Chapter 29 Patient-Controlled Analgesia

Question 1

basic variables of PCA

Answer 1

initial loading dose, demand (bolus) dose, lockout interval,
basal continuous infusions, and 1- to 4-hr
maximal dose limits

Question 2

demand dose

Answer 2

the amount of

analgesic the patient receives after activation of the pump

Question 3

Optimization of efficacy and safety depends on

Answer 3

the selection of a demand dose large enough to provide sufficient analgesia but small enough to minimize side effects

Question 4

lockout interval

Answer 4

the time during which there will be no

drug delivery, even if the patient pushes the demand button

Question 5

use of a lockout interval that is less than

the time to peak effect of the drug may result in

Answer 5

inadvertent overdosage due to stacking of analgesic doses. However,
lockout intervals between 5 and 10 min appear optimal regardless of the opioid used

Question 6

Reasons Patient-controlled analgesia is extremely popular

Answer 6

Patients like the security of knowing they can
achieve pain relief quickly and easily without involving a nurse, not having to wait for pain relief, and not having intramuscular (IM) or subcutaneous injections . Because of the ease with which each demand dose can be given, small boluses can be given frequently.

Question 7

PCA may avoid subtherapeutic opioid concentration troughs, which can be
associated with

Answer 7

unpleasant recovery secondary to guarding,

poor chest expansion, and reluctance to mobilize

Question 8

PCA may also help avoid excessive peak plasma concentrations,
with associated

Answer 8

respiratory depression and sedation

Question 9

What makes a patient is a good candidate for PCA?

Answer 9

patients must be

cooperative, must comprehend the concept, and must be able to push the PCA button

Question 10

PCA may not be appropriate for

Answer 10

very young children, or for patients with certain menta or physical limitations

Question 11

Nurse-controlled analgesia (NCA)

Answer 11

may be used if the patient’s age, developmental level, or
muscle strength interact with the ability to use the PCA device. NCA is a safe and effective method of analgesic
administration in the pediatric intensive care unit (ICU) setting.

Question 12

most frequent negative perceptions relate to PCA

Answer 12

inadequate analgesia and/or presence of side effects, but some patients also report not trusting the PCA pump, or
fearing overdose or addiction

Question 13

Oversedation with PCA can occur as a result of

Answer 13

repeated excessive use (patient misunderstanding of the analgesic goal), mistaking the PCA handset for the nurse call button, and family, visitor, or unauthorized nurse-activated demand
boluses

Question 14

Operator errors can cause oversedation

via

Answer 14

programming of incorrect bolus dose size, incorrect concentrations, incorrect background infusions, and/or unintended background infusions

Question 15

first choice for IV PCA

Answer 15

Opioids that are pure m-receptor agonists

Question 16

ideal opioid for IV PCA

Answer 16

would have a rapid onset of action, high efficacy, and intermediate
duration of action without significant accumulation
of drug or metabolites over time

Question 17

opioid-based IV PCA types

Answer 17

Morphine, hydromorphone,

and fentanyl

Question 18

why is meperidine may not be a good first choice for IV PCA?

Answer 18

meperidine metabolites can accumulate

Question 19

Drug/ Bolus (mg) / Lockout Interval (min)

Answer 19

Fentanyl:  0.015–0.05/ 3–10 min
Hydromorphone: 0.1–0.5/ 5–15 min
Meperidine:  5–15/ 5–15 min
Morphine: 0.5–3/ 5–20 min 
Oxymorphone: 0.2–0.8 /5–15 min 
Remifentanil (labor) 0.5mcg/kg/ 2 min 
Sufentanil 0.003-0.015/ 3–10 min

Question 20

Continuous infusions of PCA pose increased risk for

Answer 20

respiratory depression

Question 21

Benefit of Continuous

opioid infusion in association with PCA

Answer 21

may provide a

more constant plasma opioid levels and improve analgesia.

