A patient-controlled analgesia (PCA) pump is a device that releases medicine for pain that you control with a button. Your healthcare provider presets the dosage so you can't give yourself too much.
The patient-controlled analgesia (PCA) pump is a computerized machine that gives you medicine for pain when you press a button. In most cases, PCA pumps supply opioid pain-controlling medicines such as morphine, fentanyl and hydromorphone. The pump is attached to a thin, flexible tube (intravenous or IV line) that is placed in your vein. This medicine is usually delivered only when you press the button (bolus), but a continuous rate may be added by your doctor if needed (basal rate).
What should I know about the patient-controlled analgesia pump?
Your healthcare provider sets controls on the pump, which are programmed for the pain-relieving drug that the doctor orders based on your age, weight and type of surgery. The PCA pump is safe to use because you receive medication by pressing the button when you feel pain, but the pump won’t give you the drug if it’s not time to receive another dose yet. Remember, no one should press the button on the PCA pump except you. When the pump is empty, an alarm lets the nursing staff know.
Who might use a patient-controlled analgesia pump?
Your doctor might give you a PCA pump to use in the hospital after surgery. Pumps also can be used by people who are dealing with other kinds of pain, including cancer pain and chronic pain problems. If your pain is severe even though you are using the pump, tell a member of your healthcare team.
How often should the patient-controlled analgesia pump be used?
You can use the pump whenever you feel pain. If you’re feeling sleepy, you shouldn’t push the button. The goal of the pump is to keep your pain at a level you can tolerate.
What are the benefits of a patient-controlled analgesia pump?
People who use the pumps often have better pain control and satisfaction compared to nurse-administered boluses. People who have good pain control move around more, cutting down on the risk of blood clots after surgery and benefit from early recovery/discharge. They experience less anxiety and can relax as they feel more in control of their pain and pain medication.
Some common side effects of opioid drugs for pain include:
- Upset stomach.
- Vomiting.
- Nausea.
- Drowsiness.
- Itching.
- Dry mouth.
- Being unable to make a bowel movement (constipation).
- Slowed breathing.
Less common side effects may include having stiff muscles and being more sensitive to pain. Ask your providers about any side effects that you’re worried about. They may need to change your medicine or dosage to help stop the symptoms.
Last reviewed by a Cleveland Clinic medical professional on 03/09/2021.
References
- NIH National Library of Medicine. Patient-controlled analgesia in the management of postoperative pain (//www.ncbi.nlm.nih.gov/pubmed/17181375) , Accessed 4/30/2021.
- Institute for Safe Medical Practices. Patient-Controlled Analgesia: Making It Safe for Patients. (//collections.nlm.nih.gov/master/borndig/101570808/201109_94.pdf) Accessed 4/30/2021.
- Grissinger M. Safety and patient-controlled analgesia: part 2: how to prevent errors. (//via.ccf.org/health-library/article/Grissinger%20M.%20Safety%20and%20patient-controlled%20analgesia:%20part%202:%20how%20to%20prevent%20errors.%20P%20T.%202008;33(1%29:8-9.) P T. 2008;33(1):8-9. Accessed 4/30/2021.
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Patient-controlled analgesia is used to treat acute, chronic, postoperative, and labor pain. A variety of medications can be used for patient-controlled analgesia and are administered intravenously (IV), through an epidural or peripheral nerve catheter, and transdermally. This activity outlines and reviews the role of the interprofessional team in managing patients who undergo patient-controlled analgesia.
Objectives:
Identify the anatomical structures, indications, and contraindications of patient-controlled analgesia.
Describe the equipment, personnel, preparation, and technique in regards to patient controlled analgesia.
Review the potential complications and clinical significance of patient-controlled analgesia.
Outline interprofessional team strategies for improving care coordination and communication to advance and improve outcomes.
