Patient Controlled Analgesia (PCA) – Adult Guideline – NHS Borders

Prior to using PCAs, adequate nursing staff numbers on the ward must have undertaken relevant training.

Alongside the available infusions training every 2 years, PCA training will take place for trained nursing staff (infusions training will incorporate PCA training).

There needs to be familiarity with the PCA devices themselves (via PCA device training organised by Continuing Professional Development (CPD) department) as well as familiarity with PCA prescription charts, PCA monitoring charts, the PCA pathway, how to make up PCAs, ensuring correct device is used for PCAs (all contained within PCA booklet, see APPENDIX 1). Anaesthetic, Critical Care Team and Hospital at Night staff should be familiar with this process, including an ability to troubleshoot.

The clinical team must firstly ensure that the patient is suitable and ready for a PCA. 

An assessment of pain will be required; pain severity may be measured for example on the 0– 10 scale, and appropriate pain medication steps taken, directed by the pain score applied to the WHO ladder (references)

• Whilst trying to obtain good analgesia, fully explore the oral route unless pain is very severe. In this situation consider loading with intravenous opiate to gain more rapid control. 
• Ascertaining the cause of pain is important. Ensure the pain severity is in keeping with the working diagnosis and cause of pain; if pain seems disproportionately high consider alternative causes for the pain and have a low threshold for involving senior staff, other specialties to exclude alternative diagnoses especially in the context of unexpected worsening of the patient’s condition.
• If pain management seems more challenging e.g. patient’s opiate requirements are higher than would be expected
  • there is a background of taking opiates,
  • or there is no oral route available,

         Then a PCA may be considered.

Prior to a PCA being started pain management options should be discussed with the duty anaesthetist, ICU or the Critical Care Outreach Team/Acute Pain Team.

1. Access: Appropriate intravenous cannula inserted, as per local guidance and processes.
   
   
2. Consider initially loading up with IV opioid until the patient is more comfortable*
   
   
3. Prescription for a small background rate IV fluids e.g. 10mls/hr to ensure line patency.
   
   
4. Oxygen is normally required with adult PCAs (needs prescribed), if there are no contraindications.

*Consideration should be given to addition of analgesics on the WHO pain ladder (not just opioids), such as paracetamol, non-steroidal anti-inflammatory agents or COX II inhibitors (if not contraindicated) as they may reduce overall opioid dose requirements used in the PCA (see APPENDIX 2).

There are FOUR parts to prescribing a PCA

1. Choose a specific opioid (morphine, oxycodone or fentanyl) on the pre-printed PCA prescription chart. Morphine is the usual agent of choice, although there will be individual variation in response between agents and their side effect profile. See Table 1 below for some of the considerations to be taken in deciding which opiate to use in a PCA.
   
   
2. Write a generic prescription of “PCA (opiate chosen)” on the as required section of green drug chart Kardex (in a similar way to some antibiotics such as gentamicin being written on 2 charts).
   
   
3. Consider co-prescribing anti-emetics and laxatives to reduce likelihood and impact of opioid side effects.
   
   
4. Prescribe Naloxone in the as required section of drug Kardex, to be administered in the event of opioid toxicity. Please refer to the Right Decision Service for Naloxone guideline.

All prescribers may prescribe PCA morphine, PCA fentanyl or PCA oxycodone after discussion with anaesthetic, ICU, or Critical Care Outreach advice.

Pre-printed prescriptions must not be altered (prescription contains dose and concentration of opioid) as alteration would lead to an error in drug dosage, because PCA devices are pre-programmed to account for the concentrations on the prescription chart.

Table 1. Some factors to consider in choosing which opiate to prescribe for PCA

Documentation - When collecting PCA device from Recovery Room in Theatres, a note of patient’s details, & patient’s location is required for traceability. In addition, PCA device needs to be signed out of recovery area in the Recovery Room log.

Equipment - A dedicated IV PCA infusion line (containing an incorporated “Y” connector) and a PCA cartridge (which will be filled up with opioid) should also be collected at this time from Recovery. The PCA Booklet (containing PCA prescription and bedside guide) will already have been completed and can be found on the wards and in the Recovery Room too.

PCA devices can be obtained from Theatre Recovery and are signed out on collection for traceability.

• Before making up the PCA, the PCA will need prescribed by the parent team (PCA prescription booklets are available from Theatre Recovery and Wards).
  
  
• Prior liaison with Recovery Room is required to ensure that staff there are available to make up PCAs, to ensure they are not busy with other duties.
  
  
• To make up a PCA, a registered member of nursing staff will take a completed PCA prescription booklet up to the Theatre Recovery area. In addition, the green drug Kardex is required, complete with opioid PCA prescription, in the as required section. PCAs are made up (and refilled if needed) by the ward nurse, along with a second registered member of staff from the Theatre Recovery area.
  
  
• After making up PCA the PCA pump is locked before transporting to the clinical area. Cadd-Solis PCA key is part of each ward’s own set of master keys.
  
  
• Along with a registered staff member from Theatres, the ward nurse then takes the PCA device, documentation as above and all other necessary equipment back to the ward area (please follow the equipment checklist on the PCA shelf in Recovery Room and see below).
  
