Pain Management: PCA Pump vs Nurse-administered medication

1. Pain Management: PCA Pump vs Nurse-administered medication By: Mark Fransen Jennifer Leader Julia Reece Shayna Whitmore

2. PICO - In post-operative Abdominal Patients, ages 18-64 years, does the use of Patient Controlled Analgesia (PCA) Pump control pain more effectively than scheduled nurse-administration of medication?

3. Pain According to Lewis and Heitkemper (2007, p 12), Pain is defined as “an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.” )

4. Pain Management - The nurse plays a vital role in managing the patients pain. - The patient depends on the nurse to adequately do so. - Pain management is extremely important for the nurse to maintain.

5. Barriers to Analgesia - Fear of addiction - Fear of tolerance - Concerns about side effects of medications - Desire to be a good patient

6. Pain: The 5th Vital Sign - JCAHO standards identify pain relief as a patient right. -Pain scales measure the subjective nature of pain. -A numeric rating scale of zero to ten converts it to objective data.

7. PCA PUMP - Allows for the patient to self-administer analgesics using a computerized pump. - The PCA pump is set-up to deliver certain doses of medication following the patient pushing a button. Talk about epidural and IV methods. For this study we are using IV. Base lines, certain amount per hour. (Loading dose, lockout intervals are safety precautions) Talk about epidural and IV methods. For this study we are using IV. Base lines, certain amount per hour. (Loading dose, lockout intervals are safety precautions)

8. Roe 1963- small IV doses of opioids = increased efficacy • Forrest 1970 – Demand Dropmaster • Sechzer 1968, 1971 – RN administered doses on patient demand, then by pump • Keeri Szanto 1974 – Demanalg pump • “Cardiff Palliator” 1976 1st commercially available 1984 first hospitalPCA pump came out Roe 1963- small IV doses of opioids = increased efficacy • Forrest 1970 – Demand Dropmaster • Sechzer 1968, 1971 – RN administered doses on patient demand, then by pump • Keeri Szanto 1974 – Demanalg pump • “Cardiff Palliator” 1976 1st commercially available 1984 first hospitalPCA pump came out

9. PCA PUMP TYPES -One pump can deliver the medication through an IV access site; -Another pump can deliver pain medication subcutaneously (under the skin); -Medicine can also be delivered directly into an incision; -Yet, another type can release pain medication between the dura mater and skull (epidurally).

10. Commonly Used Medications -According to Viscusi, Jan, Lenart, and Willoughby (2009), the most common medications used in adjunct with PCA pumps include opioids such as: *Morphine sulfate *Hydromorphone (Dilaudid) *Fentanyl (Sublimaze) *Meperidine (Demoral)

11. Lehmann (1999) - Analgesic gaps are eliminated with the use of PCA pumps - More personalization Before PCA pumps everyone got the same amounts around the same time. Early studies like the one by Lehmann recognize the PCA pump revolutionized postoperative pain management by reducing lapses in pain relief referred to as analgesic gaps. Analgesic gaps are the most common complaint of patients ineffective pain management with nurse administered analgesia.Before PCA pumps everyone got the same amounts around the same time. Early studies like the one by Lehmann recognize the PCA pump revolutionized postoperative pain management by reducing lapses in pain relief referred to as analgesic gaps. Analgesic gaps are the most common complaint of patients ineffective pain management with nurse administered analgesia.

