Patient Controlled Analgesia

Executive Summary

Insufficient postoperative pain control is a global anomaly and the need to enhance its efficacy is well structured. This paper talks about some of the widely employed treatment including multimodal analgesia, patient controlled analgesia, epidurals, and perineural infusions as well as adjuvant tablets, Boswell et al., (2007). Hindrances to enhancements comprise inaccurate pain analysis, communication issues, information deficits; problems that come with incorporating evidence into practice as well as challenges in the ultra-modern healthcare backdrops will be discussed. Subsequent to this, some alternatives for the way forward will be discussed. A continuous attention of enhancing the basics entail accurate pain analysis and prompt treatment with the right analgesic management would usher in a considerable difference for myriad patients. Even though this has been a focus for quite some time, research in this domain should be advanced and innovative ways should be sought to enhance the basics. Moreover, information suggesting evidence centred, system explicit management and modern drugs may have an effect. In the end, pain regimes require becoming a bigger priority and responsibility requires to be shared to ascertain enhancements are made, Bhaskaranand, Bhat and Acharya, (2003).

1. Introduction

For far too long, the need to lessen postoperative pain control has been recognized in UK and globally. Fundamental reasons cited for poor pain control involve inadequate staff training, information deficits, unhelpful staff as well as patient attitudes, poor pain analysis, fear of analgesic after effects, and lack of responsibility. With the detailed objective of enhancing and standardising medical care, a number of global institutions have produced guidelines and recommendations. In UK for instance, most medical institutions have equally introduced multifaceted acute pain services (APSs) to assume the task for the control of postoperative ache, training, development of rules, and to undertake research and audit. Institutionalizing these teams has widely been championed. Evidence shows that application of APS guidelines results to increased standard of care, Boswell et al., (2007).
Additionally, the benefit of a committed acute pain health provider is evident. The advantage of a devoted chronic pain practitioner is also evident. The administration of APS has equally allowed an increase in the amount and sophisticated of specific pain reinforcement methods. These consist of patient controlled analgesia (PCA), epidural as well as perineural infusions in scientific wards. In reality, the evidence for the advantage of APSs is variable when viewed across the entire spectrum in which it is employed and the existence of such practitioners don’t always warrant good postoperative pain control. The perception is that these services have enhanced care; nonetheless, it is intricate to confirm that APSs enhance simple end-results such as time-frame. Reasons comprise of the variability between hospices among employees and the particular services accessible as well as various other factors that may constitute to a change in end-results, Bhaskaranand, Bhat and Acharya, (2003). It is equally apparent that skewed healthcare services and the quality of care is complex to determine but might be relatively pertinent as the period of stay. In reality one may question if the period of stay is likely to be radically impacted. Even if it is thought that certain facets of pain control have been discovered, many ailing persons still suffer considerable pain. A review conducted in 2005, in 14 medical centres in the United Kingdom confirmed that 60% of patients experienced severe pain, exactly twenty hours after surgery. In the end the literature search for this review includes the databases Medline, Cinahl, PsychINFO, Arch Phys Med Rehabil accessed through the Anglia Ruskin Library web page as well as the World Wide Web. This will enable this review to determine whether there has been any significant change to the original findings that were made on medicines management of postoperative patients with a close view at Patient-Controlled-Analgesia, Dworkin R. et al., (2007).

Patient Controlled Analgesia

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1.2 Objectives

This paper sets out to present a critical view of Patient Controlled Analgesia (PCA) with respect to postoperative patient care. The will also explore and determine the quality as well as gaps in research with respect to postoperative patient management. According to Green and Thorogood (2004), it is important to carry out both a theoretical and analytical literature review since the former provides the prepositions of researchers as they are, while the latter attempts to evaluate and analyse such prepositions with an aim of creating an in-depth understanding of the subject of discussion. In some other ways, an analytical literature review also helps researchers in giving a detailed understanding and account of the topic under research.