  
• If Theatres or ward staff are unable to assist with making up a PCA immediately, ward staff should consider alternative analgesia until this can be done. This may entail intravenous, intramuscular or subcutaneous administration of analgesics such as opioids.
• For PCA refills, the ward staff member brings green drug Kardex plus PCA booklet (containing PCA prescription) to Theatre Recovery where together with a member of registered staff, they will make up and check a new cartridge of opioid. Both staff then transport the cartridge to the ward and undertake appropriate checks before connecting the new cartridge to the patient.

In the ward area

• Connect PCA (and intravenous background fluid infusion, normally required) to patient.
  
  
• Explain to patient how to use.
  
  
• Ongoing patient and pump monitoring to be carried out by ward staff as described on monitoring chart.
  
  
• Attach a patient identifier (sticker) onto the disposable cassette on the bottom of the PCA (to ensure it is not used for another patient).

Setting up a PCA (Ward 7 ONLY)

1. Nursing staff in ward 7 will make up an adult PCA.
   
   
2. IV access will be required, and a small background of IV fluid enables line to remain patent, and opioid delivery beyond the cannula into the vein
3. IV loading with opioid may be required until pain is reasonably well controlled (PCA will not be so effective if pain is poorly controlled when handset given to patient).
   
   
4. PCA devices can be obtained from Theatre Recovery and are signed out on collection for traceability. Patient’s details and location also need to be provided.
   
   
5. If patient not already initiated on PCA treatment post operatively from Theatre, a request will be put on the portering system by ward 7 staff to collect PCA equipment from the Recovery Room. Ward 7 staff will contact theatre staff (bleep 6595) to let them know that a PCA is required. Staff in theatres will gather together the PCA equipment required (dedicated IV PCA infusion line, (includes a “Y” connector) and a PCA cartridge (for filling with opioid).
6. All equipment will be transferred to Ward 7 where ward staff will make up the syringe. To make up a PCA, the registered members of nursing staff will take a completed PCA prescription booklet up to the clinical area. In addition, the green drug Kardex is required, complete with opioid PCA prescription, in the as required section. PCAs are made up (and refilled if needed) by the ward nurses.
   
   
7. Staff need to be familiar with PCA devices and have completed PCA training (online and practical aspects of training), and to have competency signed off (on CARS). The IV Therapy course needs to be completed and signed off (yearly updates).
   
   
8. After making up or refilling cassettes with opioid, check correct patient, correct prescription, countersign prescription & pump chart:
   
   
   • Set up PCA pump and connect to patient.
     
     
   • Explain to patient how to use.
     
     
   • Lock PCA pump, key attached to ward master key.
     
     
   • Ongoing patient and pump monitoring by ward staff as on monitoring chart
     
     
9. One to one nursing supervision must be used when the PCA is started to ensure the patient is using the pump correctly.
   
   
10. A change of syringe is needed every 24 hours for PCAs. Dispose of cassette into sharps box, and if there is any unused opioid, state the volume discarded on the monitoring chart and sign this off. Plan ahead for refills.
    
    
11. A change of IV infusion line is needed every 24 hours.

In the ward area

• Connect PCA (and intravenous background fluid infusion, normally required) to patient.
  
  
• Explain to patient how to use.
  
  
• Ongoing patient and pump monitoring to be carried out by ward staff as described on monitoring chart.
  
  
• Attach a patient identifier (sticker) onto the disposable cassette on the bottom of the PCA (to ensure it is not used for another patient).

Nurses must complete routine observations as per PCA monitoring chart. Depending on observations, escalation may be required.

Daily review of the need for ongoing use of a PCA is required, to be carried out by the parent clinical team in combination with the Acute Pain/ Critical Care Outreach, ICU or Anaesthetics teams. Decisions regarding stopping or continuing with PCAs should to be documented in the patient’s clinical notes.

If the PCA is to be continued, the opioid drug, cassette (containing opioid) & IV giving set all need changed every 24 hours. Try to anticipate the need for refills in advance, and contact Theatre Recovery who will assist with this, as described above.

If Theatres are unable to assist with cassette refills immediately, ward staff should consider alternative analgesia until staff are available.

If the PCA is to be discontinued, prescription of step-down analgesia with opioids eg. Tramadol, morphine 10mg/5ml or codeine as per East Region Formulary may be required. Pre-loading with alternative opioids is usually required before the PCA is stopped, in combination with explanation to the patient. As required opioid may be prescribed in addition. Any residual opioid within the PCA cartridge will be discarded in the clinical area and documented in the patient’s clinical notes. Return PCA device to the Recovery Room within Operating Theatres, and sign that it has been returned.

Contact details for help

• Critical Care Outreach bleep 6321 during day
• Operating Department bleep 6595 (During daytime hours, Recovery Room may then be contacted)
• Hospital at Night Team bleep 6344
• Duty Anaesthetist bleep 3933

1. PCA Booklet - PCA Bedside Document
2. PCA Booklet - PCA Bedside Document – WARD 7 ONLY

Both booklets are available as printed documents from BGH Recovery Room for the usual format / all clinical areas.

WHO Guidelines link

Cancer Pain Relief.  World Health Organisation 1986.

P51 https://iris.who.int/handle/10665/439449241561009_eng.pdf