Patient-controlled Analgesia Therapy Research Articles

Early Initiation of Ketamine Infusion for Pain Management in Pediatric BMT Patients with Mucositis

Background: As many as 90% of children undergoing hematopoietic stem cell transplant (HSCT) will experience painful mucositis. The mainstay of treatment for these children has been opioid analgesia which can be associated with sedation and respiratory depression. Additionally, these children may experience heightened opioid tolerance and physiologic dependence contributing to lengthy admissions. Ketamine is an anesthetic and analgesic which has been used successfully in conjunction with opioids in the treatment of painful mucositis. This study aimed to reduce total opioid use per day by 10% and overall pain scores by 2 in pediatric patients with mucositis undergoing HSCT through initiation of ketamine at the same time as an opioid patient-controlled analgesia (PCA). Methods: Beginning April 2022, HSCT patients (both autologous and allogeneic) at Children's Hospital Colorado were started on ketamine infusion in conjunction with an opioid PCA for management of painful mucositis. Mucositis severity and duration, opioid consumption, pain and functional scores, time of initiation of ketamine therapy, ketamine side effects, and duration of PCA and ketamine therapy were recorded for a retrospective (April 2021- March 2022, n=6) and a prospective cohort (April 2022- April 2023, n=17). A 2-sample-T-test was used to calculate the difference in mean cumulative opioid use per day and the mean 24-hour average pain scores between the retrospective and prospective groups. Results: 71% of children in the prospective group underwent ketamine initiation alongside an opioid PCA. Patients in this group had a 46% reduction in mean cumulative opioid use per day (CI 1.265-2.318, p=0.000). Reduction in 24-hour pain scores between the retrospective and prospective groups was 1.18, failing to meet our goal of 2.0. However, there was still a statistically significant difference in mean scores (CI 0.499-1.860, p=0.001). Additionally, this intervention was tolerated well and only 1 patient (16%) was intolerant of ketamine side effects in the prospective cohort. Conclusions: Initiation of ketamine alongside an opioid PCA for the treatment of mucositis pain is safe and significantly reduces cumulative opioid exposure and 24-hour pain scores in children undergoing HSCT.

Patient-controlled analgesia and oral mucositis pain in hematological malignancies.

Oral mucositis (OM) pain is an anticipated complication of immunosuppressive therapies for hematological malignancies. Opioids are effective for OM-associated pain and dysfunction that is refractory to simple measures. At the study institution, parenteral opioids are preferentially prescribed for the treatment of complicated OM. This audit explores the efficacy of opioids for the management of OM pain using morphine, oxycodone, and fentanyl patient-controlled analgesia (PCA). Pain scores, opioid consumption, resumption of oral intake, and the duration of admission were retrospectively analyzed from patient records over an 18-month period. Two-thirds of included patients had ceased PCA therapy by day 6, by which time there was a meaningful 35.4 percent reduction in pain scores, with very few side effects reported. Interagent comparison demonstrated no significant differences in mean daily pain scores; however, a larger sample size would facilitate an investigation of clinically significant nuances in treatment differences, if they exist.

Comparison of Opioid-Based Patient-Controlled Analgesia with Physician-Directed Analgesia in Acute Pancreatitis: A Retrospective Cohort Study.

Patient-controlled analgesia (PCA) is commonly used for acute postoperative pain management. Clinicians may also use PCA in the management of acute pancreatitis (AP); however, there is limited data on its impact on patient outcomes. We aimed to characterize a cohort of patients receiving PCA therapy for pain management in AP compared to those patients receiving standard physician-directed delivery of analgesia. We conducted a retrospective cohort study of adult patients admitted with AP at a tertiary care center from 2008 to 2018. Exclusion criteria included patients with chronic opioid use, chronic pancreatitis and pancreatic cancer. Primary outcomes include length of stay (LOS) and time to enteral nutrition. Secondary outcomes include proportion of patients discharged with opioid and complications. Multivariate regression analysis and t-test were used for analysis. Among 656 AP patients who met the criteria, patients receiving PCA (n = 62) and standard delivery (n = 594) were similar in admission pain score, Charlson Comorbidity Index, and pancreatitis severity. There were significantly greater proportion of women, Caucasians and nonalcoholics who received PCA therapy (p < 0.01) than standard delivery. Multivariate regression analysis revealed that patients in the PCA group have a longer LOS (7.17 vs. 5.43days, p < 0.007, OR 1.03; 95% CI 1.01-1.07), longer time to enteral nutrition (3.84days vs. 2.56days, p = 0.012, OR 1.11; 95% CI 1.02-1.20), and higher likelihood of being discharged with opioids (OR 1.94; 95% CI 1.07-3.63, p = 0.03). The use of PCA in AP may be associated with poorer outcomes including longer LOS, time to enteral intake and a higher likelihood of being discharged with opioids.