2.0 Literature Review

2.1 Postoperative pain

Surgical processes almost invariably create tissue harm leading to pain. The effect of inadequate pain relief is well known and can lead into a protracted mobilisation and associated with impediments and psychological distress and apprehension. Severe post-operation pain is rather common than realised, particularly after forms of surgery; for instance thoracotomy as well as mastectomy, Boswell et al., (2007). Analytical variables for developing persistent pain comprise preoperative pain, repeat surgery, extended surgery, chronic postoperative pain, surgical methods with propensity of nerve shattering, chemotherapy or emission, and some psychological as well as depressive signs. It rather not evident how effective preventative measures like pre-emptive analgesia might be in thwarting severe pain developing, though it is highly probable that early intervention when symptoms are sensed is rather likely to be beneficial, Dillingham, Pezzin & Mackenzie, (2002). Treating postoperative ache in the current healthcare backdrop can be intricate. Managing postoperative pain in the current healthcare environment can be difficult. Busy medical institutions, fewer employees, limited time, inappropriate mind-sets or concentration on other issues and scanty information will impede optimal postoperative pain control, Green & Thorogood, (2004). This might be controlled by creating an environment where pain regimes are viewed as top most priority by putting in place regular and accurate pain control, a multimodal treatment strategy and focus on responding to patient expectations. Many healthcare systems are also under pressure to reduce length of stay and improve patient satisfaction, both of which will be compromised if pain management is not effective, Dillingham, Pezzin & Mackenzie, (2002).

2.2 Treatment with analgesics

Substantial evidence about some of the most competent ways of managing postoperative pain exists. This comprises of multimodal analgesia as well as the introduction of methods such as PCA, epidural as well as perineural infusions, Creswell, (2003).

2.3 Multimodal analgesia

The cost of using multimodal analgesia or combining the two or more analgesics is a common practice. The objective to enhancing analgesia by use of analgesics with a different mode of action and to lessen side effects by way of reducing in doses of analgesics, especially opioids. Research around this subject has been related to patients with intravenous (IV) PCA by or not augmenting agents and has quantified results such as proficiency, opoid consumption, after-effect complications, Department of Health, (2010). Various meta-reviews are now available on the subject. One screened the augmentation of paracetamol, selective cyclo-oxygenase 2 inhibitors (COX-2s) as well as nonsteroidal anti-inflammatory drugs (NSAIDS) to IV PCA indicating that all presented an opiod sparing impact. The cocaine scant impact with paracetamol was lower than 20%, with COX-2 inhibitors roughly 25% and several doses of NSAIDS roughly 40%, Sherman, (1994), Ephraim et al. (2005).

2.4 Paracetamol

This is a widely employed paracetamol is an effective analgesic that is normally employed for less pain and in combination with other analgesics for reasonable or chronic pain. Introducing an easily prescribed preparation of intravenous paracetamol has brought about enhanced enthusiasm for its application owing to its fast onset and efficiency. Intravenous pain killers like paracetamol guarantees a more predictable plasma attention and might present a considerable opioid sparing impact, Department of Health, (2010).

2.5 Utilizing PCA

The aim of PCA is to efficiently manage pain. Additionally, it allows instantaneous delivery of pain relievers without delay in case a health care provider is attending to other patients or is not in attendance (e.g. to use PCA patients are not necessarily required to be under the care of full-time nurse) (Kuzel & Engel, 2001). PCA also enables frequent though smaller doses and hence a more balanced level of analgesic in the body. PCA, which is a measure, used by patients to administer synthetic medications, such as opium–like pain relievers every 8 or 12 hours, can be a useful option, Elliott & Lanenbatt, (2004). This entails the use of a pump-like machine which delivers medication intravenously, subcutaneously (under the skin), or via an epidural. A health practitioner sets the device in a manner that the dosage delivers medication as needed by the patient and within the allowed limit of 8 – 12 hours. Many of the PCA machines are complicated; some can monitor themselves and can alert the user in case of a fault (Kuzel & Engel, 2001).

