Trust Guideline for the Management of Patient Controlled

Analgesia (PCA) in Adults

A clinical guideline recommended for use

For Use in: In all Clinical Areas
Anaesthetists, Ward Nurses, Recovery Staff
By:
Acute Pain Service Staff
Adult patients receiving Patient Controlled
For:
Analgesia
Division responsible for document: Surgical Division

Key words: PCA, analgesia, adults

Name and job title of document
Mrs Katherine Dyer, Clinical Nurse Manager
author:
Name and job title of document
Kate Booth, Matron
author’s Line Manager:
Supported by: Dr Mark Sanders, Clinical Director, Anaesthesia
Clinical Guidelines Assessment Panel (CGAP)
Assessed and approved by the:
If approved by committee or Governance Lead
Chair’s Action; tick here 
Date of approval: 05/05/2021
Ratified by or reported as approved
Clinical Safety and Effectiveness Sub-Board
to (if applicable):
To be reviewed before:
This document remains current after this 05/05/2024
date but will be under review
To be reviewed by: Mrs Katherine Dyer
Reference and / or Trust Docs ID No: 1205 (CA2048)
Version No: 7.1
Compliance links: (is there any NICE
None
related to guidance)
If Yes - does the strategy/policy
deviate from the recommendations of N/A
NICE? If so why?

This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and
management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard
guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical
circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of
relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the
patient's case notes.

The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of
healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any
misunderstanding or misapplication of this document.

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 1 of 11
 Trust Guideline for the Management of Patient Controlled
Analgesia (PCA) in Adults

Version and Document Control:

Version Date of
Change Description Author
Number Update
Due to a metal component in the
cassette mechanism, all patients with
a PCA who require an MRI scan will
7 14/02/2019 need to be completely disconnected Mrs Katherine Dyer
from the PCA pump, cassette and
giving set prior to scanning. Added to
patient monitoring section.
7.1 05/05/2021 No clinical changes. Mrs Katherine Dyer

This is a Controlled Document

Printed copies of this document may not be up to date. Please check the hospital
intranet for the latest version and destroy all previous versions.

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 2 of 11
 Trust Guideline for the Management of Patient Controlled
Analgesia (PCA) in Adults
Quick reference guideline/s

Uncontrolled Pain, Consider prn

YES oral route not NO
oral analgesia if
available. required.

Patient physically &

cognitively able to Contact APS/ on-call
use a PCA. YES anaesthetist.

NO Consider alternative
analgesia Set up PCA as
Consider contacting per protocol.
Acute Pain Service.

Regular monitoring.

NO Side-effects? Effective
NO
Pain Relief.

YES

Contact Acute Pain

Service- consider change
Nausea – give anti emetic. of prescription
Give non-opiate adjunct
Sedation / Respiratory Depression – YES medication.
stop PCA, observe, administer
oxygen if required.

Itching – oral chlorphenamine or

consider naloxone.
Consider discontinuing PCA once oral route
becomes appropriate and oral analgesia is
prescribed.

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 3 of 11
 Trust Guideline for the Management of Patient Controlled
Analgesia (PCA) in Adults
Objective/s

To facilitate the effective and safe use of PCA, outlining optimal management of
complications and side effects. The guideline also details:
 Patient selection.
 Contraindications.
 Prescription.
 Equipment.
 Setting up a PCA.
 Patient monitoring.
 Side-effects.
 Discontinuation.
 Use of PCA with other opiates.

Rationale

PCA can provide effective pain relief in a wide variety of situations. However, there
are also a number of side effects that may limit its effectiveness and result in
morbidity.

Well-designed case control studies for the management of complications from PCA
are lacking, and there are no randomised clinical trials in this area. These guidelines
are based on a review of the literature and consensus from pain specialists and
anaesthetists.

Broad recommendations

Patient Controlled Analgesia (PCA) is a method of self administration of intravenous

analgesia. By means of a mechanical “trigger”, patients initiate the delivery of a small
dose of intravenous analgesia. Patients are therefore able to titrate their own
analgesia within pre-set restrictions.

Patient Selection

Patients selected for PCA usually have severe acute pain for whom the oral or
intramuscular route is not appropriate (e.g. post operative pain, abdominal pain).
Exceptionally a PCA may be used to supplement analgesia via a different route
(epidural or oral).

A PCA may also be appropriate in patients with acute exacerbation of longstanding

pain (e.g. pain on movement in cancer patients) or acute onset of pain in chronic
conditions (e.g. sickle cell crisis).

Patients should be able to comprehend the relationship between experiencing pain

and pressing the handset. Patients should physically able to trigger the pump.

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 4 of 11
 Trust Guideline for the Management of
Patient Controlled Analgesia (PCA) in Adults

Contraindications

Absolute contraindications to PCA are:

 Patient refusal.
 Known sensitivity/allergy to opiates.
 Lack of safe nursing environment for monitoring.
 Lack of patient understanding or physical capability to press the handset.