Patient controlled analgesia for the management of acute pain in the emergency department: A systematic review.

The most common presenting complaint to the emergency department (ED) is pain. Several studies have shown that a large proportion of ED patients either receive no or sub-optimal analgesia. Patient-controlled analgesia (PCA) pumps used in the post-operative setting has shown to decrease total opioid consumption and has increased patient and nurse satisfaction. The purpose of this systematic review was to evaluate clinical trials that have used PCAs in the ED setting, to evaluate safety and efficacy as well as patient and healthcare provider experience. A search of PubMed, MEDLINE, and the Cochrane Database was conducted using the MESH search terms emergency department, patient-controlled analgesia, and acute pain up to September 2021. These terms were searched in all fields of publication and were limited to the English-language articles, clinical "human" studies, and studies that included the use of patient-controlled analgesia in the setting of the emergency department. The search initially identified 227 potentially relevant articles and a total of 10 studies met criteria for inclusion. ED use of PCA therapy was associated with increased patient satisfaction, decreased pain scores, and an overall increase in opioid consumption. The quality, the differences in study methods and outcome measures used, and heterogeneity of the studies performed to date do not provide adequate evidence to support its widespread use in the ED. Well-designed studies conducted in the ED are still needed to evaluate the ideal patient population to whom these PCAs may provide the most benefit as well as a robust cost-analysis to ensure feasibility of use in the future.

90. Impact of patient-controlled analgesia on clinical outcomes after posterior lumbar spinal fusion surgery

BACKGROUND CONTEXT Optimal postoperative pain control is critical after spinal fusion surgery. Significant variability remains in the use of postoperative intravenous opioid patient-controlled analgesia (PCA) and very little data evaluating its utility compared to nurse-controlled analgesia (NCA) in lumbar fusion patients. PURPOSE We performed a retrospective evaluation of posterior lumbar spinal fusion patients being treated postoperatively with patient-controlled analgesia (PCA) and compared their pain-related outcomes to nurse-controlled analgesia (NCA). PCA utilization was independently associated with increased opioid prescription in the postoperative period. After controlling for preoperative opioid use, we found that opioid naive patients have worse pain control with PCA than NCA, and patients with very high opioid consumption (>90 MME/day) had greater rates of opioid-related adverse events with PCA. STUDY DESIGN/SETTING Retrospective clinical study, single institution. PATIENT SAMPLE A retrospective review from a single institution was conducted in consecutive patients treated with posterior lumbar spinal fusion for degenerative pathology. Patients with scoliosis, traumatic, neoplastic, infectious and minimally invasive treatments were excluded. OUTCOME MEASURES Postoperative numerical rating scale (NRS) pain scores, length of stay, and total opioid consumption were collected and compared. Opioid-related adverse events for each patient were also measured. METHODS Patients were divided into two cohorts: those treated postoperatively with PCA or NCA. Outcome measures were compared for patients in groups. Patients were stratified according to preoperative opioid consumption as naive, low (60 morphine milligram equivalents (MME) daily), high (61-90 MME) or very high (>90 MME) for analysis. RESULTS A total of 240 patients were identified: 62 and 178 patients in PCA and NCA groups, respectively. PCA patients had higher mean preoperative opioid consumption compared to the NCA group (49.2 vs 24.3 MME, p=0.009). PCA patients had higher mean opioid consumption in first 72 hours in all preoperative opioid consumption categories. Pain control and adverse event rates were similar between PCA and traditional opioid therapy in the low to high preoperative opioid consumption groups (>0 to 90 MME daily). Opioid naive patients had worse mean and highest NRS pain scores in the first 72 hours (all p 90 MME daily) had a greater rate of opioid-related adverse events (95% vs 70%, p CONCLUSIONS Postoperative PCA utilization is associated with significantly more opioid consumption and equal or worse postoperative pain scores compared to NCA after lumbar spinal fusion surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Patient-controlled Analgesia For Vaso-Occlusive Crisis: A Cohort Study.

