Patient Controlled Analgesia (PCA)

If the patients pain score over 4 follow below.

Patients with PCA need regular observations of pain, nausea, sedation and respiratory rate, in addition to the conventional postoperative recording.

Monitoring PCA Infusions

1. Pain score must be recorded on the observation chart

• In recovery : every 15 minutes
• On ward :      
  • 1/2 hourly for 1 hour
  • hourly for first 4 hours
  • 2 hourly for next 6 hours
  • 4 hourly until PCA is stopped

2. Sedation scores and respiration rate must be recorded on the observation chart

• In recovery:   every 15 minutes
• On ward:       
  • 1/2 hourly for 1 hour
  • hourly for first 4 hours
  • 2 hourly for next 6 hours
  • 4 hourly until PCA is stopped

3. Nausea score must be recorded on the observation chart

• In recovery:   every 15 minutes
• On ward:       
  • 1/2 hourly for 1 hour
  • hourly for first 4 hours
  • 2 hourly for next 6 hours
  • 4 hourly until PCA is stopped

Respiratory depression and sedation

NSAIDs and paracetamol help to minimise opioid side-effects by reducing the total dose of opioid required and should be prescribed regularly not PRN.

Moderate respiratory depression (respiratory rate less then 9 breaths per minute AND sedation score of 1 or 2)

• Ensure a clear airway and administer Oxygen therapy 10 litres/minute via facemask.
• Monitor respiratory rate, sedation score and oxygen saturation every 15 minutes until respiratory rate is 10 per minute or more.
• Review the analgesia and consider other causes of respiratory depression.
• Contact the Acute Pain Team for further advice.

Severe respiratory depression (respiratory rate less then 7 breaths per minute OR sedation score of 3.)

CALL FOR HELP INITIATE CPR PROCEDURES IF THE PATIENT IS APNOEIC, CALL 2222

• Ensure a clear airway and administer Oxygen therapy 10 litres/minute via facemask.
• Contact the Ward FY1, Surgical Registrar or Nurse Practitioner.
• Give naloxone 100 micrograms intravenously, see Naloxone guidance
• Sign the PCA chart in the emergency section.
• Monitor respiration rate, sedation score and oxygen saturations every 15 minutes for 1 hour and hourly for 4 hours thereafter, to ensure respiratory depression does not return. Pulse oximetry should be used continuously until opioids are no longer required.
• Review analgesia, consider and exclude any other causes of respiratory depression - hypovolaemia, anaphylaxis or cardiac problems.
• Contact the Acute Pain Nurse or ITU Anaesthetist to reassess analgesic requirements and whether a Naloxone infusion is required.

Preparation of syringe

Preparation of each syringe must be witnessed by a trained nurse or doctor, in accordance with Hospital SOPs on Preparation and Administration of Controlled Drugs (requires internet connection and password).

1. Check the prescription on the PCA chart.  It must be legible, dated and signed.
2. Always use a universal clean technique and following hospital policy: Policy on the Administration of Intravenous Fluids and Medicines(requires internet connection and password).
3. Use codan spike to draw up the pre-filled vial of Morphine into a 50ml luer lock syringe.  Alternatively, insert an air-inlet into the vial of Morphine and use a green needle on 50ml syringe to draw up the Morphine.
4. Attach a blue PCA additive label ensuring that all the details are complete.  Take care that the label does not cover the numbers or graduations on the syringe.
5. Attach the PCA giving set to the syringe and prime the line. Vygon PCA Protect-A-Line Extension Sets must always be used.
6. Attach the extension set to the patient’s venflon, close the clamp and press the start button.

For opioids other than morphine pre-filled vials

Follow steps as above apart form step 3. Instead:

3. Draw up the prescribed dose of opioid and dilute with saline to 50mls in a luer-lock syringe.

Change of syringe

Each change of syringe must be witnessed by a trained nurse or doctor who has received PCA training.  Follow the Hospital SOPs on Preparation and Administration of Controlled Drugs (requires internet connection and password). 

1. Prepare syringe as described above.
2. Check patient’s identity
3. STOP PUMP AND CLAMP LINE
4. Unlock pump using key access on left side of pump.  There is no need to insert the key in the front of the pump.  
   Replace old syringe with newly filled syringe, taking note of the volume to be discarded in old syringe.  Adjust housing to accept the new syringe.
5. Check the programme with prescription on PCA chart, noting concentration, PCA bolus dose and lockout time.
6. Disconnect the PCA extension set from the patient’s venflon, unclamp the line and press the priming buttons until flow is seen at end of line.
7. Attach the extension set to the patient’s venflon, close the clamp and press the start button.

Changing PCA extension sets

• These should be changed every 24 hours, at the same time as the PCA syringe.
• Disconnect the PCA syringe giving set from the patient’s Venflon.
• Attach the PCA syringe to the new PCA extension set at the anti-reflux valve (red valve end).
• Insert the syringe back into the pump and prime the line again, using the priming button on the pump. This ensures that the syringe driver housing is in contact with the syringe barrel.
• Attach the PCA extension set to the patient’s venflon and ensure the blue clamp is unclamped.
• Document in the comments section of the PCA chart the amount (in mls) wasted whilst purging the line.