Patient-controlled analgesia in the terminally ill cancer patient

Patient-controlled analgesia (PCA) is a relatively new therapeutic modality which has allowed postsurgical patients to safely and effectively self-administer doses of intravenous narcotics via a syringe pump and sequencing device. A pilot study was designed to evaluate PCA's safety and effectiveness in the terminally ill cancer patient. Eight patients whose chronic pain was not adequately controlled by oral narcotics were permitted to use PCA for a minimum of 48 hours. Respiratory rates, sedation rankings, and pain rankings indicated these patients achieved satisfactory analgesia with a minimum of sedation and experienced no respiratory depression. Three patients were switched to oral regimens using PCA dosing as a guide. Pain and sedation rankings were similar to those registered while exclusively on PCA. This self-dosing technique was judged to be safe, effective, and able to accommodate wide fluctuations in analgesic need when treating pain in the terminally ill cancer patient. The results obtained in these patients support further trials using PCA to individualize oral analgesic regimens.     

Pharmacy-managed patient-controlled analgesia service

The implementation and functioning of a patient-controlled analgesia (PCA) service operated by staff pharmacists are described. The pharmacy-managed PCA service was introduced into the hospital in 1988. Pharmacists initiate PCA therapy upon physician request. Standard narcotic-dosing guidelines were developed for patients receiving PCA; criteria were also developed to allow the pharmacist to adjust the narcotic dose based upon the patient's response. The dosing guidelines were approved by the pharmacy and therapeutics committee. A hospitalwide education program introduced nurses and physicians to the pharmacy-managed PCA service. Of 299 patients who received PCA therapy in 1989, more than 90% were managed by staff pharmacists. Pharmacists calculate and program initial narcotic doses and are responsible for daily patient monitoring to determine the success of therapy. Using the established guidelines, pharmacists adjust the narcotic dose based upon patient response. A quality assurance review of the PCA service has documented its safety and success. A pharmacy-managed PCA service has increased the clinical involvement of pharmacists and provided safe and effective pain management for postsurgical patients.     

Patient controlled analgesia: drug options, infusion schedules, and other considerations

Patient controlled analgesia (PCA) has a number of advantages compared with traditional methods of pain management. Some of these advantages include superior pain relief, less sedation due to superior drug titration, increased psychological satisfaction due to patient control of pain management, individualized analgesic dosing, decreased staff time for patient care, and increased patient activity and mobility. Although a few cases of respiratory depression have been reported with the use of PCA, there is a relatively low risk of this complication in most patient populations. Appropriate candidates for PCA include terminally ill-cancer patients, postoperative patients, mentally clear and alert trauma patients, and patients who require massive doses of oral narcotics to control pain but are experiencing intolerable side effects. This article focuses on the principles involved in selecting the optimal analgesic and the therapeutic variables involved in using PCA.     

Variation in Postoperative Analgesic Requirements in the Morbidly Obese Following Gastric Bypass Surgery

Patient-controlled analgesia is a relatively new method of administering intravenous narcotics for postoperative pain relief. The technique involves the self-administration of a given analgesic in a bolus dose with the aid of a timed infusion and sequencing device. Ten morbidly obese patients undergoing elective gastric bypass surgery were treated in a prospective, unblinded, pilot project to evaluate the efficacy of patient-controlled analgesia. Analgesic therapy was satisfactory in all patients. The mean total dose of morphine sulfate administered during the first 36 hours postoperatively was 66 mg, an average of 1.7 mg/hr. There was a tenfold variation (17.5–175 mg) in the 36 hr total dose. The total dose was not related to body surface area, age, sex, dose per injection, or anesthetic agent. The large variation in individual narcotic analgesic requirements could be a major factor in the suboptimal management of postoperative pain with conventional dosing. Patient-controlled analgesia may circumvent these problems.     

Efficacy of patient-controlled versus conventional analgesia for postoperative pain

Patient-controlled i.v. administration and intramuscular administration of morphine sulfate were compared in a crossover study to determine their relative effectiveness in relieving postoperative pain. Twenty adult patients scheduled for abdominal surgery were randomly assigned to one of two groups; one group received i.v. morphine sulfate for 24 hours using a patient-controlled analgesia (PCA) device, after which they were given morphine sulfate i.m. for 24 hours. The treatment order was reversed for the other group. Amount of narcotic administered, respiratory rate, and levels of discomfort, activity, and sedation were assessed by the nursing staff every two hours. At the end of each 24-hour treatment phase, patients ranked their level of pain, amount of pain relief, level of sedation, ability to sleep, and ability to perform pulmonary toilet. Patients were also asked whether they preferred PCA or i.m. analgesic therapy for future surgery. Patients reported significantly less discomfort while using PCA than during i.m. morphine administration. No significant differences in amount of narcotic used, respiratory rate, nausea and vomiting, or levels of activity or sedation were noted for the two regimens. Patients' rankings of the two treatment modes did not differ significantly, but a majority of patients indicated a preference for future use of PCA. In these postoperative patients, administration of i.v. morphine sulfate by PCA was as safe as i.m. administration and possibly more effective in relieving pain.     