Sickle cell disease (SCD) accounts for over 68,000 hospital admissions each year in the United States, with long inpatient length of stays (LOS) and frequent readmission common. Patient-controlled analgesia (PCA) has been used to treat patients admitted with vaso-occlusive crisis (VOC), but it is unknown if PCA is associated with shorter LOS and reduced risk of readmission. We examined all admissions for acute VOC treated with parenteral opioids to an urban, academic health system over 3 years. We compared LOS, 30-day readmission, and discharges against medical advice between admissions treated with PCA versus standard therapy in unadjusted and adjusted analyses using generalized estimating equations to adjust for demographic and clinical characteristics. Of 823 admissions included, 536 (65.1%) were treated with PCA and 287 (34.9%) were treated with standard nurse-administered opioid therapy. Treatment with PCA was associated with significantly shorter LOS in the unadjusted analyses (7.46 vs. 9.42 d, P=0.001), but the difference was not significant after adjustment (adjusted difference: 1.47 d, P=0.06). Treatment with PCA was also associated with significantly decreased risk of 30-day readmission in unadjusted analysis (odds ratio [OR]unadj: 0.69; 95% confidence interval [CI]: 0.54-0.89, P=0.004), but after adjustment the association was no longer significant (ORadj: 0.76; 95% CI: 0.54-1.06, P=0.11). Finally, treatment with PCA was not associated with increased risk of discharge against medical advice in Generalized Estimating Equation modeled unadjusted (ORunadj: 1.10; 95% CI: 0.69-1.76, P=0.68), or adjusted analysis (ORadj: 1.19; 95% CI: 0.73-1.94, P=0.49). Treatment with PCA may be associated with shorter LOS and may be considered as the primary modality for opioid-based pain control for patients with SCD who are admitted with painful VOC.

Impact of Patient-Controlled Analgesia (PCA) Smart Pump-Electronic Health Record (EHR) Interoperability with Auto-Documentation on Chart Completion in a Community Hospital Setting.

IntroductionComplete and accurate documentation of opioids administered by patient-controlled analgesia (PCA) pumps is critical for ensuring a high-quality medication record and an accurate conversion of the intravenous (IV) regimen to oral therapy. Incomplete charting of PCA usage through a manual process may be associated with fragmented documentation of delivered therapy affecting the completeness of the medical record and the IV to oral dose conversion. This study is the first to evaluate the association between auto-documentation of opioid administration provided by PCA smart pump—electronic health record (EHR) interoperability and the completion of PCA opioid administration charting tasks.MethodsThis retrospective cohort study was conducted at Lancaster General Hospital, Lancaster, Pennsylvania. Patients were assigned to pre-auto-documentation (n = 55) or post-auto-documentation groups (n = 58) based on whether they received PCA therapy prior to or after PCA-EHR interoperability was implemented. Charting of PCA therapy included documentation of the number of patient attempts, number of doses given, and total volume infused for both pre- and post-auto-documentation groups. In addition, total dose delivered was documented for the post-auto-documentation group. The overall chart-field completion rate was evaluated as the primary outcome. Individual chart completion percentages were assessed by stratified groups as secondary outcomes.ResultsPCA smart pump—EHR interoperability with auto-documentation was associated with an increase in overall chart-field completion rate from 69.9 to 97.0% (p < 0.001). Auto-documentation was also associated with an increase in fully completed charts from 38 to 91% (139.3% increase, p < 0.001) and reductions of incomplete records in each stratified group (p < 0.001).ConclusionsPCA smart pump—EHR interoperability with auto-documentation is associated with significant improvements in the completion of opioid administration chart-fields. Improved documentation of PCA administered opioids may have implications for the safety of opioid administration. Additional studies will be needed to assess the potential clinical impact of these results.FundingICU Medical, Inc.

Patient-controlled Analgesia (PCA): an Overview About Methods, Handling and New Modalities

Patient-controlled analgesia (PCA) is one of the well established methods for the treatment of postoperative pain. A cochrane-review concluded that PCA is associated with better postoperative pain ratings and improved patient-satifaction compared to traditional way of administering opioids. Some prerequisites concerning patient selection, education of the patient and the medical staff, and supervision during PCA therapy are mandatory for a safe use of PCA. Current PCA modalities (intravenous and epidural routes of application) are expanded by newer, less invasive routes of drug administration, e.g. by the iontophoretic transdermal and the sublingual route. Their role in improving safety and the quality of pain therapy on the one hand side, and costs on the other hand side are discussion.

