kg
0.008-0.012 mg/kg/hr
0.004 – 0.006 mg/kg
6-8 minutes
0.1 – 0.14 mg/kg
**Consult with Department of Pharmacy for use of other opioids
by PCA modality.
E. Assessment and Monitoring:
1. 1. Pressing the history button on the PCA pump
allows the viewer to check how much the patient has
used the pump. It summarizes demands and injections
for the previous 1 and 24 hours. It also allows the
clinician to view each hour of use in reverse
chronological order.
a. a. Demands are the number of times the patient
requests a dose but does not receive one.
b. b. Injections are the number of times the patient
requests a PCA dose and receives one.
2. 2. Pain scores and pump history should be assessed
frequently after initiation of PCA and following any change
in pump settings.
3. 3. Document changes in pain intensity/pain score and
actions taken in nursing flowsheet and/or progress notes.
4. 4. If any of the following “triggers” are present reassess
the situation and consider the need for action:
a. a. Pain score greater than or equal to 4 out of 10
b. b. Verbal complaint of pain
c. c. Patient having more demands than injections in
a 4 hour period
d. d. Patient reaches 4 hour maximum and locks out
e. e. Anticipation that lock out will be reached
f. f. Adverse effects present.
5. 5. Consider whether adjunctive therapies (acetaminophen,
nonsteroidal antiinflammatory agents, antispasmodics) are ordered and
appropriate.
F. Dose Titration:
1. 1. If patient is in acute pain, give a separate bolus dose
(approximately 0.05 mg/kg/dose morphine or equivalent)
per physician order.
2. 2. If no relief in 30 minutes, repeat a bolus one time per
physician order.
3. 3. Reassess reason for increase in pain (e.g. ambulation,
got behind due to long period of sleep.)
4. 4. Make adjustments in dosing (listed in order of
preference):
a. a. If lock out period is long (10-12 minutes)
consider shortening interval (6-8 minutes).
b. b. Increase PCA dose by 10-20% (4 a and 4 b
may be done simultaneously).
c. c. Adjustments to basal infusion should be made
with caution since it may result in drug
accumulation and oversedation. Consider an
increase of 20-40% in basal rate. Changes to the
basal infusion rate should not be made more
frequently than every 6 hours.
d. d. If the basal rate is increased, increase the 4-hour
maximum dose by the same percentage.
G. Transition off PCA Modality:
1. Before transition off PCA consider the following:
a. a. Patient’s anticipated level of activity
b. b. PCA doses required in last 12-24 hours
c. c. Current level of pain control.
2. Steps to transition off PCA:
a. a. Step 1 – Discontinue continuous infusion mode
or consider converting it to a long acting dosage
form at approximate equianalgesic doses if pain is
expected to persist. Leave all other PCA parameters
the same.
b. b. Step 2 – Evaluate PCA only needs over the next
12-24 hours.
c. c. Transition PCA only needs to equianalgesic
doses of intermittent opiate.
H. Patient and Family Education:
1. 1. Patient and family teaching should be provided
prior to the painful event whenever possible, e.g., peroperatively.
2. 2. Teaching should include discussion of the risks of
over-sedation and respiratory depression associated
with use of PCA, and that only the patient will be
allowed to administer bolus doses using the PCA pump.
3. 3.
Provide the patient and family with any
appropriate teaching tools.
III. Documentation:
A. A. Medications:
1. 1. Record medication doses on MAR in the PRN
section and on the Proof-of-Use Pharmacy Sheet (as
appropriate).
2. 2. Record as milligrams or micrograms received every
4 hours.
3. 3. Record medication fluids on the flowsheet.
B. B. Patient teaching:
1. 1. Record initial and ongoing teaching on the patient’s
Care Plan.
2. 2. Record distribution of written teaching materials on
the patient’s Care Plan.
C. C. Assessment:
1. 1. Record vital signs and other assessments on the
flowsheet.
2. 2. Record pain scale scores (including reassessment
scores) and actions taken on the flowsheet.
3. 3. Describe details of the patient’s response to pain
medication and actions taken in the Progress Notes.
IV.
IV.
Resources for Assistance with PCA Management
PCA pump manual (technical questions)
Department of Pharmacy 5-9935
ACUTE PAIN TEAM CONSULT
V.
V.
Cross-referenced Documents:
Assessment and Reassessment of Patients
Intravenous Fluid Administration
Medication Administration
Medication Control
Monitoring Equipment: Medical/Surgical Units
Nurse-Controlled Analgesia
Pain Assessment and Management