Opioids – Role of PCA Patient-controlled analgesia (PCA) provides an effective tool for the delivery of opioid pain medication in the inpatient setting and allows patients to achieve better pain management. However, the safety of PCA is highly dependent on the practices surrounding its use.
Full Answer
What are intravenous opioids?
Intravenous formulations of opioids such as morphine, hydromorphone, and fentanyl very frequently are used to provide analgesia and supplement sedation in an inpatient setting, particularly in the perioperative setting. Fentanyl also exists formulated for transdermal patches for extended absorption.
When is opioid analgesia appropriate?
Opioid analgesia is indicated for the management of pain in patients where an opioid analgesic is appropriate. What, exactly, the term appropriate constitutes has been a recently contentious issue.
Why is proper monitoring of patients using opioid analgesia important?
Summarize proper monitoring of patients using opioid analgesia to prevent misuse, toxicity, or diversion of medications. Review the necessity of interprofessional cooperation and coordination in the management of patients receiving opioid analgesia. Access free multiple choice questions on this topic. Indications
Can opioids be used in the inpatient setting?
Opioids: frequently used in the inpatient setting. Opioids are commonly used – and at relatively high doses – during hospitalization. A Premier national study found that opioids were used in more than half of hospital admissions of non-surgical patients at the 286 US hospitals studied (Herzig 2014).
What is the best opioid for PCA?
What is IV PCA?
What is PCA in opioids?
Why do parturients use IV PCA?
How long does it take for a patient to be discharged from a hospital?
What are the benefits of IV PCA?
Is clonidine an analgesic?
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What is the most commonly used analgesics in hospitalized patients?
Non-opioids analgesics such as NSAIDS and acetaminophen are commonly used in the treatment of acute pain.
What is the route of choice for opioid analgesics after major surgery?
Individual providers and medical facilities may have different policies, procedures, and pain control options available. In most cases after surgery, oral (PO), intramuscular (IM), or intravenous (IV) opioids will be prescribed. Oral medications are usually the preferred prescribed route for use when you return home.
Why are opioid analgesics given?
They reduce the intensity of pain signals from your body and change how your brain perceives pain. Typically, opioids are prescribed to people who are injured, are recovering from surgery, or are suffering from chronic pain.
Can opioids be given IV?
Intravenous (IV) opioids are commonly used to provide analgesia and supplement sedation during general anesthesia or monitored anesthesia care (MAC) and are the most widely used agents for treatment of acute pain in the immediate postoperative period.
Why is postoperative pain controlled most effectively by giving preemptive analgesic s before the surgical procedure is carried out?
1. It should provide pre-emptive analgesia so that animal pain is already being treated as the general anesthetic is wearing off, to prevent sensitization (“ramp- up”) of pain sensory mechanisms, and to lower the overall amount of general anesthetic required for the procedure. 2.
Why post op pain management is so important?
Post-surgical pain control helps speed your recovery and reduces chances of complications, such as pneumonia and blood clots. Pain needs to be managed carefully, with you and your healthcare provider working together to come up with the right plan.
How do opioid analgesics reduce pain?
Opioids attach to proteins called opioid receptors on nerve cells in the brain, spinal cord, gut, and other parts of the body. When this happens, the opioids block pain messages sent from the body through the spinal cord to the brain.
What are opiods used for?
Prescription opioids are used mostly to treat moderate to severe pain, though some opioids can be used to treat coughing and diarrhea. Opioids can also make people feel very relaxed and "high" - which is why they are sometimes used for non-medical reasons.
What is the mechanism of action of opioid analgesics explain why the full agonist of the opioid receptor can cause an addiction effect?
An agonist is a drug that activates certain receptors in the brain. Full agonist opioids activate the opioid receptors in the brain fully resulting in the full opioid effect.
What are the IV opioids?
Intravenous opioids may include fentanyl, hydromorphone, morphine, oxycodone, oxymorphone and tramadol. Examples of opioids prescribed in pill form after surgery include oxycodone (OxyContin, Roxicodone, others) and oxycodone with acetaminophen (Percocet).