Evaluation of dexmedetomidine and postoperative pain management in patients with adolescent idiopathic scoliosis: conclusions based on a retrospective study at a tertiary pediatric hospital.

This study evaluated the effectiveness of dexmedetomidine in decreasing opioid use in children with adolescent idiopathic scoliosis following posterior spinal fusion surgery at a pediatric tertiary care hospital over the past 10 years. This was a retrospective chart review. Patients were separated into two groups: those that received opioid via patient-controlled analgesia pain therapy alone and those that received opioid via patient-controlled analgesia pain therapy with dexmedetomidine. A tertiary pediatric free-standing hospital. The study focused on care administered in the perioperative period, including the operating room, ICU, and general hospital floor. One hundred sixty-three children with adolescent idiopathic scoliosis. None. Measurements included patient demographics, American Society of Anesthesiologists Physical Status Classification System, levels of spinal fusion, length of hospital stay, complications, numeric pain scores, opioid requirement, elastomeric pain pump use, length of time until ambulation, adverse effects, and naloxone use. Data were collected through the first 72 hours of the perioperative period. One hundred six patients received opioids via patient-controlled analgesia therapy with dexmedetomidine and 57 received opioids via patient-controlled analgesia alone. Within the groups, there were 46 patients who received local anesthetic infusions via elastomeric pumps in the patient-controlled analgesia with dexmedetomidine group and 16 patients had pumps in the patient-controlled analgesia-alone group. There was no overall difference in postoperative use of morphine (or equivalents) between the two groups. However, the use of elastomeric pain pumps demonstrated a statistically significant decrease in mean overall opioid consumption (42.6 mg vs 63.1 mg, p < 0.001). There was no difference in opioid use related to dexmedetomidine on any postoperative day. The only variable showing a significant opioid sparing effect was the use of local anesthetic infusions via elastomeric pumps. Using continuous local anesthetic infusions instead of dexmedetomidine could eliminate the need for ICU admission, require shorter hospital stays, and reduce costs while still providing safe and effective pain control.

Drug overdose due to malfunction of a patient-controlled analgesia machine -A case report-

Patient-controlled analgesia (PCA) provides excellent pain control and high stability, thereby minimizing the incidence of adverse effects. However, one of our patients experienced respiratory depression and hypotension within 30 minutes of initiation of PCA therapy. We discovered that machine malfunction caused continuous activation of the PCA button, resulting in a drug overdose. The PCA machine was sent to the manufacturer, who found an electrical short in the PCA button. All PCA units of the same make and model were immediately removed from hospitals and replaced with redesigned units without defects in the PCA button. We have used the improved machines without any problems. The purpose of this report is to raise awareness of this type of malfunction in PCA units in order to help prevent adverse events in the future.

A Case Study on the Safety Impact of Implementing Smart Patient-Controlled Analgesic Pumps at a Tertiary Care Academic Medical Center

As with the use of any therapy involving opioids, patient-controlled analgesia (PCA)-related errors can lead to overdose and even death. "Smart" (computerized) pumps have medication safety enhancements, particularly those related to operator errors during administration, to improve overall safety and efficacy. After the occurrence of PCA-related errors that occurred at a tertiary care academic medical center, an analysis of PCA errors was conducted. The introduction of smart pumps was identified as a possible solution, and the medical center adopted the technology in 2006. A study was conducted to investigate the impact of implementation. The study had three primary objectives: (1) to evaluate history logs stored in the smart PCA pumps to characterize the nature of hard and soft stop alerts and identify potential errors that may have been averted, (2) to examine the impact of smart PCA pumps on voluntarily reported PCA therapy-related errors, and (3) to assess nursing perceptions regarding the improvement in safety due to the introduction of smart PCA pumps. The smart pumps potentially prevented 159 errors for the January-June 2007 period; upper hard limits had the most number of alerts, representing avoidance of errors with the greatest potential to be detrimental to the patient. In addition, pump-programming errors due to wrong concentration were eliminated after implementation. Finally, nursing staff perceived smart pumps to be valuable in improving patient safety. Smart PCA pumps had an important positive impact on PCA-related patient safety at the medical center. Other facilities should adopt PCA devices with additional safety features such as bar-code verification of the drug and concentration, as well as dosage limits, to prevent pump-programming errors.