Patient-Controlled Analgesia (PCA) has been utilized to optimize pain relief since 1971, with the first commercially available PCA pump appearing in 1976. The goal of PCA is to efficiently deliver pain relief at a patient's preferred dose and schedule by allowing them to administer a predetermined bolus dose of medication on-demand at the press of a button. Each bolus can be administered alone or coupled with a background infusion of medication. PCA is used to treat acute, chronic, postoperative, and labor pain.[1] These medications can be administered intravenously, epidurally, through a peripheral nerve catheter, or transdermally.[2][3] Drugs commonly administered are opioids and local anesthetics, but dissociatives or other analgesics are also options. PCA has proven to be more effective at pain control than non-patient opioid injections and results in higher patient satisfaction.[4]
Modalities for PCA administration include intravenous lines, central lines, epidural catheters, peripheral nerve catheters, or transdermal delivery systems. Any peripheral vein can be used to insert a catheter and begin the administration of PCA. Central lines placed in the internal jugular, subclavian, or femoral veins.[5] Epidural catheters placement is in the epidural space between the dura and the ligamentum flavum, which lines the anterior portions of the vertebral lamina. Within the epidural space sits spinal nerves, blood vessels, and fat.[6] Indwelling epidural catheter placement is at thoracic and lumbar spinal levels. Peripheral nerve catheters are placed adjacently to the nerve or plexus; they are intended to block continuously. These will run through the skin and potentially muscle depending on the desired target location.[2] Transdermal PCA delivery is through a fentanyl iontophoretic transdermal system, which is placed on the epidermis and will provide a dose of fentanyl when the patient pushes a button on the patch.[3]
PCA can be an option for acute, chronic, postoperative, and labor pain, especially in patients who are unable to tolerate oral medications. PCA can be used to reduce the stress on the nursing staff and the patient of having to adhere to a predetermined dosing schedule of as-needed analgesics that may not adequately align with the patient’s fluctuation of pain. PCA can be useful in the acute pain setting where there is inadequate pain control from the initial opioid administration in the emergency department, and continued opioid dosing has been proven to improve patient outcomes. Common examples are vaso-occlusive pain crisis, trauma, pancreatitis, or burns. PCA would be used as an adjunct therapy to treat the pain while the underlying cause gets diagnosed and treated. Patients with chronic illnesses who are suffering from lower levels of constant chronic pain would also be candidates for PCA. The most common examples are metastatic cancer, phantom limb syndrome, and complex regional pain syndrome.[7] Post-surgical patients, especially those with indwelling nerve or epidural catheters, are also ideal candidates for PCA. The ability of a post-surgical patient to titrate and administer their own pain medication allows for superior pain control to scheduled nursing dosing. It also increases patient satisfaction and will result in less intervention by PACU and acute pain service staff. Patients in labor pain are also well-established candidates for epidural PCA. The pain associated with contractions, especially when exacerbated by induction agents such as oxytocin, can be adequately reduced and controlled by the patient.[8]
Absolute contraindications to PCA include:
The patient is unable to understand the concept behind PCA
Systemic infection, or infections at the preferred site of PCA placement
Allergic reactions to the selected medication
Burns or trauma on the area of PCA placement
Preexisting neural deficits in the area of a planned indwelling nerve catheter
Increased ICP for epidural catheter placement
Relative contraindications to PCA include:
Chronic renal failure
The patient is on antithrombotic therapy
The patient has a documented bleeding disorder
Sleep apnea
The administration of PCA requires the selection of route, medication, and type of pump to in use.
Routes:
The route for PCA administration can be through an intravenous catheter, epidural catheter, indwelling nerve catheter, or an iontophoretic transdermal system. The equipment and procedure for the placement of these devices appear in the articles for those specific modalities.
Pumps:
There are a variety of PCA pumps on the market, and all contain the essential components of a locking device, medication chamber, programming screen, and patient button. A provider will insert a syringe of medication into the pump and program the pump to the prescribed initial loading dose, PCA dose, lockout interval, continuous infusion rate, and one and four-hour limits. For intravenous PCA, the medication line then gets connected to a fluid infusion line. It is best to familiarize yourself with your specific institution's pump and protocols for PCA administration.
Medications:
Medications commonly used are opioids and local anesthetics. Opioids are either used alone for intravenous PCA or in conjunction with local anesthetics for epidural catheter PCA.
Opioid medications include pure Mu opioid receptor agonists (morphine, fentanyl, hydromorphone, meperidine, sufentanil, alfentanil, and remifentanil) Mu opioid receptor agonist-antagonists (butorphanol, nalbuphine, pentazocine) and partial Mu opioid receptor agonists (buprenorphine, dezocine). Despite a variety of medication options, morphine remains the gold standard medication for intravenous PCA.