What IV pain meds do they give you during labor?
Although there are a great number of narcotics available today, only a few are commonly used for childbirth. They include meperidine (Demerol®), morphine, fentanyl, butorphanol (Stadol®) and nalbuphine (Nubain®).
Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?
The most common nursing diagnosis for opioid toxicity includes: Impaired gas exchange related to decreased ventilatory rate.
What is the best opioid for PCA?
Many opioids have been used effectively for intravenous patient-controlled analgesia (IV PCA). Opioids that are pure μ-receptor agonists tend to be the first choice for IV PCA.26 The ideal opioid for IV PCA has a rapid onset of action, high efficacy, and intermediate duration of action without significant accumulation of drug or metabolites over time. 12 Morphine, hydromorphone, and fentanyl most closely fulfill these criteria and are widely used for opioid-based IV PCA. Conversely, meperidine is generally considered a poor choice for IV PCA agent because the active metabolite, normeperidine, can accumulate and cause CNS excitation, including delirium, tremors, myoclonus, and seizures. 27 However, there may be occasions when meperidine is a reasonable analgesic option. The most recent study examining the safety and efficacy profile of meperidine PCA 28 indicated a CNS toxicity rate of 2%, and recommended a maximum safe dose of 10 mg/kg per day for no longer than 3 days. Patients should be without comorbid renal or hepatic dysfunction, and require careful evaluation and monitoring. All opioids have a similar spectrum of adverse effects, although qualitative differences are detectable. The patient’s clinical history and hospital protocols tend to influence the choice of opioid selected for IV PCA. There are few prominent differences in pain scores and incidence of adverse effects between different opioids. 26,29,30 Consequently, patients tend to be satisfied with PCA regardless of the opioid used. The typical dosing, lockout interval, and basal infusion parameters are indicated in Table 13.1.
What is IV PCA?
Intravenous patient-controlled analgesia (IV PCA) is considered the gold standard by which systemic opioids are delivered postoperatively. Unlike that seen for traditional “as needed” PRN analgesic regimens, IV PCA allows the clinician to compensate for several factors, including the wide interpatient and intrapatient variability in analgesic needs, variability in serum drug levels, and administrative delays, which might result in inadequate postoperative analgesia. By incorporating a negative feedback loop into the device itself (presence of pain leads to self-administration of opioid, whereas there should be no demands with the absence of pain), the IV PCA device per se has a safety device integrated into its design, although when the negative feedback loop is violated, excessive sedation or respiratory depression may occur. 6,7 The majority of the problems related to IV PCA usage result from user or operator errors, and are not attributable to the device itself. 6
What is PCA in opioids?
Intravenous patient-controlled analgesia (PCA) is a system of opioid delivery that consists of an infusion pump interfaced with a timing device. It allows the patient to titrate the analgesic dose required for optimal control of pain. The patient presses a button, and a preset dose of analgesic is delivered. A programmed “lockout” period (usually 6 to 15 minutes) prevents inadvertent overdoses and excessive sedation. This system may be used on top of a baseline continuous infusion. The parameters that can be set therefore include the presence, or absence, of a background continuous infusion, the bolus dose of opioid administered, and the “lockout” period (during which further opioid cannot be delivered).
Why do parturients use IV PCA?
Most parturients who have undergone cesarean delivery appear to use IV-PCA to achieve adequate, but not complete, analgesia. Parturients seem willing to accept a lesser degree of analgesia in order to be more alert, have less nausea, and thus feel better able to interact with their infants.
How long does it take for a patient to be discharged from a hospital?
Ambulation is prescribed after 24 to 48 hours, and hospital discharge is the norm after 72 hours of hospital observation. Nearly 50% of patients are off narcotic-type pain medication by the time of hospital discharge. The labial drains are removed on the day of discharge.
What are the benefits of IV PCA?
