PCA: The Indications For and the

Advantages and Disadvantages of Patient

Controlled Analgesia
Time Required:
20 minutes
Patient Controlled Analgesia (PCA) is most commonly used for intravenous opioid demand
dosing although the principle can be applied to other treatment modalities e.g. epidural, oral,
iontophoresis and intranasal. This article refers to intravenous Patient Controlled Analgesia.
Some examples of the indications for the use of intravenous PCA are as follows:
Post operative pain management
Trauma
Burns
Sickle Cell Crisis
Essentially any patient who is nil by mouth and is requiring consistent amounts of strong opioid
analgesia.
In addition to effecting a minimum effect analgesic concentration (MEAC) the main advantages
of PCA are as follows:
Empowering patients to have some degree of control over their pain will in turn help to
alleviate anxiety which will in turn reduce pain experience.
It is immediate and effective and the patient does not have to wait to have analgesia
administered.
Extremely useful for incident pain e.g. dressing changes, physiotherapy
The treatment regimen can be tailored to the needs of the individual
Improved quality of recovery and care
Decreased bed occupancy time with resultant economic benefit
More positive perception of hospital stay
However, it is not a concept that will suit all patients and the key to successful use is ensuring
that the patient understands the principle, is compliant and that compliance is monitored. The
following minority groups would be inappropriate for PCA:
Those who are confused or have learning difficulties
Those with poor manual dexterity
The very young (< 5 years) should have Nurse Controlled Analgesia (NCA)
The critically ill (NCA)
The terminology relating to the concept of Patient Controlled Analgesia is defined below.
Loading dose- this is the total opioid dose, which is initially required to provide
analgesia. It is administered either by pre-setting of the PCA pump and allowing
automatic administration, or by nurse administration in the recovery setting. Most
commonly it is the latter.
Bolus dose- this is the quantity of analgesia given to the patient at each self-
administration demand. It is assumed that patients' will demand doses of analgesic until
pain has been relieved, but the size of the demand dose influences the patient's perception
of how effective the treatment has been. If the dose is too small the patient will fail to
achieve adequate analgesia. If the dose is too large the plasma concentration will
gradually increase with repeated doses until it reaches a level causing excessive sedation
and possibly respiratory depression. The optimal dose is the minimum dose to produce
appreciable analgesia consistently without producing objective or subjective side effects.
For morphine this has been quoted as 1 mg, for pethidine 10 mg for adults ([1], [2]) and
for fentanyl 20 microgrammes [3].
Lockout interval- this is the time period between patient demands during which the
machine will not administer a further dose despite any further demands made by the
patient. The lockout interval is determined by the size of the bolus dose, the
pharmacokinetics of the drug and the pharmacodynamics of that drug in the patient (in
particular the length of time for the drug to reach peak plasma concentrations after
intravenous bolus injection). For morphine, peak concentration after intravenous bolus is
achieved after about 4 minutes. It would be inappropriate to set a lockout time shorter
than this time to peak plasma concentration.
Background infusion- the basis of PCA means that the patient experiences pain before
demanding relief or in anticipation of pain e.g. coughing or moving will use the PCA. If a
drug with a short half-life is used analgesia is rapidly achieved but a high demand
frequency is necessary. If the patient falls asleep they will frequently wake up in pain,
which then requires several demands, depending on the length of the lockout interval, to
attain analgesia. These facts lend weight to the potential benefits of a background
infusion [4]. However, the addition of a constant rate background infusion of morphine
neither improved the effectiveness of analgesia by PCA nor reduced the number of
demands ([4], [5]) Studies with other opioids confirm this general principle, even when
using short acting opioids. The addition of a background infusion can also reduce the
inherent safety of PCA. The complete control by the patient has been removed and the
patient will start to receive analgesia even if they do not need it. In particular, studies
have shown that respiratory depression can occur when a background infusion is used
([6], [7]).

References
1. Owen, H., Plummer, J.L., Armstrong, I., Mather, L.E., Cousins, M.J., 1989. Variables of
patient-controlled analgesia. 1. Bolus size.. Anaesthesia, Anaesthesia 44, 7-10.
2. Gould, T.H., Crosby, D.L., Harmer, M., Lloyd, S.M., Lunn, J.N., Rees, G.A., Roberts,
D.E., Webster, J.A., 1992. Policy for controlling pain after surgery: effect of sequential
changes in management.. BMJ, BMJ 305, 1187-93.
3. Camu, F., Van Aken, H., Bovill, J.G., 1998. Postoperative analgesic effects of three
demand-dose sizes of fentanyl administered by patient-controlled analgesia.. Anesth
Analg, Anesth Analg 87, 890-5.
4. Owen, H., Szekely, S.M., Plummer, J.L., Cushnie, J.M., Mather, L.E., 1989. Variables of
patient-controlled analgesia. 2. Concurrent infusion.. Anaesthesia, Anaesthesia 44, 11-3.
5. Vickers, A.P., Derbyshire, D.R., Burt, D.R., Bagshaw, P.F., Pearson, H., Smith, G., 1987.
Comparison of the Leicester Micropalliator and the Cardiff Palliator in the relief of
postoperative pain.. Br J Anaesth, Br J Anaesth 59, 503-9.
6. Owen, H., Reekie, R.M., Clements, J.A., Watson, R., Nimmo, W.S., 1987. Analgesia
from morphine and ketamine. A comparison of infusions of morphine and ketamine for
postoperative analgesia.. Anaesthesia, Anaesthesia 42, 1051-6.
7. Notcutt, W.G., 1988. Introducing patient controlled analgesia into a District General
Hospital.The first 200 patients.
Knowledge Level:
Intermediate
Pain Condition:
Acute Pain
Professional Issues:
Intervention
Care Setting:
Secondary Care