12. Menz and Ruiz (2004) Methods: Ten patients had a pain pump. Ten additional patients received standard oral and intramuscular pain medication. Results: Researchers found that there was a significant decrease in post-operative pain in patients using a PCA pump. "These patients used less medication, had better recovery, and resumed normal activities sooner than those that did not receive the PCA pump.” Mentz HA, Ruiz-Razura A, Newall G, Patronella CK. Use of a regional infusion pump to control postoperative pain after an abdominoplasty. Aesth Plast Surg. 2005;29:415?21. Patients received a continuous infusion of Marcaine (Bupivicacaine) directly into surgical site for pain reduction post-operatively. Ten received the Stryker Pain Pump (PCA) and Ten additional patients received standard oral and intramuscular post  operative medications for pain ie: Demerol, Percocet, Lortab,  and no use of a PCA or pain pump. Patients were asked to complete an evaluation of their post operative pain and discomfort.  - Most patients in the experimental group were able to walk within 21 hours of surgery. Patients received a continuous infusion of Marcaine (Bupivicacaine) directly into surgical site for pain reduction post-operatively. Ten received the Stryker Pain Pump (PCA) and Ten additional patients received standard oral and intramuscular post  operative medications for pain ie: Demerol, Percocet, Lortab,  and no use of a PCA or pain pump. Patients were asked to complete an evaluation of their post operative pain and discomfort.  - Most patients in the experimental group were able to walk within 21 hours of surgery.

13. Method: Meta-analyses were performed of outcomes that included analgesic efficacy assessed by a Visual Analog Scale (VAS), analgesic consumption, patient satisfaction, length of stay and adverse effects Results: A meta-analysis of fifty-five randomized controlled trials that evaluated PCA versus conventional nurse administered analgesia found that PCA provided better pain control and increased patient satisfaction. Hudcova, J., McNicol, F., Quan C., et al. Patient controlled opioid analgesic versus conventional opioid analgesia for postoperative pain. Cochrane Database System. Revised 2006 (4th ed). CD003348

14. Meissner, Hicks, Sikirica, et al (2007) Analysis Estimated that more than 13 million patients received IV PCA in the US annually (page 319). Approximately 6.5% of those patients experienced an error (page 313). Meissner, B., Hicks, RW., Sikirica, V., et al. (2007). The Rate and Costs Attributable to Intravenous Patient-Controlled Analgesia Errors. Hospital Pharmacy. 44(4). 312-324. 13,011,647 patients require IV PCA therapy annually (28.9%) Pump error, med error, by proxy Respiratory depression, nausea, death Pump error is most common by human error in the PCA programming or activation. This data, 4.5% is mentioned as being an unreliable statistic. This is because many errors go unreported. 13,011,647 patients require IV PCA therapy annually (28.9%) Pump error, med error, by proxy Respiratory depression, nausea, death Pump error is most common by human error in the PCA programming or activation. This data, 4.5% is mentioned as being an unreliable statistic. This is because many errors go unreported.

15. Practice Changes - PCA team (PCAT) -Closer monitoring of patients - Pre- operative patient education - Capnography - Pain flow sheet Universal screen Limiting the number of departments involved PFS for pts having pain above 5-10, look at papers PFS for pts having pain above 5-10, look at papers

16. Evaluation - Use of standardized pain evaluation Lack of complications Review of documentation required in pain management portion of patient chart Review flow sheets Patient satisfaction Length of stay Adverse effects

17. Conclusion With more research and different ways to reduce error associated with PCA pump use, PCA pumps could be the most beneficial way to alleviate pain in the future of nursing.

18. References Hudcova, J., McNicol, F., Quan C., et al. (2006) Patient controlled opioid analgesic versus conventional opioid analgesia for postoperative pain. Cochrane Database System. (4th ed) CD003348 Lehmann, K.A. (1999). Patient-controlled analgesia: an efficient therapeutic tool in the postoperative setting. European Surgery Volume 31 (2). 112-121. Lewis, Heitkemper. (2007). Medical-Surgical Nursing Assessment and Management of Problems. Pain. P 12 Meissner, B., Hicks, RW., Sikirica, V., et al. (2007). The Rate and Costs Attributable to Intravenous Patient-Controlled Analgesia Errors. Hospital Pharmacy.Volume 44(4). 312-324. Mentz HA, Ruiz-Razura A, Newall G, Patronella CK. (2005). Use of a regional infusion pump to control postoperative pain after an abdominoplasty. Aesth Plast Surg. 29:415?21