Local anesthetics are primarily used for epidural catheter and indwelling nerve catheter PCA. They include the sodium channel blockers (bupivacaine, levobupivacaine, and ropivacaine).
Other medications can be added to intravenous PCA in an attempt to reduce side effects and improve pain control. They include ketamine, naloxone, clonidine, magnesium, ketorolac, lidocaine, and droperidol. Experiments with these additional medications have had a variety of efficacy, but the mainstay of PCA remains opioids and local anesthetics.[9][10][11]
Multiple staff members are necessary to effectively and safely administer PCA. Individual roles include the physician ordering the route, medication, and dosing, the pharmacist preparing the drug, and the nurse setting up the pump and explaining its use to the patient while periodically monitoring them throughout their use of the device. Lastly, the patient will be personally pressing the administration button.
Before the administration of intravenous PCA, the patient needs pre-procedure assessments across a variety of domains, including cognitive, opioid naivety, pain, sedation, and respiratory assessments. A pre-procedure cognitive assessment ensures the patient has the mental capacity to participate in PCA and can understand the concepts of dosing, interval, lockout, and expected pain relief. Whether the patient is opioid naïve will determine the initial dosing, titration, and expected pain relief and side effects. Periodic pain assessments using the numerical pain rating scale are necessary to create a baseline before PCA begins and to track its efficacy throughout treatment. A sedation assessment should also take place before the procedure begins and periodically throughout. Finally, a respiration assessment of the rate, depth, effort, and sound of breaths should be performed to establish a patient baseline and to monitor the effects of the medications during treatment. These assessments allow for adjustments to be made during administration to meet desired outcomes.[12][13]
Before the administration of PCA through a peripheral nerve catheter or an epidural catheter, a neurological exam assessing for pain sensation, light touch sensation, and motor function over the targeted dermatomes and myotomes require assessment, allowing for the establishment of a baseline function and sensation to be tracked throughout PCA administration.
PCA dosing contains a variety of variables, including the initial loading dose, bolus or demand dose, lockout interval, continuous infusion rate, and one and four-hour limits. The initial loading dose can be titrated by a nurse to reach the minimum effective concentration (MEC) of the desired medication. The bolus or demand dose is the dose of medication delivered each time the patient presses the button. A lockout interval is the time after a demand dose in which a dose of medication will not get administered even if the patient presses the button; this is done to prevent overdosing. A continuous infusion rate can be used in the background of PCA dosing to maintain the MEC of the medication independent of patient demands. One and four-hour limits put a cap on the maximum allowed amount of medication to be administered within those time periods and are usually less than the dose given if the patient were to press the dosing button at every possible interval. This mechanism allows for an added safety benefit and can notify the nurse and provider that the patient’s pain is not under adequate control with the prescribed medication and dosing parameters.[14]
There is a variety of debate and discussion about different dosing strategies regarding PCA such as how much of a loading dose to administer, which medications to use, the amount of drug in the demand dose, the duration of lockout interval, whether to add a continuous background infusion, and what one and four-hour maximums should be. It is best to review the specific literature on PCA dosing strategies for the pain condition you are attempting to treat with PCA.[15]
Common side effects and complications of PCA relate to the inherent mechanism of the procedure and the medications involved. Complications of PCA pumps include “run-away” pumps, failure to use anti-reflux valves, incorrect syringe placement, PCA by proxy, and machine tampering.
Runaway pumps are a result of a mechanical error in which a pump malfunctions and delivers doses at incorrect intervals and amounts. This error can lead to a potentially fatal overdose. While this type of mechanical failure is rare, is it still essential to be aware that this type of complication exists, and patients require periodic monitoring for overdose symptoms.
Anti-reflux valves prevent the opioid medication from flowing up into the intravenous fluid infusion line instead of the intended line that goes towards the patient. Failure to use an anti-reflux valve can result in refluxed medication into the fluid infusion line. This medication could then all be delivered to the patient at once if the intravenous line is flushed, resulting in an overdose.
If the syringe containing the medication is damaged or incorrectly placed into the PCA machine, it could potentially empty by gravity and administer the entire syringe of medication to the patient at once. To prevent this from happening, lines should be cross-clamped when changing the syringe, and machines should be kept level to or below the intravenous catheter in the patient. Some devices are even equipped with anti-siphon valves to prevent this complication.
