ASPMN Position Statement: Authorized Agent Controlled Analgesia.

The American Society for Pain Management Nursing (ASPMN) has reviewed and updated its position statement on the use of authorized agent controlled analgesia (AACA) for patients who are unable to independently utilize a self-dosing analgesic infusion pump, commonly known as patient-controlled analgesia (PCA). ASPMN continues to support the use of AACA to provide timely and effective pain management while promoting equitable care for vulnerable patient populations who are unable to use PCA. ASPMN does not support the use of "PCA by Proxy" in which unauthorized individuals activate PCA for a patient. This position statement includes an updated review of the evidence related to AACA. Clinical practice recommendations for authorized agents, nurses, prescribers, and organizations are provided with an emphasis on the importance of appropriate authorized agent selection, education, diligent patient assessment and medication management.

Continuous Ambulatory Delivery Device Use for Patients Managed by an Inpatient Palliative Care Team.

BACKGROUND: The use of Patient Controlled Analgesia (PCA) via a Continuous Ambulatory Delivery Device (CADD) is a common and effective means of pain and symptom management for hospitalized patients with a malignancy. Studies exploring the indications for starting such a device for hospitalized inpatients referred to inpatient palliative care teams are limited. AIM: This retrospective chart review aims to explore indications, timing of initiation, and barriers to the use of a CADD. METHODS: Over a six month period, during daily inpatient palliative care consult team rounds, patients who required a CADD were enrolled in this study. Sixty-one adult patients were identified who required a pump for symptom control. The team's database sheets were used to capture patient demographics. RESULTS: The main reasons for initiating a Continuous Ambulatory Delivery Device in the above setting included: lack of efficacy of oral opioids and to increase patient autonomy of their pain management. Approximately 20% of patients required transfer to another unit that could accommodate the CADD. The median length of stay for these patients was 13 days, with a median length of half a day for a pump to be started. CONCLUSIONS: This initial study provides the Palliative Care Consult Team with information on the indications for the use of a CADD. The lack of universal access to a CADD in various areas of our hospital due to differences in departmental protocols may compromise good symptom management and patient safety. These results strengthen the argument that the existing hospital policy requires revamping to improve CADD access. A CADD has been shown to provide hospitalized patients, with a malignancy, with timely access to effective symptom management, and in turn, reducing their length of stay in hospital. These findings will help inform this organization's CADD policy and support the need to broaden access to this device.

The effectiveness of an oral opioid rescue medication algorithm for postoperative pain management compared to PCIA : A cohort analysis.

BACKGROUND: Standard protocols or algorithms are considered essential to ensure adequate analgesia. Germany has widely adopted postoperative protocols for pain management including oral opioids for rescue medication, but the effectiveness of such protocols has only been evaluated longitudinally in a before and after setting. The aim of this cohort analysis was to compare the effectiveness of an oral opioid rescue medication algorithm for postoperative management of pain to the gold standard of patient-controlled intravenous analgesia (PCIA). MATERIAL AND METHODS: This study compared cohorts of patients of two prospective observational studies undergoing elective total hip replacement. After surgery patients received piritramide to achieve a pain score of ≤3 on the numeric rating scale (NRS 0-10). A protocol was started consisting of oral long-acting oxycodone and ibuprofen (basic analgesia). Cohort 1 (C1, 126 patients) additionally received an oral opioid rescue medication (hydromorphone) when reporting pain >3 on the NRS. Cohort 2 (C2, 88 patients) was provided with an opioid by PCIA (piritramide) for opioid rescue medication. Primary endpoints were pain intensity at rest, during movement, and maximum pain intensity within the first 24 h postoperative. Secondary endpoints were opioid consumption, functional outcome and patient satisfaction with pain management. RESULTS: Pain during movement and maximum pain intensity were higher in C1 compared to C2: pain on movement median 1st-3rd quartile: 6 (3.75-8) vs. 5 (3-7), p = 0.023; maximum pain intensity: 7 (5-9) vs. 5 (3-8), p = 0.008. There were no differences in pain intensity at rest or between women and men in either group. The mean opioid consumption in all patients (combined PACU, baseline, and rescue medication; mean ± SD mg ME) was 126.6 ± 51.8 mg oral ME (median 120 (87.47-154.25) mg ME). Total opioid consumption was lower in C1 than C2 (117 ± 46 mg vs 140 ± 56 mg, p = 0.002) due to differences in rescue opioids (C1: 57 ± 37 mg ME, C2: 73 ± 43 mg ME, p = 0.006, Z = -2.730). Basic analgesia opioid use was comparable (C1: 54 ± 31 mg ME, C2: 60 ± 36 mg ME, p = 0.288, Z = -1.063). There were no differences in respect to the addition of non-opioids and reported quality of mobilization, sleep, frequency of nausea and vomiting, or general satisfaction with pain management. CONCLUSION: In this study PCIA provided a better reduction of pain intensity, when compared to a standardized protocol with oral opioid rescue medication. This effect was associated with increased opioid consumption. There were no differences in frequencies of opioid side effects. This study was a retrospective analysis of two cohorts of a major project. As with all retrospective studies, our analysis has several limitations to consider. Data can only represent the observation of clinical practice. It cannot reflect the quality of a statement of a randomized controlled trial. Observational studies do not permit conclusions on causal relationships.