A multidisciplinary approach to patient controlled analgesia.

Patient controlled analgesia (PCA) is an innovative method for delivering intravenous analgesia, which requires therapeutic and technical expertise from various health care professionals. This article describes a multi-disciplinary process of implementing a PCA program including approaches to solving problems encountered. A pharmacy and therapeutics subcommittee was established with various aspects of the program assigned to the medical, nursing and pharmacy staffs, intravenous (IV) therapy team, and clinical equipment support. A detailed comparison of PCA pumps was prepared to aid in selection. A pharmacy-based protocol describes the role of each health care professional. Usage guidelines are presented and evaluated. Physician order sheets and narcotic disposition forms were designed specifically for PCA. Problems encountered include dedicated IV access, PCA use in specialized hospital units, and use in pediatric patients. A multi-disciplinary approach was successful in implementing and maintaining a quality PCA program. Similar approaches should be used for other sophisticated drug-delivery systems.     

Patient-controlled analgesia: a review.

The patient-activated analgesic system was introduced in 1968. Early trials, although uncontrolled, supported the safety and efficacy of patient-controlled analgesia (PCA) in several kinds of pain, such as that relating to surgery, cancer, trauma, and obstetric procedures. In the past decade, prospective, randomized trials have reported several advantages of PCA over conventional analgesia in the early postoperative period. Although not supported by all controlled trials, they include improved pain relief, less sedation, lower level of narcotic consumption, fewer postoperative complications, greater patient satisfaction, and improved pulmonary function. Preliminary results in the management of chronic pain indicate that PCA can lead to significant lifestyle improvements in ambulatory patients with cancer. The most significant, although infrequent, adverse effect is respiratory depression, the majority of cases occurring in patients predisposed secondary to concomitant illness or as a result of human error. The clinical use of PCA will likely see a significant increase among persons with cancer, and an increase in epidural administration. The cost benefit of PCA has yet to be assessed in inpatient and outpatient settings.     

Analgesia with oral narcotics and added ibuprofen in cancer patients

A scheduled regimen of oral narcotic analgesics was compared with a regimen of oral narcotic analgesics plus ibuprofen for analgesic efficacy in patients with cancer. Ten patients with metastatic cancer were randomly assigned to receive either ibuprofen 400 mg or a look-alike placebo four times daily in addition to each patient's existing regimen of scheduled oral narcotics. A two-period changeover study design was used. The 24-hour narcotic intake equated to injectable morphine was computed for each patient at baseline and during the nine study days. A visual analogue scale was used to evaluate pain relief, nausea, mood depression, daytime drowsiness and nighttime sleeplessness. The analgesic efficacy of the narcotic-ibuprofen combination was significantly greater than the analgesic efficacy of the narcotic-placebo combination. Eight patients demonstrated a positive treatment effect with added ibuprofen; the overall improvement in analgesia averaged 39.1% in these patients. There was no significant increase from baseline in the incidence of nausea, mood depression, daytime drowsiness or nighttime sleeplessness. At the doses used in this study, a treatment regimen of oral narcotic analgesics plus ibuprofen was more effective than oral narcotics alone in relieving pain associated with cancer.     

我院2013年麻醉性镇痛药临床应用分析Δ

目的:调查分析临床麻醉性镇痛药的应用情况,促进合理用药。方法:统计2013年我院麻醉性镇痛药应用情况,包括使用量、销售金额、使用科室及用途等,同时进行处方点评,分析用药合理性。结果:我院以硫酸吗啡缓释片、枸橼酸芬太尼注射液、盐酸布桂嗪注射液用药频度(DDDs)最大。芬太尼注射液及盐酸布桂嗪注射液主要用于手术镇痛;硫酸吗啡缓释片则主要用于癌症等中重度疼痛患者的口服止痛。多数药物销售金额/DDDs排序比接近于1,表示同步性良好。麻醉性镇痛药的主要用途是手术麻醉辅助用药及术后镇痛、癌症镇痛、普通外伤镇痛等。使用科室主要以外科、肿瘤科、妇产科、急诊科为主。在用药合理性方面,用药剂量、频次等方面仍存在问题,还需改进。结论:对于癌痛患者的镇痛治疗,还需临床医师严格按照《癌症三阶梯止痛指导原则》使用麻醉性镇痛药,提高用药合理性。     