Other important benefits of IV-PCA appear to be a lower incidence of opioid-mediated side effects, such as pruritus, 81–83 and a greater degree of patient control over these side effects. 84.
Is clonidine an analgesic?
Clonidine is an α2-adrenoreceptor agonist with analgesic properties. The addition of clonidine to morphine PCA significantly reduced nausea and vomiting in a female population undergoing lower abdominal surgery. 43 However, other studies fail to show significant benefits from inclusion of clonidine with IV PCA. 44.
How effective is continuous monitoring for IV opioids?
However, studies from hospitals using electronic monitoring for all patients on IV opioids are proving that continuous monitoring technologies are cost-effective and create a return on investment by reducing patient harm, length of stay and follow-up care. Two of the monitoring technologies that are being used are pulse oximetry to measure the oxygen saturation in blood with a non-invasive sensor, usually a finger probe and capnography to measure respiratory rate and concentration of exhaled carbon dioxide with a sensor connected to a nasal cannula.
When are opioids used?
Opioids: Frequently Used in the Inpatient Setting. Opioids are commonly used – and at relatively high doses – during hospitalization. A Premier national study found that opioids were used in more than half of hospital admissions of non-surgical patients at the 286 US hospitals studied ( Herzig 2014 ).
What is multimodal pain management?
The use of multimodal, or “balanced,” pain management allows for lower doses of each analgesic and may reduce the severity of side effects associated with each drug. An additional advantage of a multimodal regimen is the synergistic effects on analgesia when drugs with different mechanisms of action are combined.
How many hospitals monitor opioid use?
A recent study on the monitoring practices of eight hospitals testing an e-quality measure for the Centers for Medicare and Medicaid Services (CMS) found that only 25 percent of hospitalized patients receiving opioids are monitored according to guidelines.
When did the Joint Commission update their pain management standards?
The Joint Commission has revised their pain assessment and management standards, effective January 1, 2018, for its accredited hospitals. Effective January 1, 2019 there are new standards for Ambulatory settings opens in a new tab. The revised standards focus effective pain management and opioid prescribing, to include identifying a program leader/team, involving patients in their treatment plans, identifying and monitoring high risk patients, facilitating clinician access to prescription drug monitoring programs, and conducting performance improvement activities on pain assessment and management.
What organization monitors oxygenation?
Many safety and professional organizations recommend continuous monitoring of oxygenation and/or ventilation of patients receiving opioids postoperatively, including the Anesthesia Patient Safety Foundation (APSF ) and the Institute for Safe Medication Practices (ISMP).
How often should you monitor oxygen levels after surgery?
The recommended protocol is to monitor blood oxygen saturation, respiratory rate and level of sedation every two to four hours for the first 24 hours after surgery or the onset of opioid administration.
What is the most common opioid used for postoperative pain?
They can be administered via oral, transdermal, parenteral, neuraxial, and rectal routes. The most commonly used intravenous opioids for postoperative pain are morphine, hydromorphone (dilaudid), and fentanyl. Morphine is the standard choice for opiates and is widely used.
What is the mainstay of postoperative pain therapy?
Opioid Analgesia. Despite years of advances in pain management, the mainstay of postoperative pain therapy in many settings is still opioids. Opioids bind to receptors in the central nervous system and peripheral tissues and modulate the effect of the nociceptors.
How long does it take for fentanyl to work?
It has a rapid onset of action with peak effect occurring in 1 to 2 hours. Fentanyl and hydromorphone are synthetic derivatives of morphine and are more potent, have a shorter onset of action, and shorter halflives compared with morphine. All opioids have significant side effects that limit their use.
Do opioids cause respiratory depression?
All opioids have significant side effects that limit their use. The most important side effect is respiratory depression that could result in hypoxia and respiratory arrest. Hence, regular monitoring of respiration and oxygen saturation is essential in patients on opioids postoperatively.
Is acetaminophen a pain reliever?