Ultrasound-guided continuous thoracic paravertebral block alleviates postoperative delirium in elderly patients undergoing esophagectomy: A randomized controlled trial.

BACKGROUND: Delirium is a common postoperative complication in older patients undergoing thoracic surgery and presages poor outcomes. Postoperative pain is an important factor in the progression of delirium. The purpose of this study was to test whether continuous thoracic paravertebral block (PVB), a more effective approach for analgesia, could decrease the incidence of delirium in elderly patients undergoing esophagectomy. METHODS: A total of 180 geriatric patients undergoing esophagectomy were randomly divided into 2 groups and treated with PVB or patient-controlled analgesia (PCA). Perioperative plasma CRP, IL-1ß, IL-6, and TNF-α levels were detected in all patients. Pain intensity was measured by a numerical rating scale. Delirium was assessed using the confusion assessment method. RESULTS: The incidence of postoperative delirium was significantly lower in the PVB group than in the PCA group. Patients in the PVB group had lower plasma CRP, IL-1ß, IL-6, and TNF-α levels and less pain when coughing after surgery. CONCLUSIONS: Ultrasound-guided continuous thoracic paravertebral block improved analgesia, reduced the inflammatory reaction and decreased the occurrence of delirium after surgery.

Current state of opioid stewardship.

PURPOSE: The opioid epidemic continues to result in significant morbidity and mortality even within hospitals where opioids are the second most common cause of adverse events. Opioid stewardship represents one model for hospitals to promote safe and rational prescribing of opioids to mitigate preventable adverse events in alliance with new Joint Commission standards. The purpose of this study was to identify the prevalence of current hospital practices to improve opioid use. METHODS: A cross-sectional survey of hospital best practices for opioid use was electronically distributed via electronic listservs in March 2018 to examine the presence of an opioid stewardship program and related practices, including formulary restrictions, specialist involvement for high-risk patients, types of risk factors screened, and educational activities. RESULTS: Among 133 included hospitals, 23% reported a stewardship program and 14% reported a prospective screening process to identify patients at high risk of opioid-related adverse events (ORAEs). Among those with a prospective screening process, there was variability in ORAE risk factor screening. Formulary restrictions were dependent on specific opioids and formulations. Patient-controlled analgesia was restricted at 45% of hospitals. Most hospitals reported having a pain management service (90%) and a palliative care service providing pain management (67%). CONCLUSION: The absence of opioid stewardship and prospectively screening ORAEs represents a gap in current practice at surveyed hospitals. Hospitals have an opportunity to implement and refine best practices such as access to pain management specialists, use of formulary restrictions, and retrospective and prospective monitoring of adverse events to improve opioid use.

Factors Influencing Satisfaction with Patient-Controlled Analgesia Among Postoperative Patients Using a Generalized Ordinal Logistic Regression Model.