Narcotic cuing and analgesic activity of narcotic analgesics: Associative and dissociative characteristics

By using a discrete-trial, two-lever, food-reinforced discrimination learning paradigm, rats were trained to discriminate the narcotic analgesic fentanyl (0.04 mg/kg) from saline. Stimulus generalization experiments with lower fentanyl doses (0.0025 to 0.02 mg/kg) were carried out to generate individual threshold doses. The latter were compared with the sensitivity of the same rats to the analgesic effect of fentanyl, and it was found that there is no correlation between these two sets of data. In a time-effect experiment, the duration of fentanyl's cuing effect was compared with that of its analgesic effect, and it was found that the time-effect characteristics of the narcotic cue are similar to those of analgesia. Again, however, there was no correlation between the duration of both effects within the same group of animals. The results further deliniate the associative and dissociative characteristics of the narcotic cue and narcotic analgesia.     

Prospective patient-controlled analgesia quality assurance: one year's experience

The goal of this project was to develop a prospective patient-controlled analgesia (PCA) quality assurance (QA) program and evaluate its impact on patient care. Initial elements selected for inclusion into the QA were: patient satisfaction, pain relief, clarity of instructions, respiratory rate, and nausea and vomiting. Standards were initially set at 100% with the exception of nausea and vomiting, which was 90%. Preliminary evaluation in 26 patients indicated initial standards were unrealistically high. Standards were revised to 90% for all elements except respiratory rate, which was left at 100%. Nausea and vomiting were eliminated from the QA because it was difficult to establish a cause and effect relationship with narcotic. Data were collected through patient interviews and chart reviews on a bimonthly basis. Cumulative data on 297 patients revealed standards were met in all categories. Two systematic problems identified early in the QA were that there was no recording of respiratory rate and there was a high incidence of unclear instructions. As a result of pharmacist interventions, outcomes improved. Patient outcomes with PCA therapy can be improved using a prospective PCA QA program. Pharmacy Department's without resources for daily monitoring of PCA patients should consider implementing a prospective PCA QA program.     

Pharmacy-initiated introduction of patient-controlled analgesia to a 400-bed community hospital

The pharmacist's role in the implementation of patient-controlled analgesia (PCA) in a 400-bed community hospital is described. PCA for postoperative patients was introduced on the recommendation of the pharmacy and therapeutics committee. A subcommittee selected a PCA pump, developed a physician order form and patient monitoring sheet, and in March 1987 initiated a two-month pilot study of PCA therapy in orthopedic-surgery patients. An orthopedic-service pharmacist developed an inservice-education program for the physicians, anesthesiologists, and nurses involved in the care of these patients. Because of the support of anesthesiologists for this program, PCA use during the two-month period rapidly expanded beyond orthopedics to include general and genitourinary-gynecologic patients. Nursing staff demand for PCA inservice education became so great that all staff pharmacists participated in the teaching. Pharmacists in the decentralized areas also provided one-on-one instruction to physicians, nurses, and patients. Positive evaluations of PCA therapy by patients and nurses and favorable patient pain assessment scores, in addition to the hospital-wide acceptance and use of PCA by medical staff, indicated that the program was a success. Active pharmacist participation was a major factor in PCA being well accepted by physicians, nurses, and patients as an effective alternative method of narcotic administration.     

The fentanyl HCl patient-controlled transdermal system (PCTS): an alternative to intravenous patient-controlled analgesia in the postoperative setting

