Patient-controlled analgesia

Michael Stone MB ChB FRCA

Bob Wheatley MB ChB FRCA

Although the term patient-controlled analgesia postoperative period is one of the major limita-
(PCA) covers a variety of techniques where tions of the analgesic techniques that preceded Key points
patients self-administer analgesic drugs (e.g. PCA. Intermittent intramuscular opioid injections Patient-controlled analge-
entonox in labour or oral analgesia postoperative- and fixed-rate infusions of opioids are unable to sia, when used appropri-
ately, is a safe and effec-
ly), the term is usually taken to refer to self- deal with a 10-fold difference in opioid consump- tive method of providing
administration of intravenous drugs. The tech- tion between patients in the postoperative period. opioid-based pain relief
nique was developed initially for the relief of pain Similarly, they are often not flexible enough to Safety and efficacy is
in labour using a simple mechanical arrangement cope with the varying demands of an individual optimised by education,
where patients opened a clamp to self-administer patient whose pain is likely to increase during local guidelines and mon-
itoring supervised by an
a dilute solution of meperidine. Sophisticated mobilisation or physiotherapy or at different
acute pain team
electronic pumps were subsequently developed times of the day. The underlying principle of PCA
Choice of opioid does
but these were used mainly for research purposes. is that the patient controls the dose of analgesia not effect the incidence
It was not until the late 1980s that simple, administered. This allows each patient to receive of side-effects or effec-
portable PCA pumps were introduced into every- the appropriate dose of analgesia for them at that tiveness of analgesia
day clinical practice. PCA is now used common- particular time in their postoperative course. A background infusion
ly in many hospitals throughout Europe. The pharmacokinetic basis of PCA is that increases the risk of res-
piratory depression
Although postoperative pain control is the com- patients titrate their plasma opioid concentra-
There is little evidence
monest indication for PCA, the technique is also tions to values above the minimum effective to suggest that patient-
used in other acutely painful situations such as analgesic concentration (MEAC) but below controlled-analgesia
pancreatitis, rib fractures, sickle cell crisis and the minimum toxic concentration (MTC), the improves surgical out-
acute exacerbations of chronic pain. so-called analgesic window (Fig. 1). Although come
this is a useful concept to explain PCA, it is
important to remember that the log dose–
A rationale of PCA response curve for opioid analgesia is not linear
The marked between-patient and within-patient but a steep sigmoidal curve. This means that,
variability seen in the response to opioids in the once the analgesic threshold is reached, small
Serum opioid concentration

Increasing
side effects

MTC
Analgesic
window
MEAC

Increasing Michael Stone MB ChB FRCA

pain Specialist Registrar, Department of
Anaesthetics,York District Hospital,
York YO30 7HE
22 4
4 6
6 8
8 10
10 12
12 16
14
Bob Wheatley MB ChB FRCA
Loading dose PCA bolus doses Retired Consultant Anaesthetist
(for correspondence)
Time (h) Tel: 015394 88981
E-mail: docbobw@hotmail.com
Fig. 1 Pharmacokinetic basis of patient-controlled analgesia.