Häusliche Behandlung von Tumorschmerzpatienten mit patientenkontrollierter Analgesie (PCA)

Only limited data and experience with patient-controlled analgesia (PCA) in outpatients for palliative home care, related to organization, effectiveness and costs are available. In our retrospective study we analyzed the effectiveness, care intensity and pain reduction of 108 palliative cancer pain patients with PCA, included in a palliative home care system. After equivalent conversion of the opioid doses from oral/transcutaneus to parenteral administration a dose increase was necessary in 12.9% of the patients. The pain therapy was effective until death for an average of 38.9 days (median 21 days). During 3,889 days of PCA therapy there were 76 unscheduled visits based on technical problems. In cases of cancer pain patients with failed oral or transcutaneous opioid medication, sufficient pain reduction can be achieved with parenteral drug administration by PCA. Domestic PCA requires a lot of human and financial resources, with trained nursing services and regular house visits by physicians experienced in palliative medicine but this method is sufficient and safe to use.

Initial Experience with the IMPROVE Trial-a Phase III Analgesic Trial for Hospitalized Sickle Cell Painful Episodes

AbstractAbstract 2667 Background:Acute pain is the leading cause of hospitalization in both children and adults with sickle cell disease (SCD). Opioid analgesics are used for pain relief, but are associated with significant adverse effects that are bothersome to patients and may predispose to serious sickle-related pulmonary events. Evidence is limited for the most effective opioid administration strategy that maximizes analgesia and minimizes adverse effects. Patient Controlled Analgesia (PCA) has the potential advantage to allow a patient to optimize pain control without dependence on healthcare providers for administration. PCA generally consists of an opioid given by constant infusion with additional demand doses as needed; the proper dosing for each is largely unknown, particularly at high opioid doses. The SCDCRN conducted a multi-center phase III clinical trial comparing two alternative opioid PCA dosing strategies (HDLI-higher demand dose with low constant infusion or LDHI- lower demand dose and higher constant infusion). The required sample size for the trial was 278 subjects. Patients and Methods:SCD patients ≥ age 10 years hospitalized for significant pain (baseline pain VAS ≥ 4.5/10) who had received < 12 hours of previous analgesic therapy and provided informed consent were eligible; patients with renal/hepatic dysfunction, who received large amounts of oral opioids prior to admission, or who had evidence of acute chest syndrome were excluded. Investigators used standardized opioid dosing tables for morphine or hydromorphone, and for participants weighing ±50 kg. Opioid-related symptoms were assessed with a validated daily questionnaire; multimodal assessments of pain, physical function, and sleep were conducted by an assessor blinded to treatment assignment/dose level; because of safety concerns, individuals responsible for making dosing decisions were not blinded. The assigned PCA strategy was continued until patients were transitioned to oral analgesics. An intention to treat analysis was planned for the time to a significant (2.5 cm) improvement in average daily 10 cm pain VAS. Secondary endpoints included total opioid usage and frequency of opioid-related symptoms. Results:From January 1, 2010 to June 8, 2010, a total of 1050 patients age ≥ 10 years were hospitalized for pain; 216 were ineligible, 796 were missed for logistic/staffing issues at sites, and 38 subjects completed randomization prior to trial closure (due to inadequate time to complete enrollment prior to Network termination in March 2011). Average age of enrolled subjects was 23.9 ± 12.2 years (range 10–52 years), and 53% were female. The HDLI arm had 50% morphine and 40% pediatric subjects (10-17 years); the LDHI arm had 44% morphine and 50% pediatric subjects. Four subjects were withdrawn (1 parent permission withdrawal, 2 inadvertent withdrawals by PI, 1 ineligible). Baseline VAS was high (mean 7.5 cm HDLI, and 7.7 cm LDHI). A reduction in pain intensity during PCA treatment was observed in both treatment arms (mean difference from baseline ± SEM: 2.7 ±1.5 cm HDLI vs 2.8 ±2.0 cm LDHI; time to significant improvement 22.0 ±3.0 hours HDLI vs 22.1 ±3.8 hours LDHI), with 75% of the HDLI subjects and 79% of the LHDI experiencing a significant improvement in pain. Average length of hospitalization was 143.7 ±94.2 hours HDLI vs 102.4 ±42.6 hours LDHI. The reliability or significance of any similarities or differences noted in this descriptive analysis is limited by the small sample size. Opioid utilization in the two treatment arms is currently being analyzed. Opioid-related symptoms were well managed and similar in both treatment arms (mean daily opioid symptom severity score (1-4): 0.9 ± 0.6 HDLI vs 0.8 ± 0.6 LDHI). Four episodes of serious hypoxia, likely relate to exacerbation of pulmonary hypertension, developed in adult subjects during the study (2 HDLI, 2 LDHI). Conclusions:The premature closure of the study limits potential conclusions regarding safety and efficacy, or superiority of either treatment regimen. The data gathered will help resolve potential design issues related to the complexity of running an inpatient opiod PCA trial and help guide modification of subject selection and enrollment, optimization of opioid dosing and monitoring, and endpoint assessments. Given the clinical priority of adequate pain management and the challenges of opioid PCA therapy, completion of this trial is imperative. Supported by NHLBI. Disclosures:Dampier:Anthera Pharmaceuticals Inc:; Glycomimetics Inc:.Telen:GlycoMimetics: Consultancy, clinical trial sponsorship.

