Patient-controlled analgesia opioids

Severe pain should be treated with an IV opioid titrated to pain relief and then administered on a scheduled basis with as-needed dosing for breakthrough pain. Patient-controlled analgesia is commonly utilized. 

Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev. 2005 CD004088. 

Choiniere M, Rittenhouse BE, Perreault S, et al. Efficacy and costs of patient-controlled analgesia versus regularly administered intramuscular opioid therapy. Anesthesiology. 1998 89 1377-1388. 

Maxwell LG, Kaufmann SC, Bitzer S, et al. The effects of a small-dose naloxone infusion on opioid-induced side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia a double-blind, prospective, randomized, controlled study. Anesth Analg. 2005 100 953-958. 

The use of patient-controlled analgesia (PCA) (SEDA-15, 68) highlights the importance of adequate monitoring, in order to avoid potentially catastrophic adverse effects, such as respiratory depression. With PCA, patients generally use less morphine but still achieve the same degree of pain control (7). This supports the view that selfadministration of opioids does not put patients at risk of over-medication or drug dependence. 

Patient-controlled analgesia with epidural pethidine or a single bolus of epidural morphine 4 mg during the 24 hours after cesarean section has been studied in 78 women (91). There were no differences in the degree of analgesia or opioid adverse effects profiles. 

One of the fundamental pharmacological treatments in this group of patients is the opioid continuous infusion with devices adapted to outpatient treatments as patient-controlled analgesia pump. 

Chou WY, Wang CH, Liu PH, et al. Human opioid receptor Al 18G polymorphism affects intravenous patient-controlled analgesia morphine consumption after total abdominal hysterectomy. Anesthesiology 2006 105(2) 334-7. 

In a double-blind, placebo-controlled study in 72 patients undergoing laparoscopic cholecystectomy, oral etoricoxib 120 mg given 1.5 hours before surgery reduced the need for postoperative patient controlled analgesia (PCA) with fentanyl, but opioid-related adverse effects were not reduced. Furthermore, the safety of short-term perioperative use of coxibs has been questioned, as some studies have reported more adverse effects (including myocardial infarction, cardiac arrest, stroke, and pulmonary embolism) with parecoxib or valdecoxib compared with placebo. ... 

Nelson KL, Vaster M, Kost-Byerly S, Monitto CL. A national survey of American pediatric anesthesiologists patient-controlled analgesia and other intravenous opioid therapies in pediatric acute pain management. Anesth Analg 2010 110(3) 754-60. 

Patient-controlled pumps are specific infusion pumps that can be activated by the patient via a pressure pad or button. It is the method of choice for patient-controlled analgesia (PCA), in which repeated small doses of opioid are delivered, with the device coded to stop when the maximum dose per interval is reached. 

Patient-controlled analgesia as primary therapy or as supplementation for epidural or regional techniques Continue neuraxial opioids intrathecal or epidural analgesia Continue continuous neural blockade... 

Epidural anesthesia has been demonstrated to be an effective and acceptable alternative to opioid patient-controlled analgesia in many patients. However, the increased risks of hematoma in patients receiving anticoagulants have limited its use beyond the recovery period in these patients. 

Yeh Y-C, Lin T-F, Lin F-S, Wang Y-P, Lin C-J, Sun W-Z. Combination of opioid agonist and agonist-antagonist patient-controlled analgesia requirement and adverse events among different-ratio morphine and nalbuphine admixtures for postoperative pain. Br J Anaesth 2008 101(4) 542-8. 

Patient controlled transdermal analgesia (PCTA) is one of the newest variations on PCA. PCTA uses a delivery system consisting of a small patch that is approximately the size of a credit card.29,45 This patch is adhered to the patient s skin, usually on the arm or upper chest. The patch is impregnated with an opioid such as fentanyl, and the patient can self-administer a... 

Walder B, Schafer M, Henzi I, Tramer MR. Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain. A quantitative systematic review. Acta Anaesthesiol Scand. 2001 45 795-804. 

The more novel routes of administration of opioids, including oral, nasal, rectal, transdermal, spinal, and by patient-controlled methods, have been outlined (SEDA-17, 78). Oral transmucosal fentanyl administration, avoiding first-pass metabolism, produces analgesia and sedation in both adults and children undergoing short, painful outpatient procedures. The quality of analgesia is good, and the adverse effects are those typical of the opioids. 

Patient-controlled epidural analgesia (PCEA) with fentanyl gives superior analgesia and reduces opioid doses, but without a reduction in adverse effects. However, PCEA with sufentanil offers no advantage (SEDA-19, 87). 

Iontophoretic transdermal fentanyl (fentanyl ITS) was FDA-approved for short-term management of acute post-operative pain in hospitalized adults. The system is intended to be a patient-controlled method for maintenance of analgesia. Titration of a loading dose with opioids to an acceptable analgesic level prior to initiation of the system is recommended. Moreover, since the current (and hence the dose) are not adjustable, this system is most appropriate for opioid-naive patients and should not be preferred for opioid-tolerant subjects or those requiring a basal infusion. 

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