Oral acetaminophen is widely used for acute pain relief. Acetaminophen is a common ingredient in many combination oral pain medications, so it is vital to counsel the patient not to exceed the 4000 mg daily maximum dose due to the risk of hepatotoxicity.
Can opioids cause constipation?
In addition, nausea, vomiting, pruritus, and reduction in bowel motility leading to ileus and constipation are also common side effects of these medications.14,15Longer-term use of opioids can lead to dependence and addiction.
What is persistent opioid use?
Development of persistent opioid use is a risk when prescribing opioids for the treatment of acute pain. This risk is amplified by increased doses, additional days supplied, and duration of use. The likelihood of long-term opioid use significantly increases after five days of opioid therapy [ 501 ].
What is a postoperative opioid stewardship program?
“Perioperative opioid stewardship” may be defined as the judicious use of opioids to treat surgical pain and optimize postoperative patient outcomes. The paradigm is not simply “opioid avoidance,” and requires balancing the risks of both over- and under-utilization of these high-risk agents. To this end, postoperative opioid minimization should be pursued only in the greater context of optimizing acute pain management, reducing adverse events, and preventing persistent postoperative pain through comprehensive multimodal analgesia [ 19, 33, 55, 56, 57, 58, 59, 60, 61 ]. Multimodal analgesia, or the use of multiple modalities of differing mechanisms of action, is key to decreasing surgical recovery times and complications, and so is also a fundamental component of the enhanced recovery paradigm promoted by the international Enhanced Recovery After Surgery (ERAS ®) Society [ 19, 24, 62, 63, 64, 65 ]. Dedicated resources and care coordination are often required for institutions to align analgesic use with best practices, so Opioid Stewardship Programs (OSPs) are taking hold, modeled after antimicrobial stewardship practices [ 29, 38, 66, 67, 68 ].
What is regional anesthesia?
Regional anesthesia is a cornerstone of multimodal analgesia and opioid minimization , in addition to reducing perioperative morbidity and mortality. General anesthetics can be reduced or sometimes avoided with regional anesthesia, resulting in shorter recovery times and less adverse drug effects such as postoperative nausea and vomiting. Hence, regional anesthesia is integral to the enhanced recovery paradigm [ 23, 62, 63, 243, 244, 245 ]. The benefits of regional anesthesia continue to be explored and include reduced cancer recurrence when used in oncologic surgeries, likely owing to the mitigation of inflammatory marker surges and other immunomodulatory effects [ 246, 247 ]. While regional anesthesia is a foundational modality for perioperative analgesia and opioid stewardship, it requires input from patients, expertise from clinicians, and careful procedural assessment and institution-specific tailoring of anesthetic options [ 15, 62, 63, 248 ]. Key components and considerations for regional and local anesthetic strategies are summarized in Table 5.
What is the preoperative phase of surgery?
The preoperative phase of surgical care begins at patient presentation to the preoperative area on the day of procedure (“postoperative day zero” or POD0). This onsite period, prior to the administration of sedatives or anxiolytics, is ideal to renew education and expectation-setting regarding perioperative analgesia. The patient and caregiver (s) should be engaged in shared decision-making to finalize the anesthetic plan and complete consent documentation.
What is perioperative pain management?
Perioperative pain management planning should be pursued through a shared decision-making approach and necessitates an accurate pre-admission history and evaluation. Pain assessment should include classification of pain type (s) (e.g., neuropathic, visceral, somatic, or spastic), duration, impact on physical function and quality of life, and current therapies. Other key patient evaluation components include past medical and psychiatric comorbidities, concomitant medications, medication allergies and intolerances, assessment of chronic pain and/or substance use histories, and previous experiences with surgery and analgesic therapies [ 15 ]. Barriers to the safe use of regional anesthetic and analgesic strategies can be identified and considered, such as certain anatomic abnormalities, prior medication reactions, a history of bleeding disorders, or need for anticoagulant use [ 73 ]. Likewise, chronic medications that synergize postoperative risks for ORAEs and complications can be managed expectantly, such as benzodiazepines (e.g., respiratory depression, delirium). While such medications may not be avoided feasibly due to the risk of withdrawal syndromes, consideration could be given to preoperative tapering and/or increased education and monitoring for adverse effects in the perioperative period [ 15, 74 ].