A PCA usually contains opiate medication. Certain medical conditions may dictate
cautious use of opiates:

Raised intra-cranial pressure (ICP): Known or suspected raised ICP of any cause
represents a relative contraindication to PCA analgesia, although in exceptional
circumstances its use in areas with high nurse/patient ratios may still be appropriate.

Severe respiratory disease: Opiate analgesia should be used with caution in patients
with severe respiratory disease, although PCA delivery may confer decreased risk
compared to other routes of opiate delivery.

Gastro-intestinal morbidity: Opiate analgesia is associated with delayed gastric

emptying and contributes to post-operative ileus. The route of opiate delivery does
not influence this effect significantly. Alternative analgesic strategies should be
considered.

Previous or ongoing use of narcotics (prescribed or recreational) is not a

contraindication to PCA in appropriate circumstances.

Prescription

A PCA should be prescribed on a standard Adult Drug Chart in the dedicated, pre-
printed PCA section.

The standard prescription will be for 100milligrams (mg) of morphine diluted with 100
millilitres (mL) of saline to a concentration of 1 mg/mL.

Each patient demand will trigger the administration of 1 millilitre (equal to 1 milligram
morphine). The ‘lock-out’ function on the PCA will preclude further dosing through
the PCA for five minutes.

The prescription may be varied only at the discretion of the Acute Pain Service (APS)
or supervising anaesthetist.

The use of a continuous background infusion of opiate may be considered by the

Acute Pain Service or by Consultant Anaesthetists in exceptional circumstances.
These proposals must be discussed with senior nursing staff from the patient’s ward
and the APS must be informed.

Recommended alternative regimes may be:

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 5 of 11
 Trust Guideline for the Management of
Patient Controlled Analgesia (PCA) in Adults
1. For patients who use neuropathic descriptors to describe their pain the
addition of ketamine can be considered after discussion with the Acute Pain
Service. The standard dose would be 50mgs. This would be added to the usual
100mgs morphine in 100mLs saline with a 1mL bolus and 5 minute lockout.
2. Pethidine 500 milligrams in 50mL (10 milligram/mL) bolus dose 1mL lock out 5
minutes [Pethidine is not recommended for use in opiate tolerant patients as
excessive usage may result in the accumulation of significant levels of the
metabolite, norpethidine. Consideration should be given to imposing a maximum
4 hourly limit of 200mg. Pethidine is also not recommended in patients with renal
failure due to the risk of accumulation of norpethidine].
3. Fentanyl 2000 micrograms in 100mL (20 microgram/mL) bolus dose 1mL
lockout 5minutes [Fentanyl may be particularly useful in patients who may
accumulate active metabolites of other opiates e.g. renal failure].

Patients with a PCA should have an anti-emetic (e.g. Cyclizine) prescribed, and the
prescription of REGULAR non-opiate medication (e.g. non-steroidal anti-
inflammatory drugs, paracetamol) should be considered.

No other opiates should be given whilst a PCA is in progress, unless directed by the
Acute Pain Service a Consultant Anaesthetist.

Use of a PCA with other Oral Opiates

Ordinarily a patient should not be given other oral opiates when a PCA is insitu.

The only exceptions to this are where the patient normally takes high dose opiate
medication for a longstanding condition, or where patients are part of an established
Substance Misuse programme.

Is these cases, the usual opiate doses should be confirmed with the patients GP or
the Substance Misuse team. Where possible, the patient should be given their
regular medication and a PCA maybe considered to cover any short-term acute pain.

For further advice, the Acute Pain Team or Substance Misuse nurses should be
contacted.

Equipment

Equipment necessary for the preparation of the PCA includes:

 Lockable PCA pump (obtained via Main Theatre Recovery NNUH).
 100ml dedicated cassette.
 Dedicated giving set, incorporating an anti-syphon and non-return valve.

The PCA should be connected to an dedicated intravenous cannula or through a 2

way non-return connector (Octopus2) if additional intravenous access is required.

Once discontinued, the PCA pump should be returned to the Equipment Library for
maintenance and cleaning.

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 6 of 11
 Trust Guideline for the Management of
Patient Controlled Analgesia (PCA) in Adults

Setting up a PCA

A PCA should only be set up by anaesthetists, members of the Acute Pain Team and
trained Recovery/ Critical Care Nurses.

The PCA should be checked and set up as per the Medicines Management Policy
(Trustdocs IDs: 10629 and 10630.

A PCA will only work effectively if adequate pain relief is established prior to the
commencement of the PCA. The patient may require several bolus or loading doses
to gain pain relief. This should be administered through the PCA so that an accurate
total can be recorded.

Patient Monitoring

All patients with a PCA should only be nursed on wards within the Norfolk and
Norwich University Hospital where specific training has been undertaken and nurses
are familiar with the management of patients using the designated PCA equipment.

