Thomas S. Foster

Patient controlled analgesia.

Patient-controlled analgesia is a relatively new and investigational technique that permits patients to treat pain by directly activating doses of intravenous narcotics. The technique was developed in response to the undertreatment of pain in hospitalized patients. Continuous narcotic infusion and intraspinal narcotic administrations also have the potential to provide continuous, uninterrupted analgesia, but do not allow simple dose attentuation to avoid overdosage. Patient-controlled analgesia is used to treat postoperative and labor pain and pain associated with terminal illness; it delivers analgesic more effectively with fewer side effects than conventional parenteral narcotic therapies. The technique is also an ideal investigative instrument for studying equianalgesic states. Several foreign-made devices are now being used under investigational sanctions in this country, and it is anticipated that several American manufacturers will be seeking regulatory approval to market the devices.

Patient-Controlled Analgesia in the Terminally Ill Cancer Patient:

Patient-controlled analgesia (PCA) is a relatively new therapeutic modality which has allowed postsurgical patients to safely and effectively self-administer doses of intravenous narcotics via a syringe pump and sequencing device. A pilot study was designed to evaluate PCAs safety and effectiveness in the terminally ill cancer patient. Eight patients whose chronic pain was not adequately controlled by oral narcotics were permitted to use PCA for a minimum of 48 hours. Respiratory rates, sedation rankings, and pain rankings indicated these patients achieved satisfactory analgesia with a minimum of sedation and experienced no respiratory depression. Three patients were switched to oral regimens using PCA dosing as a guide. Pain and sedation rankings were similar to those registered while exclusively on PCA. This self-dosing technique was judged to be safe, effective, and able to accommodate wide fluctuations in analgesic need when treating pain in the terminally ill cancer patient. The results obtained in these patients support further trials using PCA to individualize oral analgesic regimens.

Patient-Controlled Analgesia: A Review of Effectiveness of Therapy and an Evaluation of Currently Available Devices

Patient-controlled analgesia (PCA) is a major advance in the management of pain in postoperative and cancer patients. The success of PCA has resulted in a proliferation of marketed devices to administer small bolus doses of parenteral pain-control drugs at fixed intervals controlled by the patient with the push of a button. Because patients demonstrate marked individual variation in pain medication requirements, PCA devices should be able to accommodate rapidly changing requirements for drugs with a minimum amount of effort on behalf of health care personnel. Crude electronic devices were developed in the late 1960s and the early 1970s and usually consisted of a syringe pump connected to some sort of timing device. Most modern PCA devices marketed in the past five years are much more sophisticated devices that are microprocessor based and some newer devices even generate hard copy for a permanent record of drug administration. Although many such devices are available (including a totally disposable PCA device), few have undergone extensive clinical evaluation. A review of the literature shows many devices are available for use without a single publication to document the safety and utility of the device in the routine patient care situation. Use of the PCA method of pain control will grow, and all hospital-based health care personnel should become familiar with their use and limitations.

Extraordinary Analgesic Requirement in a Patient Previously Unexposed to Narcotics

Patient-controlled analgesia (PCA) is a relatively new therapeutic modality that allows patients to administer doses of intravenous narcotics, using a syringe pump and sequencing device. We used PCA to deliver analgesic therapy to a 35-year-old man seriously injured in an aviation accident. Although the patient gave no previous history of narcotic use or abuse, he required morphine dosing rates as high as 56 mg/h to maintain adequate analgesia. The delivery of relatively high doses of narcotic was not accompanied by significant sedation, as might be expected. The patient underwent two surgical procedures while on PCA therapy. Following each procedure, dosing requirements increased, but within three days after each operation, dosing tapered. The patient was converted to oral hydromorphone therapy, which gradually was tapered and then discontinued. PCA should be considered a useful therapeutic adjunct in the management of patients refractive to empirical narcotic analgesic regimens.

Clinical Outcome of Nosocomial Pneumonia following Imipenem/Cilastatin Therapy

Eighteen patients in a neurosurgery intensive care unit who had nosocomial pneumonia and/or bacteremia were treated with imipenem/cilastatin. The 16 patients who were evaluable had pneumonia; 4 of these had concurrent bacteremia. Eleven patients had a satisfactory clinical response (69 percent) and all patients with positive blood cultures had the organism eradicated. There were 44 organisms isolated from the initial culture of bronchial secretion and 32 of these organisms were gram-negative bacilli (72.5 percent). One patient with pneumonia who initially had Pseudomonas aeruginosa sensitive to imipenem developed resistance during therapy. Adverse effects were minimal; one case of nausea occurred, which was thought to be related to a short infusion time. The most prominent laboratory abnormality was an increase in platelet count, seen in 50 percent of treated patients.