Patient-Controlled Analgesia in High-Risk Populations: Implications for Safety

Abstract

We aim to (1) identify the benefits and risks of patient-controlled analgesia and (2) analyze the risks of using various modalities of PCA among patients with traumatic injuries, sleep apnea, chronic pain, or neuropathies. An oral sufentanil PCA system may be as effective as an intravenous PCA. The overall incidence of PCA device error is less than 1%. While IV PCA may not be more effective than nurse-administered opioid among trauma patients, thoracic epidural analgesia may improve outcomes. Patients with obstructive sleep apnea or obesity are at increased risk of opioid-induced respiratory depression (OIRD). Patients with chronic pain or opioid tolerance, who may require higher opioid dosing, benefit from close monitoring. Continuous pulse oximetry and capnography can improve detection of OIRD. Risk of nerve injury after nerve block may be higher among patients with peripheral neuropathy, but this risk may be decreased with lower local anesthetic total dose or concentration. PCA, whether in intravenous, neuraxial, or peripheral nerve form, can have a significant role in postoperative analgesia. Regardless of technique, use of a PCA method should account for the potential risks to the patient, particularly in the presence of comorbidities such as sleep apnea, polytrauma, chronic pain, and preexisting neuropathy.