Question 22

ketamine

Answer 22

(an N-methyl-d-aspartate [NMDA] receptor antagonist) to IV PCA solutions may improve analgesian in some

Question 23

Clonidine

Answer 23

an a2-adrenergic agonist with analgesic
properties. Addition of clonidine to morphine PCA significantly
reduced nausea and vomiting

Question 24

two common alternative

routes of NONINTRAVENOUS PCAs

Answer 24

patient-controlled epidural analgesia and

patient-controlled peripheral nerve catheter analgesia

Question 25

PCEA compared

with IV PCA.

Answer 25

providing better
pain control, epidural analgesia also has the potential benefits
of decreased morbidity such as fewer cardiopulmonary
complications, less thromboembolism, better mental status, earlier restoration of gastrointestinal function, enhanced functional exercise capacity and health-related quality of
life, and earlier discharge from the hospital.

Question 26

potential risks associated with the placement of a catheter

Answer 26

epidural

hematoma, infection, or neurologic injury

Question 27

Epidural analgesia with a local anesthetic combined with an opioid provides better
postoperative analgesia

Answer 27

than epidural or systemic opioids alone, and may improve postoperative outcome

Question 28

Use of local anesthetic alone may result in

Answer 28

excessive motor blockade

Question 29

complications of PCEA

Answer 29

hypotension and motor blockade.

Question 30

PCEA with clonidine plus local anesthetic can provide

Answer 30

adequate analgesia without the usual opioid-related side effects such as nausea or pruritus

Question 31

to reduce side effects and facilitate transition

to oral analgesia

Answer 31

the PCEA settings can be reduced gradually
rather than abruptly terminating the PCEA. This can be done, for example, by eliminating the basal rate 6 hr prior to stopping the PCEA

Question 32

Many common nerve blocks for extended postoperative analgesia.

Answer 32

brachial plexus, sciatic, and femoral nerve blocks are amenable to having peripheral nerve catheters inserted

Question 33

compared to bupivacaine, Ropivacaine may be associated with reduction
of

Answer 33

complete motor and sensory block,

Question 34

Peripheral nerve catheter patient-controlled analgesia (PNC PCA) Common concentrations of local anesthetic

Answer 34

ropivacaine, 0.2% to 0.3%, and

bupivacaine, 0.12% to 0.25%.

Question 35

During Labor, IV PCA (compared to intermittent IM dosing)

Answer 35

may provide better pain relief and reduce maternal sedation,
respiratory depression, and nausea. it reduces umbilical cord blood opioid levels (indicating less placental drug
transfer); in most cases IV PCA does not cause significant
fetal depression

Question 36

PAIN CONTROL IN PEDIATRIC PATIENTS

Answer 36

children younger
than 4 years of age are not good candidates for PCA use. Children aged 4 to 6 years can use PCA pumps with the
encouragement of nursing staff and parents. Nonetheless, the success rate in this age-group is low. Children older
than 7 years of age often can use PCA independently

Question 37

Pediatric PCA Dosing

Drug/ Bolus (mg/kg) Lockout (min)

Answer 37

Morphine: 10–20 /7–15 min
Hydromorphone: 5–15/ 15 min
Fentanyl: 0.1–0.2/ 7–15 min

Question 38

Pediatric PCEA Dosing

Answer 38

Drug: Bupivacaine 0.06% + hydromorphone 10 mcg/ml
Basal Rate (ml/hr): 0.1–0.3 ml/kg/hr
Demand Dose: 0.1 mg/kg
Lockout (min): Minimum of 10 min
One-Hour Limit (ml):  Max 5 0.4 ml/kg/hr

Question 39

Pediatric Peripheral Nerve Catheter PCA Dosing

Answer 39

Drug: Ropivacaine 0.2%
Basal Rate (ml/hr) :0.1–0.2 ml/kg/hr
One-Hour Limit (ml): 0.2 ml/kg/hr