PCA Management

If the patient does not receive adequate pain relief with a given demand dose, increase the dose per activation using the parameters suggested in Table 18.6.

Table 18.6 Usual patient-controlled analgesia demand dose changes for inadequate analgesia.

Opioid agonist

Demand dose increase

Morphine

0.5-1 mg

Hydromorphone

0.1 mg

Fentanyl

5-10 mcg

Methadone

0.5-1 mg

Meperidine

5-10mg

A small subset of opioid-na'ive patients may "prove" that they need and can be safe with a continuous infusion. For example, if following several demand dose increases over several hours a patient continues to need to use the PCA frequently to maintain analgesia without evidence of side effects (i.e., sedation or respiratory depression) and they repeatedly "get behind," because they fall asleep, and then awaken in severe pain not adequately treated with the demand doses or easily treated with rescue doses, then a low-dose continuous infusion may be appropriate. The starting continuous infusion for the opioid-na'ive patient should generally not be more than a single demand dose per hour (e.g., 1-2 mg/h for morphine).

If a continuous infusion is being used in any patient, one must be cautious if the amount of pain is assumed to be decreasing with time (e.g., continued healing following surgery). If a patient has a continuous infusion and they do not need to activate the PCA or if side effects (i.e., pruritus, nausea, sedation) begin to increase, then the basal rate should be decreased or discontinued. This allows for the maintenance of the inherent safety of the PCA device in that the patient controls the amount of opioid received to help reduce the chance of severe side effects (i.e., respiratory depression).

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