PCA by proxy is when someone besides the patient is pressing the button to administer a dose because they believe the patient is in pain and needs it. This phenomenon has been documented to lead to respiratory depression. Patients, family members, visitors, and health care providers need to understand the dangers of someone besides the patient pressing the button before PCA treatment modalities can commence.[16]
To prevent tampering with PCA pumps, access to the medication and programming portion of the pump should only be permitted by a health care provider who has a key or code to the pump. Therefore, any tampering that occurs to the machine or medication will be evident. Devices should be routinely checked to make sure there has been no compromise to their locking mechanisms.
Complications of epidural and indwelling nerve catheter PCA include infection, catheter dislodgement, medication leakage, skin irritation, allergic reaction, and short and long term nerve damage.[17][18] They can also include complications resulting from incorrect placement of the catheter such as intravascular, intrapleural, intraneural, and intrathecal placement.
Side effects of PCA administration can be related to the medications or the delivery device used and include nausea and vomiting, constipation, urinary retention, pruritus, respiratory depression, and local anesthetic toxicity.[19][20]
The use of PCA has been proven to be more effective at pain control than non-patient controlled opioid injections and results in higher patient satisfaction. PCA has also been found to be preferred by nurses because it allows for a reduction in their workload. PCA will enable patients to be in more control over their pain and helps them shift toward a more internal locus of control over their care.
PCA has been found to be less cost-effective than traditional dosing and does not affect the average length of hospital stay. When comparing PCA to traditional dosing, it was documented to result in higher opioid consumption, but those same studies also found no significant difference between opioid-related side effects, potentially indicating that the amount of opioid consumption is irrelevant.[21][22]
PCA can be an effective way to control acute, chronic, postoperative, and labor pain. However, it requires a competent interprofessional healthcare team consisting of a physician, pharmacist, nurse, and patient. It is essential to educate healthcare team members about the variety of routes, medications, dosing regimens, complications, pre-procedure, and post-procedure assessments, side effects, and expected outcomes involved. The pharmacist should double-check the dose and ensure that the delivery rate is safe. The nurses should double-check the order and ensure that the correct amount of drug is delivered. The team can inspect the records kept by the device and see if dosing has been optimal for patient pain control. While PCA can reduce the direct involvement of a physician and nurse in pain control, a supervisory role is still necessary to monitor the proper function and effectiveness of the PCA treatment along with the avoidance of undesired outcomes. The entire interprofessional team must communicate with each other to achieve optimal pain control results and avoid poor outcomes. [Level 5]
The nurses should monitor the patient carefully and frequently to assess pain and sedation levels every one to two hours for the first 24-48 hours because the patient is at the highest risk of hypoventilation and nocturnal hypoxemia during this time. Other routine opioid medications ordered for the patient should be avoided when the patient is using an opioid PCA. Nurses should assess for comfort using standard numeric or behavior scales and evaluate the number of demands the patient has made for medication. Based on the patient's requirements, the dose of the PCA can be adjusted.
Nurses are responsible for the placement of peripheral intravenous lines, setup of PCA pumps, insertion of medication into the pumps, and monitoring of the patient’s pain, sedation, and respiration. They ensure that the pump is functioning correctly, and the medications are achieving their intended purpose while avoiding complications and reducing side effects.
While PCA can reduce the need to round and respond to patient calls to administer analgesics, it does not diminish their workload; this is because of the time and effort needed to educate the patient, set up the machine, and monitor its effectiveness and side effects. However, it has been shown to be a preferred method because nurses and patients have more control over their work and pain, respectively.
Review Questions
1.