Reducing Errors During Patient-Controlled Analgesia Therapy Through Failure Mode and Effects Analysis

Despite the technologic advances in design, resulting in the development of "smart" pumps to help deliver analgesia more safely, patient-controlled analgesia (PCA) is still involved in a significant proportion of the medication errors ascribed to intravenous (IV) drug administration, many of which have harmed patients. In 2003, Failure Mode and Effects Analysis (FMEA) was used to assess the PCA process at a 695-bed teaching and research tertiary hospital. IDENTIFYING AND ADDRESSING FAILURE MODES: For the three processes with hazard scores > 8--patient selection, prescribing, and medication administration-the potential cause(s) were identified, allowing the process to be redesigned to eliminate the potential cause(s). In January 2003 to May 2003, before the FMEA process began, there were 11 PCA errors (extrapolated to 26 for the entire 2003 calendar year). In 2004, when most of the corrective actions were taken, there were 22 reported PCA errors. In October 2007, a new online occurrence-reporting program was implemented, making reporting much easier. From October 2007 through September 2008, there were only 8 reported PCA errors, representing a 69% reduction from baseline. No serious adverse events were associated with any of these PCA errors. Despite the reduction in PCA errors since the FMEA was conducted, misprogramming of drug concentration remains a common PCA error. Solutions include safety software for IV infusion pumps, an integral bar-code reader for detecting concentration errors, and interoperability of the software with other hospital information systems. One lesson learned was that an FMEA can lead to resolution of problems beyond the scope of original intent-in this case, the development of a new system for identifying all broken equipment.

Zirkadianer Rhythmus des PCA-gesteuerten Opioidverbrauchs bei Kindern mit chemotherapiebedingter Mukositis

In order to match the interindividual and intraindividual differences in opioid requirements of pediatric oncology patients with mucositis, patient-controlled analgesia (PCA) seems to be the optimal pain therapy option, but scientific data are lacking. A retrospective chart review of PCA-treated children with mucositis was carried out over a 6-year period (2000-2006) at the university hospital for children in Erlangen. The median age of the patients was 12.6 years and they mainly suffered from forms of acute leukemia. Daily morphine equivalent dose (MED) requirements increased with the start of the PCA therapy from 14.5 mg/day to 18.7 mg/day (p=0.021; Wilcoxon test). Children required more opioids by bolus request during the night (10:01 p.m. to 06:00 a.m.; 6.28 mg; 13%) than during the other 8-hour intervals (06:01 a.m. to 02:00 p.m. and 02:01 p.m. to 10:00 p.m.; both 21.3 mg (43.5%) during the whole 10-day study period. In 8 out of 10 days there was a significant diurnal variation in opioid requirement with significantly lower requirement during the night (p<0.05 Friedman test). The median count of delivered and un-delivered bolus requests during the night was 0-1 and 0, respectively. PCA seems to be an ideal, dependable and feasible mode of analgesic administration for the individual titration of dose in children with chemotherapy-induced mucositis. This is expressed through the increase in daily self-administered opioid doses after starting PCA, the huge interindividual variability in opioid consumption and the rare event of an un-delivered bolus request during lock-out time. With the use of a background infusion, additional bolus requests are rare during the night.