PURPOSE: The purpose of this study was to identify the factors affecting the satisfaction with patient-controlled analgesia (PCA) of patients using a generalized ordinal logistic regression model and to evaluate the difference in results of the ordinal regression from those of binary regression. METHODS: The study design involved secondary analysis of electronic medical records from a single tertiary care hospital in Seoul, Korea. It included 2,409 patients treated with PCA for postoperative pain management after open or laparoscopic abdominal surgery. Binary logistic regression and generalized ordinal logistic regression were used to identify factors affecting satisfaction. RESULTS: Binary logistic regression analysis showed that there was insufficient information for analysis. Generalized ordinal logistic regression revealed that sex, age, pain, PCA usage, and side-effects were common factors affecting PCA satisfaction. However, the effect of some factors affecting PCA satisfaction differed with the level of satisfaction. In open surgery patients, the effect of pain at 6 hours after surgery was significantly greater in the group with lower satisfaction. While, in the laparoscopic surgery patients, the effect of pain at 6-24 hours after surgery was significantly greater in the group with lower satisfaction. CONCLUSION: Generalized logistic regression may be an appropriate statistical method for analyzing ordinal data. Degree of postoperative pain and assessment interval are the most important factors associated with PCA satisfaction. Because the factors affecting PCA satisfaction were different for the two types of abdominal surgeries, customizing PCA to individual patients may potentially improve pain management and consequently increase PCA satisfaction.

A Prospective Randomized Trial of an Oral Patient-Controlled Analgesia Device Versus Usual Care Following Total Hip Arthroplasty.

BACKGROUND: Multimodal pain management for surgery patients may include the use of a combination of scheduled oral pain medications with as-needed (PRN) oral opioids. Multiple concurrent time demands on nursing staff frequently cause delays in the delivery of oral PRN pain medication compromising pain management. PURPOSE: Postoperative pain control was compared using a wireless oral patient-controlled analgesia device for the delivery of oxycodone with a control group receiving PRN oxycodone from nursing staff. METHODS: Thirty patients were prospectively randomized into each of 2 groups after total hip arthroplasty. Patient demographics, pain scores, drug dose data, and physical therapy data were collected from chart reviews. Additional data were obtained from patient and nursing surveys. RESULTS: Device patients recorded statistically lower pain scores while taking lower doses of oxycodone on postoperative Day 1 as compared with the control group. Patient surveys indicated that those in the device group reported lower pain scores 24 hours prior to discharge, albeit not statistically different from the control group. Men in the device group reported statistically lower pain scores with physical therapy than men in the control group. Findings from the nursing survey indicate that nurses favored the device over nurse-administered PRN. CONCLUSION: Patients using the wireless patient-controlled analgesia (PCA) (oral) device had less pain at rest and with activity (men) while taking lower doses of oxycodone with each dose. Nursing surveys indicated that nursing staff in this orthopedic postoperative unit found the device easy to use, reliable, and efficient. They also recommended its adoption for those capable of using it.

Factors Related to the Consumption of Patient-Controlled Postoperative Analgesics in Korea: A Retrospective Study.

BACKGROUND: Pain is the most common symptom among inpatients, and patient-controlled analgesia (PCA) is one of the effective pain management methods for postoperative patients. AIMS: This study aimed to identify the predictors of analgesic consumption in patients using postoperative PCA. DESIGN: As part of a descriptive and retrospective study, data were collected from the nursing records of 662 patients who underwent postoperative intravenous PCA for three days after surgery at one medical institution. Stepwise multiple regression analyses were conducted to select significant variables that could predict total analgesic consumption. RESULTS: The results demonstrated that surgical sites, physical characteristics, donation surgery, and postoperative pain significantly influenced total analgesic consumption (POD 3, R2 = 53%, p < .001). CONCLUSION: The present findings provide valuable information for the effective postoperative administration of intravenous PCA and may contribute to the development of customized patient-centered pain management intervention by nurses through more accurate predictions of analgesic consumption based on individual characteristics, the surgical site, and the type of surgery-especially organ donation surgery. This study could contribute to improving preventive interventions by general nurses as well as pain control nurses by enabling more accurate predictions of patients' pain and consumption of self-controlled analgesic agents based on personal characteristics and surgical characteristics.