Inadequate pain control in the postoperative period not only contributes to patient discomfort, but also causes physiological changes that may result in increased risk of myocardial ischaemia, deep vein thrombosis and pulmonary embolism. These events complicate postoperative recovery and may lead to longer hospital stays as well as increased healthcare costs. Patient-controlled analgesia (PCA) has emerged as an effective way for patients to manage their pain, allowing self-administration of small doses of analgesics to maintain a certain level of pain control. PCA is most commonly delivered via an intravenous (IV) or epidural route, and while patient satisfaction is higher with PCA than with conventional methods of analgesic administration, the invasiveness, costs and risk of errors associated with currently available modalities may limit their utility. These systems also require significant healthcare resources, as nurses must manually program the pumps to deliver the correct amount of medication. Several new PCA modalities are being developed to address these limitations. These systems deliver drug through a variety of routes, including nasal transmucosal and transdermal. Most notably, a self-contained, credit card-sized, transdermal PCA system is currently in the final stages of development. The fentanyl HCl patient-controlled transdermal system (PCTS; IONSYS, Ortho-McNeil Pharmaceutical, Inc., Raritan, NJ) uses an imperceptible, low-intensity direct current to transfer fentanyl on demand across the skin into the systemic circulation. This compact system is patient-activated, can be applied to the patient's upper arm or chest, and is designed to manage moderate-to-severe pain requiring opioid analgesia. The system delivers a preprogrammed amount of fentanyl HCI over 10 minutes, for a total of 80 doses, or for 24 hours, whichever occurs first. The on-demand dosing and pharmacokinetics of this system differentiate it from the passive transdermal formulation of fentanyl designed for the management of chronic pain. Clinical studies have shown that the fentanyl HCl PCTS is effective in the management of acute postoperative pain. These studies have also demonstrated that the system is safe and well tolerated by patients.     

Epidural analgesia.

The process of nociception, the anatomy of the epidural space, and the placement of the epidural catheter are reviewed, and the pharmacology and pharmacokinetics, analgesic efficacy, and potential adverse effects of epidurally administered narcotics and local anesthetics are discussed, as well as patient monitoring standards and solution preparation guidelines for these agents. The epidural space is located between the dura mater (the outer-most membrane surrounding the spinal cord) and the vertebral canal. The site of catheter placement is determined by the dermatomes corresponding to the site of desired analgesia. The primary factors that differentiate epidural narcotics are related to their pharmacokinetic profiles. Morphine, which is hydrophilic, has a slower onset of action and a longer duration of analgesia than lipophilic compounds such as fentanyl; morphine also results in less segmentalization (the degree to which analgesia is limited to discrete dermatomal segments corresponding to the level of the epidural narcotic injection) than is seen with lipophilic compounds. Studies have shown that epidural narcotics provide superior pain relief compared with systemic narcotics. Common adverse effects associated with therapeutic doses of intraspinal narcotics include itching, nausea and vomiting, urinary retention, and sedation; respiratory depression is uncommon after epidural administration of narcotics. The most bothersome adverse effect encountered with analgesic doses of local anesthetics is paresthesia. Solutions for epidural administration must be sterile and preservative free. Epidural administration of narcotics and local anesthetics seems to provide better pain relief than conventional methods but may be associated with more bothersome adverse effects.     

Postoperative patient-controlled analgesia in the elderly: risks and benefits of epidural versus intravenous administration

Postoperative patient-controlled analgesia provided by the intravenous route using morphine (PCA) or by the epidural route using an opioid in combination with a local anaesthetic (patient-controlled epidural analgesia; PCEA) is not yet routinely used in the elderly. However, this modality theoretically provides adequate control of postoperative pain in such patients. Firstly, an assessment of the level of pain is particularly difficult in the elderly, and patient-controlled techniques that enable the self-administration of analgesic could resolve this problem. Secondly, these techniques provide a fine and controlled titration of analgesic doses. Since analgesic-induced adverse effects increase with age, the risk of overdose is therefore reduced. Thirdly, effective postoperative patient-controlled analgesia may attenuate detrimental physiologic responses, and contribute to improvement in patient outcomes. In the elderly, PCEA provides better pain relief, particularly for dynamic pain, and improves postoperative recovery with a low incidence of adverse effects compared with PCA. PCA and PCEA techniques have a good safety profile in the elderly only when there is careful preoperative patient selection and strict postoperative monitoring. Standard observation of vital signs, sedation and pain scores and assessment of mental status are required. Patient selection is necessary to identify those patients who may be incapable of using the device (e.g. patients with evidence of cognitive dysfunction or physical disabilities). In addition, caution is required among patients with respiratory, renal or hepatic insufficiency. PCA and PCEA are particularly useful for elderly patients undergoing major thoraco-abdominal surgery. However, there is a need for further research in elderly patients. In the future, improvements in the management of postoperative pain in the elderly will lead to a greater expansion of self-controlled techniques.     