What is perioperative care?
Perioperative care consists of a complex orchestra of medical professionals, physical locations, processes, and temporal phases. This continuum begins prior to the day of surgery (DOS), continues across inpatient or ambulatory stay, and extends through recovery and follow-up phases of care. A maximally effective institutional strategy for perioperative pain management and opioid stewardship includes all phases and providers across this continuum. Though there is no definitive evidence-based regimen, effective multimodal analgesia requires institutional culture and protocols for pre-admission optimization, consistent use of regional anesthesia, routine scheduled administration of nonopioid analgesics and nonpharmacologic therapies, and reservation of systemic opioids to an “as needed” basis at doses tailored to expected pain and preexisting tolerance [ 15, 18, 33 ]. Figure 1 summarizes the recommended strategies at each phase of care, which will be discussed in greater detail.
What is the pre-admission phase of care?
The pre-admission phase of care occurs prior to the day of surgery (DOS) and represents the ideal opportunity for patient optimization. Safe and effective interventions exist during the pre-admission phase to improve pain control and decrease opioid requirements in the subsequent perioperative period. Recommended pre-admission interventions include evaluation of patient pain and pain history, education to patients and caregivers, assessment of patient risk for perioperative opioid-related adverse events (ORAEs) and implementation of mitigation strategies, optimization of preoperative opioid and multimodal therapies, and advance planning for perioperative management of chronic therapies for chronic pain and medication-assisted therapy for substance use disorders.
What is the most important aspect of opioid administration?
The most important aspect of opioid administration is dose-titration, rather than the selection of any particular drug. Other opioids, especially tramadol and meperidine, have numerous side effects and no role in managing critically ill patients. It is commonly taught that there is no “maximal dose” of opioids.
What is analgesic ladder?
(back to contents) The concept of an analgesic ladder was developed by the World Health Organization in 1986, as a theoretical construct to encourage rational use of opioids. It focused on optimizing the use of non-opioid analgesics, before escalating to opioids.
What are the early signs of lidocaine toxicity?
Early signs of toxicity: Perioral paresthesias, visual or auditory disturbance, metallic taste, tinnitus, lightheadedness, and sedation. These should serve as triggers to discontinue the lidocaine infusion, and thus avoid more severe toxicity.
Can you pause ketamine infusion?
If troublesome psychomimetic side effects occur, then pause the ketamine infusion for an hour or two and resume at a lower dose (a dose which didn't cause psychomimetic side effects). Psychomimetic side effects are dose related, and therefore not a contraindication to using ketamine.
Is ketamine infusion safe?
Pain-dose ketamine infusions are extraordinarily safe, especially in an ICU environment (noting that low-dose ketamine infusions can be given safely on the wards). Of all the medications described in this chapter, ketamine is arguably the safest one. Ketamine doesn't suppress respiration or airway protection.
Can opioids cause delirium?
Inadequate pain control or overmedication are both problematic, so this requires thoughtful management. Opioids have traditionally been front-line analgesics in the ICU. However, these cause numerous side effects (delirium, constipation/ileus, vomiting, delayed extubation). For patients with ongoing pain, combining drugs from different ...
Is acetaminophen a good analgesic?
Acetaminophen is a mild-moderately effective analgesic with an excellent safety profile. It forms the first level of the analgesic ladder due to its safety, rather than its efficacy. Acetaminophen is often overlooked because it isn't very potent. However, scheduled acetaminophen may nonetheless play a useful role in multi-modal analgesia. RCTs and meta-analyses demonstrate that acetaminophen is an effective analgesic in a variety of contexts, with benefits which may include reduced opioid requirements, avoidance of delirium, and avoidance of nausea/vomiting. ( 20189753, 30726545, 30305124, 30778597)
What is the best opioid for PCA?