2.6 Differences chronic and acute pain

In order to understand the management of postoperative pain it is important to consider the various definitions of pain – in particular acute and chronic paid – for, although they may sound similar, they are not the same. Acute pain starts abruptly and in most cases is felt as a sharp sensation; it acts as a signal for an infection or danger to the body. It is likely to be as a result of sudden injury or heart pain, as well as childbirth, surgical procedures, broken bones, burns or cuts. This pain can really be prolonged over a period of time. Generally, acute pain doesn’t last over six months, and fades away when primary cause of the pain have been managed or even healed, Dworkin et al. (2007) However, unrelieved acute pain may culminate in chronic pain if it is not treated over the long-term. In comparison, chronic pain may be perceived as a condition of an illness and includes pain which outlasts normal healing time if related to an illness or injury. With chronic pain, pain warning signals stays active in the nerves over a long period of time: weeks, months and even years. In some case, chronic pain occurs through emotional conditions such as stress – in this case it can lack an identifiable end-point, Bradbrook, (2004). Physical consequences of chronic pain include restricted mobility and tense muscles, while emotional consequences include depression, fear, anxiety and anger. Some of the general complaints of chronic pain are lower back pain, neurogenic pain, psychogenic pain and headache. Under (Dillingham et, al. 2002) Chronic pain may begin due to trauma or injury, or because of an underlying condition, while some individuals experience chronic pain without necessarily having a past injury or indication of body injury (Dillingham et, al. 2002).

2.7 Evidence based practice

As nursing practice is evidence based, Kyberd, et al. (2007) mentions that primary importance has been placed on the application of proof in every branch of health and well-being. Evidence based practice in this respect can be viewed as the only certified government approach that is worthy using. by the government policy (Pearson & Craig 2002). Evidence based practice refers to the application of the best medical evidence in arriving at informed clinical decisions. However, such evidence in nursing profession mainly emerges from research carried out by nurses and other specialized health staff. Nursing has experienced extraordinary developments since the implementation of Evidence Based approach in proving services to clients in 2000. This is the period that marked the genesis of presenting care givers with nothing less to sound evidence foundation from which to operate. Nevertheless various questions persist and much remains to be done to incorporate study based evidence into the nursing profession, Pitt & Harris (2008). Risky PCA cases have been cited that present medical practitioners with insight. The elderly group for instance was negatively affected before it came to the public light, Pearson and Craig (2002). Equipment associated issues, like incorrect measurement of PCA dosages, also had implications. Widespread errors involve measurement errors where millilitres were mistaken for “mg”, saturation was set incorrectly, leading to overdose (Beckley, 2008). Suggestions for safer PCA application entail using specific saturation, by use of the same pump throughout the medical centre, having two medical practitioners confirm the order against the pump when administering PCA or making certain changes, and substantiating the IV line where the prescription is inculcating. In addition, the medical practitioner should ensure that the patient is monitored regularly – every 2 hours in the first 24 hours – in order to analyse pain as well as sedation levels. Basal doses should also be avoided in opiate-naïve patients, this is to say, patients who have attained opiates for less than seven days (Beckley, 2008).

2.8 Who is eligible for PCA?

PCA recipients should be able to adhere to instructions and also be able to push the administering button without external help. However, PCA safety aspects, such as self-administration, can be overlooked if the patient is in pain; in this case someone else should be expected to help the patient (Nikolajsen et al., 2006). PCA mishaps can be clustered into two sections namely human blunder and equipment failure. PCA should however not be administered to young children, mentally disabled adults or anyone that cannot adhere to basic instructions, such as people with considerable developmental problems, Kuzel & Engel, (2001). In addition, obese and asthmatic patients especially those using highly effective drugs like tranquilizers, muscle relaxants as well as antiemetics should not be administered with PCA (Taylor, 2001). The same applies to patients with sleep apnea; indeed, in this regard all patients should be examined for sleep apnea before taking allowing to self-administer an analgesic. Patients that have a history of substance misuse are equally not the best candidates; because this can lead to a scenario where pain is hard to differentiate from drug cravings, hence the ability to be administered medication might underpin the drug seeking tendency, Buckley, (2008).