Dexmedetomidine and sufentanil combination versus sufentanil alone for postoperative intravenous patient-controlled analgesia: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Previous studies have demonstrated that dexmedetomidine improves the quality of postoperative analgesia. In the present study, we performed a meta-analysis of randomized controlled trials to quantify the effect of dexmedetomidine as an adjuvant to sufentanil for postoperative patient-controlled analgesia (PCA). METHODS: PubMed, Embase, the Cochrane Library, and Web of Science were systematically searched for randomized controlled trials in which dexmedetomidine was used as an adjuvant for PCA with sufentanil. In the retrieved studies, we quantitatively analyzed pain intensity, sufentanil consumption, and drug-related side effects. RESULTS: Nine studies with 907 patients were included in this meta-analysis. Compared with sufentanil alone, dexmedetomidine-sufentanil for postoperative intravenous PCA reduced pain intensity at 24 h (mean difference (MD) = - 0.70points; 95% confidence interval (CI): - 1.01, - 0.39; P < 0.00001) and 48 h postoperatively (MD = -0.61points; 95% CI: - 1.00, - 0.22; P = 0.002). Moreover, dexmedetomidine-sufentanil reduced sufentanil consumption during the first 24 h (MD = -13.77 µg; 95% CI: - 18.56, - 8.97; P < 0.00001) and 48 h postoperatively (MD = -20.81 µg; 95% CI: - 28.20, - 13.42; P < 0.00001). Finally, dexmedetomidine-sufentanil improved patient satisfaction without increasing the incidence of side effects. CONCLUSIONS: Dexmedetomidine as an adjuvant to sufentanil for postoperative PCA can reduce postoperative pain score and sufentanil consumption.

The Effect of Patient-Controlled Oral Analgesia for Acute Abdominal Pain after Discharge.

BACKGROUND: During hospitalization, patients who were admitted with acute abdominal pain must be prepared to care for themselves at home after discharge to continue established treatment, promote recovery, and avoid readmission. AIMS: Our aim was to investigate the quality of pain management after discharge, when patient-controlled oral analgesia was compared with standard care for patients admitted to hospital with acute abdominal pain. The primary outcome measures were pain intensity and patient perception of care. The secondary outcome measures were pain interference with activity, affective experiences, side effects, and use of analgesics. DESIGN: A questionnaire study measuring the effect of an intervention on patient-controlled oral analgesics. SETTINGS: An emergency department and a surgical department in Denmark. PARTICIPANTS: Patients admitted to hospital with acute abdominal pain. METHODS: A pre- and postintervention study was conducted in an emergency department and a surgical department with three subunits. Data were collected using a Danish modified Revised American Pain Society Patient Outcome Questionnaire with five subscales (scale 0-10) completed in weeks 1 and 4 after discharge. RESULTS: In total, 117 patients were included. The median scores at week 1 and week 4 in the control and intervention groups were, respectively, 2/1 and 1/0 on the pain subscale (p = .11/.16), 3/0 and 3/0 on the activity subscale (p = .19/.80), 1/0 and 0/0 on the emotional subscale (p = .02/.72), 1/0 and 1/0 on the side effect subscale (p = .95/.99), and 8/5 and 7/7 on the patient perception subscale (p = .35/.49). There was no significant difference in the use of analgesics at week 1. CONCLUSIONS: Patient-controlled oral analgesia during the hospital stay did not improve the quality of pain management after discharge.

Comparison of programmed intermittent bolus infusion and continuous infusion for postoperative patient-controlled analgesia with thoracic paravertebral block catheter: a randomized, double-blind, controlled trial.