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2.Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. 2012;2012:560879. [PMC free article: PMC3385590] [PubMed: 22761615]
3.Viscusi ER, Reynolds L, Chung F, Atkinson LE, Khanna S. Patient-controlled transdermal fentanyl hydrochloride vs intravenous morphine pump for postoperative pain: a randomized controlled trial. JAMA. 2004 Mar 17;291(11):1333-41. [PubMed: 15026400]
4.McNicol ED, Ferguson MC, Hudcova J. Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2015 Jun 02;(6):CD003348. [PMC free article: PMC7387354] [PubMed: 26035341]
5.Smith RN, Nolan JP. Central venous catheters. BMJ. 2013 Nov 11;347:f6570. [PubMed: 24217269]
6.Bos EME, Hollmann MW, Lirk P. Safety and efficacy of epidural analgesia. Curr Opin Anaesthesiol. 2017 Dec;30(6):736-742. [PubMed: 28938298]
7.Ahuja V, Thapa D, Ghai B. Strategies for prevention of lower limb post-amputation pain: A clinical narrative review. J Anaesthesiol Clin Pharmacol. 2018 Oct-Dec;34(4):439-449. [PMC free article: PMC6360885] [PubMed: 30774224]
8.Srivastava U, Gupta A, Saxena S, Kumar A, Singh S, Saraswat N, Mishra AR, Kannaujia A, Mishra S. Patient Controlled Epidural Analgesia during Labour: Effect of Addition of Background Infusion on Quality of Analgesia & Maternal Satisfaction. Indian J Anaesth. 2009 Dec;53(6):649-53. [PMC free article: PMC2900073] [PubMed: 20640091]
9.Takieddine SC, Droege CA, Ernst N, Droege ME, Webb M, Branson RD, Gerlach TW, Robinson BRH, Johannigman JA, Mueller EW. Ketamine versus hydromorphone patient-controlled analgesia for acute pain in trauma patients. J Surg Res. 2018 May;225:6-14. [PubMed: 29605036]
10.Tseng WC, Lin WL, Lai HC, Huang TW, Chen PH, Wu ZF. Fentanyl-based intravenous patient-controlled analgesia with low dose of ketamine is not inferior to thoracic epidural analgesia for acute post-thoracotomy pain following video-assisted thoracic surgery: A randomized controlled study. Medicine (Baltimore). 2019 Jul;98(28):e16403. [PMC free article: PMC6641791] [PubMed: 31305450]
11.Firouzian A, Gholipour Baradari A, Alipour A, Emami Zeydi A, Zamani Kiasari A, Emadi SA, Kheradmand B, Hadadi K. Ultra-low-dose Naloxone as an Adjuvant to Patient Controlled Analgesia (PCA) With Morphine for Postoperative Pain Relief Following Lumber Discectomy: A Double-blind, Randomized, Placebo-controlled Trial. J Neurosurg Anesthesiol. 2018 Jan;30(1):26-31. [PubMed: 27673505]
12.Overdyk FJ, Carter R, Maddox RR, Callura J, Herrin AE, Henriquez C. Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesth Analg. 2007 Aug;105(2):412-8. [PubMed: 17646499]
13.Pasero C, McCaffery M. Safe use of a continuous infusion with i.v. PCA. J Perianesth Nurs. 2004 Feb;19(1):42-5. [PubMed: 14770384]
14.Momeni M, Crucitti M, De Kock M. Patient-controlled analgesia in the management of postoperative pain. Drugs. 2006;66(18):2321-37. [PubMed: 17181375]
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16.Sellers CL. Avoid PCA by proxy. Nursing. 2015 Oct;45(10):9. [PubMed: 26629580]
17.Maddali P, Moisi M, Page J, Chamiraju P, Fisahn C, Oskouian R, Tubbs RS. Anatomical complications of epidural anesthesia: A comprehensive review. Clin Anat. 2017 Apr;30(3):342-346. [PubMed: 28165638]
18.Ilfeld BM. Continuous Peripheral Nerve Blocks: An Update of the Published Evidence and Comparison With Novel, Alternative Analgesic Modalities. Anesth Analg. 2017 Jan;124(1):308-335. [PubMed: 27749354]
19.Jamison RN, Mao J. Opioid Analgesics. Mayo Clin Proc. 2015 Jul;90(7):957-68. [PubMed: 26141334]
20.Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014 Sep;34(7):1111-9. [PubMed: 25028740]
21.Hudcova J, McNicol E, Quah C, Lau J, Carr DB. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003348. [PubMed: 17054167]
22.Bainbridge D, Martin JE, Cheng DC. Patient-controlled versus nurse-controlled analgesia after cardiac surgery--a meta-analysis. Can J Anaesth. 2006 May;53(5):492-9. [PubMed: 16636035]