Pre-reading about Patient
Controlled Analgesia (PCA)
for Children
Royal Children’s Hospital
Melbourne Australia
What is Patient Controlled
Analgesia?
• Patient Controlled Analgesia (PCA) uses a
programmable syringe pump to allow patients
to self-administer their own intravenous
analgesia
• PCA was first described in 1968
• In the late 1980’s improvements in syringe
pump technology allowed PCA to become
available for general use
Childrens Pain Management Service,
RCH, Melbourne
The PCA pump used at RCH:
Alaris PCA pump P5000
Childrens Pain Management Service,
RCH, Melbourne
Advantages of PCA
• Patients can titrate their analgesia to their
pain
• Patients are in “control”
• Rapid response to demand for analgesia
• Reduced patient anxiety compared with other
analgesia techniques
Childrens Pain Management Service,
RCH, Melbourne
Advantages of PCA
• Fewer complications when opioids are
administered this way
• Excellent analgesia for the majority of
patients
• Increased staff, patient and family satisfaction
• Decreased staff workload
Childrens Pain Management Service,
RCH, Melbourne
Safety Factors
• PCA is safer than IM or IV opioid boluses
• Its safety depends on several factors:
• The patient should be the only person to use the handset/button
• The PCA should be set up and supervised by experienced staff
• The PCA program should be standardised according to a fixed
protocol to eliminate error
• At RCH only Anaesthesia staff, Recovery
room nurses and members of the Children’s
Pain Management Service may program
PCA’s
Childrens Pain Management Service,
RCH, Melbourne
Understanding PCA
• The PCA device is a programmable syringe
pump, which delivers the opioid infusions
according to individualised settings:
• Bolus dose
• Lockout time
• Dose duration
• Background infusion
Childrens Pain Management Service,
RCH, Melbourne
Bolus dose
• When the patient presses the remote button,
the PCA delivers the programmed bolus dose
• In cases of severe pain or in patients with
large opioid requirements the bolus dose may
be several times higher than the usual
protocol
Childrens Pain Management Service,
RCH, Melbourne
Lockout time
• Lockout time is usually set at 5 minutes
• The PCA will not deliver a dose during lockout
time, even if the patient presses the button
• This allows each bolus to reach peak effect
before the patient has another bolus
• Lockout time reduces the risk of overdose
Childrens Pain Management Service,
RCH, Melbourne
Good tries / Bad tries
• A good try is when the PCA delivers a bolus
dose of analgesia
• A bad try is when the patient presses the
button during the lockout time and no bolus
dose is delivered
• Knowing the proportion of good and bad tries
allows CPMS to adjust the PCA settings to
meet the patient’s needs or whether further
patient education is required
Childrens Pain Management Service,
RCH, Melbourne
Dose duration
• Dose duration is normally set as ‘stat’
• Alaris PCA ‘stat’ is 70 seconds
• The dose duration may be increased to
prevent problems such as lightheadedness or nausea associated with a
rapid peak of onset of analgesia
Childrens Pain Management Service,
RCH, Melbourne
Background infusion
• Background infusion (continuous infusion)
may be added to improve analgesia
• Generally background infusion is only
required for patients following major surgery
or patients with oncology-related pain and
high opioid requirements
• Background infusions may increase the risk
of the side effects associated with opioids:
• sedation, respiratory depression, itch,
nausea
Childrens Pain Management Service,
RCH, Melbourne
Patient selection
• PCA is suitable for treatment of most types of
acute and acute-on-chronic pain:
• Surgical
• Medical
• Trauma
• Burns
• Oncology
Childrens Pain Management Service,
RCH, Melbourne
Contraindications to PCA
• Inability to understand the concept of PCA
• Children not wishing to control their own
analgesia
Childrens Pain Management Service,
RCH, Melbourne
What aged child can use PCA?
• The child needs to understand the concept of
pressing a button to self-administer
analgesia when required
• Most children of normal intellect over 7 years
can use PCA
• Some younger children can manage PCA
Childrens Pain Management Service,
RCH, Melbourne
Alaris PCA handset
• The Alaris handset is an
electronic switch
• The button is lit at all
times
Childrens Pain Management Service,
RCH, Melbourne
Hand function
• Lack of normal hand function does not mean
children cannot use PCA
• There are a number of alternate handsets
and an oral set available
Childrens Pain Management Service,
RCH, Melbourne
Alternate PCA handsets
• This handset is for patients
with a weak handgrip
• A velcro loop holds the
handset in the palm
• The white button is
pressed to trigger the PCA
Childrens Pain Management Service,
RCH, Melbourne
Alternate PCA handsets
• This handset is for patients
with a very weak handgrip or
no use of their hands
• It is very easy to press so
careful patient selection is
important
• Forearms, feet or knees can
be used to trigger the PCA
• An electronic conversion box
is needed to activate the air
pump
Childrens Pain Management Service,
RCH, Melbourne
• This child with two injured
arms was able to use an
alternate PCA handset with
his fingertips
Childrens Pain Management Service,
RCH, Melbourne
Oral PCA switch
• In rare situations the patient is unable to use
any body part to trigger the PCA
• Using a mouthpiece it is possible for a PCA to
be triggered by a breath from the patient
Childrens Pain Management Service,
RCH, Melbourne
Caring for children using PCA
•
•
•
•
•
•
Correct dose of opioid
Correct programming of PCA pump
Accurate documentation
Observation of vital signs
Documented pain scores
Adequate analgesia achieved
Childrens Pain Management Service,
RCH, Melbourne
Caring for children using PCA
• Monitoring:
•


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sedation scores
respiratory effort, rate, depth
oxygen saturation
heart rate
• The number of good and bad tries are
documented
• The total dose of opioid received is also
recorded
Childrens Pain Management Service,
RCH, Melbourne
Pre-operative education
• The anaesthetist will discuss PCA with the
parents and child pre-operatively
• It is helpful if nurses also explain the basic
principles of PCA to the child prior to surgery
• Many children need further reminding postoperatively about using PCA effectively
• A fact sheet is available for families
Childrens Pain Management Service,
RCH, Melbourne
What to tell children about PCA
The nurse teaching the child and their family
about using PCA should cover the following
topics:
• how the PCA pump works
• when to push the button
• how the PCA helps the child get the right amount of pain
relief medicine
• how the PCA stops the child getting too much pain relief
medicine
Childrens Pain Management Service,
RCH, Melbourne
What to tell children about PCA
• Children should not be told to expect
complete pain relief but instead to use the
PCA to reduce pain to a level where they feel
comfortable
• If the child is experiencing problems with
using the PCA, notify the Children’s Pain
Management Service for review
Childrens Pain Management Service,
RCH, Melbourne
Pre-emptive analgesia
• The PCA device can be used in a pre-emptive
manner to reduce pain from physiotherapy,
dressing changes, turning and ambulation
• Children should be reminded to use their PCA
once or twice before the painful event occurs
• It is helpful that staff remember to give the
child enough time so the analgesia peaks
prior to the painful event
Childrens Pain Management Service,
RCH, Melbourne
Children's Pain Management Service
• The Children's Pain Management
Service supervises all patients with PCA
at Royal Children's Hospital
• CPMS can be contacted at all times on
pager 5773
Childrens Pain Management Service,
RCH, Melbourne
Finally…
Optimal pain management
is the right of all patients
and the responsibility of
all health professionals
Childrens Pain Management Service,
RCH, Melbourne