Continuous axillary block for paediatric trauma patients who failed with PCA therapy

Summary The purpose of this paper is to report the effectiveness and safety of axillary nerve blocks in reducing pain in paediatrics after the failure of other pain treatments. We describe two cases of paediatric patients with traumatic injury who had successful pain control with continuous axillary blocks after failed pain treatment with a patient controlled analgesia (PCA). Recommendations regarding pain management strategies follow these cases.

Patient-Controlled Analgesia Safety Issues

Patient controlled analgesia (PCA) offers meaningful advantages over traditional analgesia. However, PCA medical errors with PCA can be dangerous and even fatal. Errors associated with patient controlled analgesia (PCA) therapy are described as are ways to minimize such errors. This report is based on data from the United States Pharmacopeia (USP) and Institute for Safe Medication practices (ISMP) Medication Errors Reporting Program. PCA by proxy, appropriate patients selection for PCA, patient monitoring, patient education, medication mix ups and practice related errors are discussed. Staff training is addressed. Methods to minimize errors associated with pump purchasing, PCA prescribing, initiation, and monitoring are described. Recommendations for pharmaceutical manufacturers elated to PCA therapy are provided.

Patient-Controlled Analgesia Safety Issues

Patient controlled analgesia (PCA) offers meaningful advantages over traditional analgesia. However, PCA medical errors with PCA can be dangerous and even fatal. Errors associated with patient controlled analgesia (PCA) therapy are described as are ways to minimize such errors. This report is based on data from the United States Pharmacopeia (USP) and Institute for Safe Medication practices (ISMP) Medication Errors Reporting Program. PCA by proxy, appropriate patients selection for PCA, patient monitoring, patient education, medication mix ups and practice related errors are discussed. Staff training is addressed. Methods to minimize errors associated with pump purchasing, PCA prescribing, initiation, and monitoring are described. Recommendations for pharmaceutical manufacturers elated to PCA therapy are provided.

Emetic effects of morphine and piritramide

Successful management of postoperative pain requires that adequate analgesia is achieved without excessive adverse effects. Opioid-induced nausea and vomiting is known to impair patients' satisfaction, but there are no studies providing sufficient power to test the hypothesis that the incidence of opioid-induced nausea and vomiting differs between micro -opioid receptor agonists. Thus, we tested the hypothesis that the incidence of vomiting and nausea differs between morphine and piritramide. In a prospective, randomized, double-blind fashion, we administered either morphine (n=250) or piritramide (n=250) by patient-controlled analgesia (PCA) for postoperative pain relief. We used a bolus dose of 1.5 mg with a lockout time of 10 min. Incidence and intensity (numerical rating scale) of postoperative nausea, vomiting, pain, patient satisfaction (score 0-10), side-effects (score 0-3) and drug consumption were measured. Mean drug consumption did not differ between the piritramide and morphine groups (30.8 (SD 22.4) mg day(-1) vs 28.4 (21.8) mg day(-1)) during the first postoperative day and there were no significant differences in the overall incidence of nausea (30% vs 27%) and vomiting (19% vs 15%). Intensity of nausea correlated inversely (P=0.01) with morphine consumption but not with piritramide consumption. Pain scores both at rest (2.2 (1.9) vs 2.6 (2)) and during movement (4.4 (2.2) vs 4.9 (2.3)) were slightly but significantly less with morphine. Opioid-induced emesis was observed in about one-third of the patients using morphine and piritramide for PCA and the incidence of vomiting was one-half of that. Potential differences in the incidence of vomiting during PCA therapy between these micro-opioid receptor agonists can be excluded.

Patient-controlled analgesia for the pediatric patient.

Pediatric patients benefit from patient-controlled analgesia (PCA), which eliminates the need for painful intramuscular injections of opioids and improves the child's sense of control. Age is often used inappropriately as a criterion for PCA use in children. Children must be carefully screened for their cognitive and physical ability to manage their pain using PCA. Family-controlled analgesia and nurse-controlled analgesia may be considered in select cases as alternatives to PCA in children with cognitive or physical disabilities. PCA dosage regimens must be individualized on the basis of age. Monitoring parameters must be age appropriate. Potential adverse effects of PCA therapy, including respiratory depression, nausea, vomiting, and pruritus, can be prevented or controlled. Clinicians must become aware of age-related and developmental differences in the pharmacokinetic, pharmacodynamic, and monitoring parameters for the pediatric patient. The safety and efficacy of PCA in pediatric patients has been established, and its role has increased beyond postoperative pain management.