British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 3 2002

© The Board of Management and Trustees of the British Journal of Anaesthesia 2002 79
Patient-controlled analgesia
Table 1 Ideal characteristics of an electronic PCA device
Regulatory approval
Ease of use for patients and staff and readily distinguishable from other
infusion devices
Lightweight, portable, with a power source, battery back-up and a power
failure alarm
Flexible programming to allow
reliable delivery of a set dose
lockout facility
maximum hourly dose
background infusion
record of dose given and failed attempts
Occlusion and air-in-the-line alarm
Method of telling the patient that a dose is available
Lock to prevent tampering
increases in plasma concentration may result in effective anal-
gesia. Further increases may lead to opioid side-effects rather
than further improvements in analgesia. In some patients (e.g.
elderly, obese patients undergoing upper abdominal surgery),
the difference between MEAC and MTC may be so small that
it will be very difficult to provide analgesia without signifi-
cant opioid side-effects, including respiratory depression.
Equipment
The majority of commercially available delivery systems are
electronic pumps which are simplified, robust versions of the
Cardiff Palliator that was introduced in 1976. The ideal charac-
teristics of an electronic PCA device are shown in Table 1.
PCA should be administered to patients with colour-coded
giving sets which incorporate anti-syphon and anti-reflux
valves. Many of the ideal characteristics of a PCA pump are met
by disposable devices which are able to provide PCA as effec-
tively as electronic PCA pumps.
PCA regimens
PCA is a technique for the maintenance of analgesia. Therefore,
it is assumed that the patient will have been titrated to comfort
with a loading dose of opioid prior to the commencement of
PCA. Variables of the PCA prescription are the choice of opioid
drug and settings of the PCA pump, i.e. bolus dose, lockout
interval, dose limits and background infusion.
Choice of drug
The most commonly used opioid for PCA is morphine but
others are used also (e.g. diamorphine, meperidine, fentanyl,
tramadol). There is no evidence from clinical studies that any
80 British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 3 2002
particular opioid is more effective or associated with a lower
incidence of opioid side-effects. However, individual patients
may have a markedly different response to different opioid
drugs. The benefits for an individual patient of changing from
one opioid to another have to be weighed against the
increased complexity and risks within a hospital of using
more than one drug for PCA.
PCA settings
Bolus dose
The bolus dose delivered to the patient should be the smallest
amount capable of producing an appreciable analgesic effect.
If the bolus is too small to produce an effect, the patient can
lose confidence in the system and will often stop pressing the
demand button. If too large a bolus size is selected, the inci-
dence of side-effects can be increased. Frequently prescribed
bolus doses are morphine 1–2 mg, meperidine 10–20 mg and
fentanyl 10–20 µg. The volume of the bolus dose is also
important. Volumes of < 0.5 ml will often fail to trigger an
occlusion alarm.
Lockout interval
The lockout interval should be set to prevent further doses
being delivered until the bolus dose has had time to achieve
peak effect. Despite the fact that i.v. morphine takes 15 min to
exert its peak effect, the lockout interval is usually set at 5–10
min.
Dose limits
Although most modern PCA pumps have the ‘safety feature’
of allowing the user to set hourly or 4-hourly limits for opioid
usage, there is no clear opinion on how this facility should be
used. It is not a substitute for careful patient monitoring to
ensure patient safety.
Background infusion
There is little evidence that the use of a background infusion
improves analgesia or sleep in the postoperative period.
Furthermore, the addition of a background infusion has been
shown to increase the incidence of respiratory depression and
the incidence of programming errors compared with PCA
alone. Although background infusions should not be used rou-
tinely, they may be useful in patients who are already on high
dose opioids.
The widely used morphine PCA regimen of a 1 mg bolus
dose with a 5 min lockout interval and no background infu-
sion allows the patient to administer a maximum of 12 mg h–1.
This maximum dose is adequate for the majority of patients in

