Patient-controlled analgesia: Is it worth the painful prescribing process?

In the last 10 years, the assessment and treatment of pain have become a priority for health care organizations, especially after the introduction of regulatory standards and patient satisfaction surveys directly correlating pain control with a favorable satisfaction score. While much of the focus is on increasing the number of patients receiving adequate pain relief, there has been a subsequent increase in overaggressive attempts to ensure comfort (1). Severe acute pain is best treated with intermittent, intravenous doses of opioids, which allow rapid titration of effect. Appropriately and accurately prescribed patient-controlled analgesia (PCA) is an effective and efficient method of controlling severe acute pain; the risk of oversedation is significantly reduced, and there is considerable potential to improve pain management for patients (2, 3). PCA allows patients to self-administer more frequent but smaller doses of analgesia than the traditional nurse-administered larger and less frequent bolus doses, thus making PCA a favorable choice to comply with standards and patients' goals for comfort. PCA offers advantages especially when protocols are in place to assess the level of pain and sedation; assess the rate, depth, and quality of respirations; perform a preprocedure cognitive assessment; and note whether the patient is opioid tolerant or naive. However, serious unintended consequences such as oversedation, respiratory depression, and undertreated pain may occur from the use of PCA. Contributing factors that lead to these events include improper patient selection, inadequate patient monitoring, pump programming errors, PCA by proxy, patients' self-administration of home analgesics while receiving PCA, imprudent polypharmacy, and insufficient health care team member training or education about medications administered via PCA and their dosing and lockout periods. Adverse events due to one of these many contributing factors are preventable and can be significantly reduced with guidance for treatment team staff, patients, and family members. Numerous adverse event reports totaling in the thousands and a few resulting in patient harm or fatality have occurred since the introduction of PCA (4). In response, the Institute for Safe Medication Practices (ISMP) and the Joint Commission have issued a number of PCA-related safety alerts to health care organizations (2, 3, 5–8). Based on these warnings, many organizations have formed focused, team-based approaches to review PCA-related events and design measures to address the contributing factors leading to these events. Much of the focus is on five areas: patient selection, prescribing errors, staff training, monitoring, and patient education. Developing criteria for selecting appropriate patients to receive PCA is one of the most overlooked but preventable mechanisms to significantly impact events. Well-documented risk factors for oversedation and respiratory depression include opioid-naive status, obesity, age, mental status, and multiple comorbid conditions such as intrinsic lung disease, obstructive sleep apnea (OSA), and renal and hepatic impairment.