Many opioids have been used effectively for intravenous patient-controlled analgesia (IV PCA). Opioids that are pure μ-receptor agonists tend to be the first choice for IV PCA.26 The ideal opioid for IV PCA has a rapid onset of action, high efficacy, and intermediate duration of action without significant accumulation of drug or metabolites over time. 12 Morphine, hydromorphone, and fentanyl most closely fulfill these criteria and are widely used for opioid-based IV PCA. Conversely, meperidine is generally considered a poor choice for IV PCA agent because the active metabolite, normeperidine, can accumulate and cause CNS excitation, including delirium, tremors, myoclonus, and seizures. 27 However, there may be occasions when meperidine is a reasonable analgesic option. The most recent study examining the safety and efficacy profile of meperidine PCA 28 indicated a CNS toxicity rate of 2%, and recommended a maximum safe dose of 10 mg/kg per day for no longer than 3 days. Patients should be without comorbid renal or hepatic dysfunction, and require careful evaluation and monitoring. All opioids have a similar spectrum of adverse effects, although qualitative differences are detectable. The patient’s clinical history and hospital protocols tend to influence the choice of opioid selected for IV PCA. There are few prominent differences in pain scores and incidence of adverse effects between different opioids. 26,29,30 Consequently, patients tend to be satisfied with PCA regardless of the opioid used. The typical dosing, lockout interval, and basal infusion parameters are indicated in Table 13.1.
What is IV PCA?
Intravenous patient-controlled analgesia (IV PCA) is considered the gold standard by which systemic opioids are delivered postoperatively. Unlike that seen for traditional “as needed” PRN analgesic regimens, IV PCA allows the clinician to compensate for several factors, including the wide interpatient and intrapatient variability in analgesic needs, variability in serum drug levels, and administrative delays, which might result in inadequate postoperative analgesia. By incorporating a negative feedback loop into the device itself (presence of pain leads to self-administration of opioid, whereas there should be no demands with the absence of pain), the IV PCA device per se has a safety device integrated into its design, although when the negative feedback loop is violated, excessive sedation or respiratory depression may occur. 6,7 The majority of the problems related to IV PCA usage result from user or operator errors, and are not attributable to the device itself. 6
What is PCA in opioids?
Intravenous patient-controlled analgesia (PCA) is a system of opioid delivery that consists of an infusion pump interfaced with a timing device. It allows the patient to titrate the analgesic dose required for optimal control of pain. The patient presses a button, and a preset dose of analgesic is delivered. A programmed “lockout” period (usually 6 to 15 minutes) prevents inadvertent overdoses and excessive sedation. This system may be used on top of a baseline continuous infusion. The parameters that can be set therefore include the presence, or absence, of a background continuous infusion, the bolus dose of opioid administered, and the “lockout” period (during which further opioid cannot be delivered).
Why do parturients use IV PCA?
Most parturients who have undergone cesarean delivery appear to use IV-PCA to achieve adequate, but not complete, analgesia. Parturients seem willing to accept a lesser degree of analgesia in order to be more alert, have less nausea, and thus feel better able to interact with their infants.
How long does it take for a patient to be discharged from a hospital?
Ambulation is prescribed after 24 to 48 hours, and hospital discharge is the norm after 72 hours of hospital observation. Nearly 50% of patients are off narcotic-type pain medication by the time of hospital discharge. The labial drains are removed on the day of discharge.
What are the benefits of IV PCA?
Other important benefits of IV-PCA appear to be a lower incidence of opioid-mediated side effects, such as pruritus, 81–83 and a greater degree of patient control over these side effects. 84.
Is clonidine an analgesic?
Clonidine is an α2-adrenoreceptor agonist with analgesic properties. The addition of clonidine to morphine PCA significantly reduced nausea and vomiting in a female population undergoing lower abdominal surgery. 43 However, other studies fail to show significant benefits from inclusion of clonidine with IV PCA. 44.