pain and ineffective analgesia is usually due to failure to use
the device properly. Pre-operative patient education and post-
operative re-inforcement are more likely to improve analgesia
than merely increasing the bolus dose or introducing a back-
ground infusion.
Patient factors
Patients’ expectations of quality of pain relief are likely to be
formed by their previous experience and the information they
receive pre-operatively. Quality of pain relief is not necessar-
ily the most important factor for the patient when judging the
quality of postoperative care. Several other factors are seen as
important to patients, e.g. independence, self-control, privacy
and re-assurance. The use of PCA for postoperative pain relief
allows the patient to retain some degree of control at a time
when they often have to relinquish other areas of personal
control. Other advantages of PCA from the patient’s perspec-
tive include not having to bother nursing staff, avoidance of
repeated intramuscular injections and a rapid onset of effec-
tive analgesia.
Patient selection
It is important to realise that not everybody will benefit from
PCA. Any patient having an operation who is likely to require
potent opioids for postoperative analgesia can be considered.
Exclusions include patients unable to understand how to use the
system, e.g. the very young, confusional states. The safe use of
PCA in children over 5 years of age requires education of staff,
patients and parents and the use of standardised protocols.
Although PCA has been shown to be more effective than
intramuscular analgesia in elderly patients, caution should be
exercised in this age group because of alterations in postoper-
ative cognitive function and reduced opioid requirements.
Care should be taken in patients with impaired renal excre-
tion of the metabolites of morphine or meperidine and those
who are particularly sensitive to the airway effects of opioids,
e.g. morbid obesity, obstructive sleep apnoea.
Safety of PCA
The major safety concern regarding the use of PCA is severe
opioid-induced respiratory depression. The incidence of this
complication in hospitals with acute pain services (APS) is
0.1–0.8%. This compares with a risk of 0.2–0.9% for respira-
tory depression following intermittent intramuscular opioid
analgesia and 1.7% for continuous i.v. opioid infusions.
British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 3 2002
Patient-controlled analgesia
Table 2 Risk factors for respiratory depression with PCA
Background infusion
Morphine bolus dose > 1 mg
Elderly
Respiratory disease (including obstructive sleep apnoea)
Proxy control
Concomitant sedatives
Operator error
Equipment failure
However, the risk of respiratory depression with PCA is
increased to 1.1–3.9% if a background infusion is used. Although
the incidence of respiratory depression in a hospital with an APS
and appropriate supervision is likely to be low, well-publicised
cases of respiratory depression still occur. Table 2 lists the risk
factors for the development of respiratory depression.
Documented operator errors have included the use of the
wrong drug (e.g. mixtures designed for epidural use) and pro-
gramming errors (e.g. inappropriate bolus doses), incorrect
drug concentrations and incorrect background infusions.
Equipment failure is a rare cause of respiratory depression
with PCA as modern pumps have several ‘fail-safe’ design
features. Early reports of siphoning of syringe contents asso-
ciated with pump failure or cracked syringes have led to the
routine use of anti-syphon valves and avoidance of position-
ing PCA pumps above patient heart level. Failure of anti-
reflux valves or failure to use them has led to cases of respi-
ratory depression.
The safe use of PCA within a hospital relies on the imple-
mentation of agreed guidelines and supervision by the APS
(Table 3). There is clear evidence that this approach improves
the safety and efficacy of PCA.
Table 3 Key responsibilities of the acute pain service (APS)
• Provision of a continuing education programme for both medical and
nursing staff caring for patients using PCA
• Ensuring the use of a single regimen throughout a hospital so all staff
are familiar with the drug, pump and settings
• Clear instructions on who is responsible for problems related to PCA
and provision of easy access to the APS if they arise
• Ensuring availability of staff capable of dealing with emergencies associ-
ated with PCA, e.g. respiratory arrest
• Ensuring minimum standards of observations, including respiratory
rate, sedation score, pain score at rest and on movement, pulse and
blood pressure
• Provision of a written action plan for the management of common
problems, e.g. inadequate analgesia, emesis, respiratory depression.
81
Patient-controlled analgesia
Patient outcome
Have the initial claims for PCA in terms of improved analge-
sia, reduced opioid consumption, high levels of patient satis-
faction, improved outcome and a reduction in side-effects
been substantiated by recent clinical studies?
Analgesic efficacy
In the majority of studies, PCA has been shown to be as effec-
tive or more effective than intermittent intramuscular analge-
sia. The inability to demonstrate a conclusive improvement in
analgesic efficacy is not as surprising as it seems as many of
the studies compare PCA with optimised forms of intramus-
cular analgesia in well-staffed units. A reduction in opioid
consumption with PCA compared with other forms of opioid
analgesia has not been confirmed in clinical trials.
Patient satisfaction
The reports of high levels of patient satisfaction due to
improved patient-control have recently been tempered by
reports that patients perceive several disadvantages to using
PCA. In a study where a third of patients feared an overdose
or addiction, only 43% of patients had received pre-operative
education. Use of written information at an early stage may be
useful to allay patient anxiety.
Postoperative morbidity
In terms of surgical outcome, there is little evidence to suggest
that PCA is associated with a more rapid recovery of bowel
and respiratory function or a reduction in hospital stay.
Side-effects
A variety of drugs have been used to treat the side-effects of opi-
oids administered by PCA either symptomatically (e.g. anti-
emetics), or indirectly by improving the efficacy of PCA with
opioid-sparing drugs (e.g. NSAIDs and ketamine). Postoperative
nausea and vomiting (PONV) is a common complaint in the post-
operative period and is often regarded by patients (and staff) as
more troublesome than inadequate analgesia. Although PONV
has not been shown to be more common in patients using PCA,
82 British Journal of Anaesthesia | CEPD Reviews | Volume 2 Number 3 2002
failure to treat PONV in these patients often results in aban-
donment of PCA resulting in poor analgesia.
There is little consensus on the ideal drug, or combination
of drugs, that can be best utilised to prevent PONV. Various
strategies have been employed and none are entirely success-
ful. Droperidol, cyclizine and ondansetron have all been
added to PCA syringes. There is still no clear evidence that the
routine addition of anti-emetics to PCA syringes is more ben-
eficial than separate administration of anti-emetics. Any
potential benefits have to be offset against the side-effects and
increased complexity and cost of adding anti-emetics to PCA
syringes.
Conclusions
PCA has become established in the last decade as a safe and
effective method of pain relief. The degree of safety and effi-
cacy has been clearly shown to increase if the technique is
supervised by an APS. Whilst there is little evidence that PCA
has marked advantages over well-organised intermittent intra-
muscular analgesia, the latter technique is more difficult to
provide on busy, poorly-staffed wards.
Future developments in PCA include the use of different
routes of administration (e.g. intranasal route), new drug
delivery systems (e.g. iontophoresis) and new pump technol-
ogy (e.g. adaptive PCA).
Key references
Ballantyne JC, Carr DB, Chalmers TC, Dear KB, Angelillo IF, Mosteller F.
Postoperative patient-controlled analgesia: meta-analyses of initial
randomised control trials. J Clin Anaesth 1993; 5: 182–93
Chumbley GM, Hall GM, Salmon P. Patient-controlled analgesia: an
assessment by 200 patients. Anaesthesia 1998; 53: 216–21
Coleman SA, Booker-Milburn J. Audit of postoperative pain control.
Influence of a dedicated pain nurse. Anaesthesia 1996; 51: 1093–6
Etches RC. Patient-controlled analgesia. Surg Clin North Am 1999; 79:
297–312
Macintyre PE. Safety and efficacy of patient-controlled analgesia. Br J
Anaesth 2001; 87: 36–46
See multiple choice questions 54–58.