2.9 Pharmacologic Administration

Medications widely employed for intravenous PCA are generally comprised of hydromorphone, morphine and fentanyl. Morphine is however the most widely applied opiates owing to its uncomplicated titration as well as various routes of administration. Taylor, (2001) asserts that Morphine is the first lane agent proposed by medics for critical medical attention, it is also the main prescription for both acute as well as chronic pain control. Morphine may accrue in patients with impaired renal operation protracting sedation and respiratory despair, Fieldsend and Wood S (2011). Hydromorphone is a semi- artificial tranquilizer that is more effective than morphine. It generates more sedation with minimal euphoria than equianalgesic (generating the same level of analgesia as) dosages of morphine and is also less likely to cause respiratory depression or physical reliance, Katz, & Melzack, (2003). However, it might also bring about ephemeral hyperglycemia. It works well with patients suffering from renal malfunctioning because it does not exhibit metabolite build-up, Rowena (2011). The last drug, Fentanyl, is an artificial opiod. Measure for measure, it is one hundred times more effective than morphine and has a somewhat faster effect as well as recovery than morphine or hydromophone; even though it might be the cause for a prolonged impact in terminally ill patients when prescribed time and again. Fentanyl which hardly causes histamine discharge is more often used over morphine when hypotension is an issue (Beckley, 2008).

3.0 Discussion

3.1 Pain assessment and communication

The main stage in ensuring maximum pain management is an correct assessment. Owing to the fact that pain is personal experience, thus, for majority of patients, personal report is the suitable approach of recounting pain, Sherman, (1994). Nevertheless, patients should comprehend what is being asked and the reason why. A detailed assessment will also expose issues including patients’ fear of taking painkillers as well as restrictions as a result of negative effects. Regardless, of the principles well recognised, in many instances these phases are never followed. Some of the previous studies on nursing conduct revealed that nurses have a tendency to doubt when patients describe their pain, regularly do not enquire regarding the pain and miscalculate the number of patients who over-describe their pain, Department of Health, (2010). Another study in United Kingdom, established that regularly nurses thought of pain as an psychological or imaginary when patients failed to respond to analgesics, Weeks & Tsao, (2010). Scores of studies, reveal that there exist a disparity between what nurses articulate and what they really practice, Dworkin R. et al., (2007). Based on these studies, nurses seemingly depended on what patients described their pain, however in practice tended to depend on the patients’ physical appearance as well as experience to explain the greatness of pain. Even though pain is a personal experience, these studies clearly evidently indicate that there is disparity in practice. Unfortunately, patients regularly fail to volunteer information about their pain since they are unwilling to disrupt busy nurses and hesitant to ask for pain killers for fear of being considered as ‘nuisance’.

3.2 Administering analgesia

When administering analgesia, it is important to assess pain precisely and decide on the most suitable medicine and approach available and its negative effects. Studies show that regularly nurses fail to administer suitable analgesia regardless of patients’ pain. This is because of the inadequate knowledge and attitude, Melzack et al., (1990).
3.3 Knowledge, education and attitudes
Efficient pain management is largely affected by inadequate knowledge, behaviour and attitude. Inadequate knowledge on pharmacology, risk and possibility of negative effects and pain assessment are prevalent. A number of nurses are unwilling to administer opiods due to likely side effects such as fear of addiction that regularly results in unsuccessful pain management. Contrary, patients fear negative effects that in some cases are reinforced by nurses’ unwillingness as well as fears, Buckley, (2008).

4.0 Conclusion

Research shows that Patient-Controlled Analgesia or PCA can significantly enhance pain control for patients. This is because PCA allows patients to self-administer repeated but smaller analgesic doses. When employed as required, Patient-Controlled Analgesia minimises the danger that comes with over sedation, which is an unintended outcome of conventional approaches of nurse-controlled analgesia in larger, less repeated doses, Boswell et al., (2007). In addition, with Patient Controlled Analgesia, patients frequently develop a synergism with the mechanism and through this they can learn measures of pain management while preventing unwarranted mental clouding.

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