骨科患者术后疼痛控制影响因素的灰色关联分析

摘 要 目的：分析骨科患者术后急性疼痛控制的现状,探讨影响疼痛控制的主要因素,为临床选择镇痛药物和方案提供参考依据。 方法：运用灰色关联分析法,对某院2016年3~4月的骨科手术患者病例资料中的指标进行回顾性分析。结果：术后疼痛控制各影响因素的关联度由高到低依次为：手术类型>患者自控镇痛泵（Patient controlled analgesia, PCA）类型>给药方式>镇痛药类型>医疗保险类型>使用镇痛药数量>性别>年龄。结论：大创伤手术后的疼痛控制尤为重要和棘手;对患者加强疼痛认识和PCA使用方法的宣教,提高PCA使用正确率和镇痛效果;深入研究PCA高效镇痛配方,提高PCA有效率。     

Gabapentin enhances the analgesic response to morphine in acute model of pain in male rats

Whenever opioids as drug of choice result in inadequate analgesia, the combinational therapy would be the solution. In this study the co-administration of gabapentin with morphine is evaluated in acute model of pain. Therefore the antinociceptive effect of gabapentin (30 or 90 mg/kg, s.c.) and morphine (0.5, 1 or 3 mg/kg, s.c.) alone or in combination were measured by tail-flick test in intact adult male rats. Control rats received normal saline. Tail-flick latency time and Area Under Curve (AUC), as antinociception index were calculated for each groups. There was not any significant difference between the antinociceptive response of 0.5 mg/kg morphine and 30 mg/kg gabapentin as compared to controls, but co-administration of these subanalgesic doses increased significantly AUC as compared to morphine alone. The co-administration of gabapentin with analgesic doses of 1 and 3 mg/kg morphine had also increased significantly AUC. Therefore gabapentin enhanced the antinociceptive effect of both analgesic and subanalgesic doses of morphine in a dose dependent manner. In conclusion co-administration of gabapentin with low doses of morphine produced therapeutic analgesia which could have important clinical application.     

青少年特发性脊柱侧凸矫形术后混合镇痛液局部注射的疗效

目的评价青少年特发性脊柱侧凸(AIS)矫形术后局部注射混合镇痛液的疗效和安全性。方法 30例青少年AIS患者随机均分成两组:试验组术后局部注射混合镇痛液;对照组注射生理盐水。两组术后48h内使用患者自控镇痛(PCA),记录PCA的用量,采用视觉模拟评分法(VAS)评估患者疼痛程度。结果试验组术后各时段PCA使用量和48h内PCA使用总量比对照组明显少(P<0.05)。与对照组相比,试验组术后在3、6、12、24、36、48h时的静息状态VAS评分明显低(P<0.05)。结论青少年AIS矫形术后局部注射混合镇痛液安全、有效。     

Meptazinol. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy

Meptazinol is a new opioid-type analgesic with mixed agonist/antagonist properties. It may be given orally, intravenously or intramuscularly. In studies in patients with moderate to severe pain of various aetiologies, usually following surgery or in obstetrics, the characteristics of analgesia with meptazinol were comparable to those seen with equianalgesic doses of pentazocine, pethidine or a combination of dextropropoxyphene and paracetamol. Preoperative use and use as a component of anaesthesia require further investigation before conclusions may be drawn on its effectiveness in these areas. Onset of action, recorded in a few studies, was faster than that with the other analgesics but duration was shorter than that of morphine, buprenorphine and pentazocine. Only a small number of patients with chronic pain have received long term therapy with meptazinol; in such patients there was no need for increased doses as treatment progressed. Respiratory depression has only been observed in patients receiving meptazinol as a premedication or while undergoing anaesthesia. Similarly any haemodynamic changes have been limited to preoperative patients or patients undergoing anaesthesia. Like other agonist/antagonist analgesic drugs, the abuse potential of meptazinol seems relatively low, but only wider clinical use for longer periods can establish this with certainty. The most commonly reported side effects have been gastrointestinal in nature, and although the incidence of central nervous system side effects has been relatively low, drowsiness and dizziness have caused occasional problems. Thus, meptazinol is a relatively potent but safe addition to the analgesics available for treatment of the patient with moderate to severe pain.     

Constant morphine infusion for severe sickle cell crisis pain

The use of a constant infusion of intravenous morphine sulfate in a patient with severe sickle cell crisis is described. After several days of poor control with intramuscular and intravenous narcotic injections, adequate analgesia was obtained with the infusion of morphine within two hours of initiation of therapy. No adverse effects were noted. With the advantages provided by an intravenous narcotic infusion, this protocol should be considered as a suitable alternative to conventional methods for providing pain control in patients in sickle cell crisis.