BACKGROUND AND OBJECTIVES: In this randomized, double-blind, controlled study, we hypothesized that programmed intermittent bolus infusion (PIBI) of local anesthetic for continuous paravertebral block (PVB), combined with patient-controlled analgesia (PCA), provided better pain control, better patient satisfaction, and decreased in local anesthetic consumption when compared with a continuous infusion (CI) combined with PCA, after video-assisted thoracoscopic unilateral lung resection surgery. METHODS: Preoperatively, patients undergoing video-assisted thoracoscopic unilateral lung resection surgery received ipsilateral paravertebral catheters inserted at the level of thoracic vertebrae 4 and 5. All the subjects received an initial bolus of 15 mL 0.375% ropivacaine via the catheters. Subjects were randomized to receive 0.2 % ropivacaine 8 mL/h as either PIBI (n=17) or CI (n=17) combined with a PCA pump. The pain scores, frequency of PCA, local anesthetic consumption, patient satisfaction, and the need for rescue analgesia with tramadol were recorded until 48 hours postoperative. RESULTS: The numeric rating scale scores in the PIBI group were significantly lower than the CI group at 4, 8, 12 hours and 4, 8, 12, 24 hours postoperatively, at rest, and during coughing, respectively. PCA local anesthetic consumption (30 mg (20-60 mg) vs 120 mg (70-155 mg), p=0.000) and frequency of PCA use over 48 hours (3 (2-6) vs 12 (7-15.5), p=0.000) was lower in the PIBI group as compared with the CI group. Additionally, the PIBI group showed greater patient satisfaction. The need for tramadol rescue was similar in the two groups. CONCLUSIONS: In PVBs, local anesthetic administered as a PIBI in conjunction with PCA provided superior postoperative analgesia to a CI combined with PCA in patients undergoing video-assisted thoracoscopic unilateral lung resection surgery. CLINICAL TRIAL REGISTRATION: ChiCTR-IOR-17011253.

Impact of Frequent Interruption on Nurses' Patient-Controlled Analgesia Programming Performance.

OBJECTIVE: The purpose was to add to the body of knowledge regarding the impact of interruption on acute care nurses' cognitive workload, total task completion times, nurse frustration, and medication administration error while programming a patient-controlled analgesia (PCA) pump. BACKGROUND: Data support that the severity of medication administration error increases with the number of interruptions, which is especially critical during the administration of high-risk medications. Bar code technology, interruption-free zones, and medication safety vests have been shown to decrease administration-related errors. However, there are few published data regarding the impact of number of interruptions on nurses' clinical performance during PCA programming. METHOD: Nine acute care nurses completed three PCA pump programming tasks in a simulation laboratory. Programming tasks were completed under three conditions where the number of interruptions varied between two, four, and six. Outcome measures included cognitive workload (six NASA Task Load Index [NASA-TLX] subscales), total task completion time (seconds), nurse frustration (NASA-TLX Subscale 6), and PCA medication administration error (incorrect final programming). RESULTS: Increases in the number of interruptions were associated with significant increases in total task completion time ( p = .003). We also found increases in nurses' cognitive workload, nurse frustration, and PCA pump programming errors, but these increases were not statistically significant. APPLICATIONS: Complex technology use permeates the acute care nursing practice environment. These results add new knowledge on nurses' clinical performance during PCA pump programming and high-risk medication administration.

Audit of postoperative pain management after open thoracotomy and the incidence of chronic postthoracotomy pain in more than 500 patients at a tertiary center.

STUDY OBJECTIVE: To evaluate the quality of postoperative pain relief during the first 3 days after surgery and to evaluate with the incidence of persistent pain at 6 months after surgery. DESIGN: Retrospective single-center audit. SETTING: University hospital. PATIENTS: Five hundred four patients who underwent thoracotomy. INTERVENTIONS: Review of patient records, questionnaire, and telephone review. RESULTS: Of the 364 survivors, 306 were contacted. Five or more episodes of severe pain (numerical rating scale >6/10 at rest or movement) during the first 72 hours after surgery occurred in 133 patients. Persistent postsurgical pain at 6 months was present in 82% (109/133) of these patients. Patient satisfaction with acute postoperative pain management was excellent (36%), good (43%), and fair or poor (21%).The incidence of postthoracotomy pain was 56% (mild 32%, moderate 18%, and severe 6%). CONCLUSIONS: Poorly controlled acute postoperative pain correlated with persistent postsurgical pain at 6 months. In view of such a high incidence in thoracotomy patients, preventative strategies assume great significance.