Monitoring that must be carried out includes:

 Blood pressure, pulse, respiratory rate, sedation, pain and nausea should be
recorded hourly for the first eight hours after initiation of a PCA on the pain
assessment tool (Appendix A).
 Thereafter, these observations should be repeated two hourly for another 48
hours.
 Subsequently four hourly observations are appropriate until discontinuation of
the PCA treatment.

Due to a metal component in the cassette mechanism, all patients with a PCA who
require an MRI scan will need to be completely disconnected from the PCA pump,
cassette and giving set prior to scanning.

Side-effects

Common side-effects of a PCA include nausea, sedation, respiratory depression and

itching. These are side-effects of opiate analgesia rather than of the PCA route of
administration.

Problem Action
Excessive Nursing Staff:
sedation
(Sedation  Remove PCA handset.
score >2/3)  Monitor oxygen saturation continuously with pulse oximeter.
 Record pain and sedation scores on Trust Pain Assessment
Chart.
 Record blood pressure, pulse and temperature.

If no improvement in sedation after 30 minutes contact the patient’s

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 7 of 11
 Trust Guideline for the Management of
Patient Controlled Analgesia (PCA) in Adults
medical team.

Medical Staff:
 Consider other possible causes of sedation e.g.
hypoglycaemia, hypoxia, cerebrovascular event, sepsis etc.
 Ensure adequate non-opiate analgesia prescribed regularly.
 Consider discussion of analgesia management with Acute
Pain Service (APS) staff (bleep 0571) during 0900-1700
weekdays, or duty anaesthetist (bleep 0900) at other times.

Nursing Staff
 Give oxygen by mask at 4 litres/min.
 Switch off PCA.
 Monitor oxygen saturation continuously with pulse oximeter.
 Inform medical team.
Respiratory  Record pain and sedation scores on Trust Pain Assessment
Depression Chart.
(Respiratory
rate < 8  Record blood pressure, pulse and temperature.
breaths/min)
Medical Staff
 Assess and document respiratory function.
 Consider Naloxone 200-400 micrograms intravenously.
 Consider discussing analgesia with Acute Pain Service on
bleep 0571 during 0900-1700 weekdays, or duty anaesthetist
(bleep 0900) at other times.

Medical Staff:
Itching  Consider Chlorphenamine.
4 milligrams tds orally.
 Consider Naloxone 10-20 micrograms intravenously. This is
an off-label indication.

Nursing Staff:
 Give Cyclizine 50mgs im tds.
Nausea/
Vomiting  Offer reassurance and privacy.
 Offer regular mouthcare.
 Contact medical team if no improvement.

Discontinuation

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 8 of 11
 Trust Guideline for the Management of
Patient Controlled Analgesia (PCA) in Adults
There is no specific time limit for the use of a PCA. It is not normally necessary to
continue a PCA once the patient is able to take analgesia via the oral route.
Discontinuation of the PCA should only be undertaken if an alternative form of
analgesia is prescribed and available.

Clinical audit standards

 Management of complications of PCA.
 Appropriate selection of patients.
 Completeness of monitoring of PCAs.
 Adequacy of training for PCA usage.

Summary of development and consultation process undertaken before

registration and dissemination

During its development, the guideline has been circulated for comment to
anaesthetists and members of the Acute Pain Service. This version has been
endorsed by the Anaesthetic Directorate.

This version has been endorsed by the Clinical Guidelines Assessment Panel.

Distribution list/ dissemination method

Theatre Recovery
All Medical, Surgical and Orthopaedic wards
Anaesthetic department
Trust Intranet

References/ source documents

1) ANZCA (2010) Acute Pain Management: Scientific Evidence 3 rd Edn p175-184

2) The Cochrane Collaboration (2012) Patient controlled opioid analgesia versus
conventional opioid analgesia for postoperative pain (Review) JohnWiley & Sons,
Ltd.
3) MacIntyre PE Safety and efficacy of patient-controlled analgesia British
Journal of Anaesthesia 2001; 87:36-46
4) Carstensen M, Moller AM. Adding ketamine to morphine for intravenous
patient-controlled analgesia for acute postoperative pain. British Journal of
Anaesthesia 2010;104:401-6
.

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 9 of 11
 Trust Guideline for the Management of
Patient Controlled Analgesia (PCA) in Adults

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 10 of 11
 Trust Guideline for the Management of
Patient Controlled Analgesia (PCA) in Adults
Appendix A

Trust Guideline for the Management of Patient Controlled Analgesia (PCA) in Adults
Author/s: Katherine Dyer Author/s title: Clinical Nurse Manager
Approved by: CGAP Date approved: 05/05/2021 Review date: 05/05/2024
Available via Trust Docs Version: 7.1 Trust Docs ID: 1205 Page 11 of 11