Colocación de analgesia controlada por el paciente epidural por vía venosa periférica / Inserting epidural patient controlled analgesia into a peripheral venous line

Se presenta un caso comunicado en la base de datos del Sistema de Notificación en Seguridad en Anestesia y Reanimación. El evento se produce en una paciente sometida a cirugía abdominal a la que se coloca preoperatoriamente un catéter epidural para analgesia. Al finalizar la intervención se traslada a la Unidad de Reanimación, donde se programa la analgesia controlada por el paciente (PCA). Por error, se conecta la PCA a una vía venosa periférica, detectándose precozmente sin que le produzca daño a la paciente. El análisis de este incidente permitió implantar un nuevo protocolo de administración de fármacos a través de PCA, lo que incluye la obligatoriedad de prescribir las PCA en el sistema electrónico, un sistema de doble chequeo antes de la conexión de la PCA, el etiquetado de las bolsas de medicación y las líneas tanto en el extremo proximal como en el distal, la estandarización de la visita diaria a los pacientes y el control mensual de los resultados obtenidos (AU)

A case is reported from the Safety Reporting System in Anaesthesia and Resuscitation database. The event occurred in a patient undergoing abdominal surgery in whom an epidural catheter was inserted for analgesia. After the intervention, the patient was transferred to the recovery unit where the patient controlled analgesia (PCA) is programmed. Due to an error, the PCA was connected to a peripheral venous line, which was detected early without harm to the patient. Communication and analysis of this incident served to introduce a new drug delivery protocol through PCA pumps, including the obligation to prescribe the PCA in the electronic system, a dual computerised check immediately before connecting PCA, labelling the medication bag as well as the proximal and distal lines, standardisation of daily visits to patients, and monthly monitoring of results (AU)

Multimodal Versus Patient-Controlled Analgesia After an Anterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective analysis of a prospectively maintained surgical registry. OBJECTIVE: To compare postoperative narcotic consumption between multimodal analgesia (MMA) and patient-controlled analgesia (PCA) after an anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Studies suggest that a multimodal approach to pain management leads to decreased pain and morphine consumption after total joint arthroplasty and lumbar spinal procedures. Patients and surgeons would benefit from knowing whether a multimodal approach to pain management is superior to PCA for ACDF. METHODS: A retrospective cohort study of ACDF patients receiving either MMA or PCA was conducted. Inpatient narcotic consumption, pain scores, nausea/vomiting, hospital length of stay, and narcotic dependence during the months after surgery were compared between MMA and PCA. RESULTS: A total of 239 patients met inclusion criteria. Of these, 55 (23.0%) received MMA and 184 (77.0%) received PCA. Patients who received MMA had a lower rate of inpatient narcotic consumption (2.5 OME/h vs. 5.8 OME/h, P < 0.001) were less likely to experience nausea/vomiting during the hospitalization (5.5% vs. 37.5%, P < 0.001), and had a shorter hospital length of stay (27.3 vs. 40.1 h, P < 0.001). However, there was no difference between groups in mean visual analogue pain scale during postoperative day zero (4.7 for MMA vs. 5.2 for PCA, P = 0.126) or during postoperative day one (4.1 for MMA vs. 4.1 for PCA, P = 0.937). In addition, there was no difference in the rate of narcotic dependence at the first (P = 0.626) or second (P = 0.480) postoperative visits. CONCLUSION: These data suggest that MMA results in lower narcotic consumption than PCA after an ACDF. This difference is associated with a shorter inpatient stay and a decrease in postoperative nausea/vomiting. Critically, MMA and PCA appear to provide similar postoperative analgesia. LEVEL OF EVIDENCE: 3.

American Society for Pain Management Nursing position statement with clinical practice guidelines: authorized agent controlled analgesia.

The American Society for Pain Management Nursing (ASPMN) has updated its 2007 position statement on the use of authorized agent controlled analgesia (AACA) for patients who are unable to independently utilize patient-controlled analgesia (PCA). ASPMN continues to support the use of AACA to provide timely and effective pain management while promoting equitable care for vulnerable patient populations who are unable to utilize PCA. ASPMN does not support the use of "PCA by Proxy" in which unauthorized individuals activate PCA for a patient. The background of the development of the position statement, definitions related to AACA, and application of ethical principles to the use of AACA are presented in the document. This position statement includes an updated review of the evidence related to AACA and a call for further research. Clinical practice recommendations for authorized agents, nurses, prescribers, and organizations are provided with an emphasis on the importance of appropriate authorized agent selection, education, diligent patient assessment and medication management.