Patient-controlled analgesia versus patient-controlled analgesia plus continuous infusion after hip replacement surgery.

OBJECTIVE: To compare the efficacy and adverse effect profile of patient-controlled analgesia (PCA) versus PCA plus continuous infusion (PCACI) after hip replacement surgery. DESIGN: Prospective, randomized, open pilot study. SETTING: Large teaching institution. PARTICIPANTS: Thirty-four patients undergoing hip replacement or revision of hip replacement surgery. INTERVENTIONS: Patients were randomized to receive PCA morphine: 1 mg with 6-minute lockout, or PCACI, using the same dose, with a 0.5-1 mg/h continuous infusion. Pain intensity, sedation, narcotic use, injection/attempt ratio (I/A), and adverse effects were assessed. RESULTS: No significant differences in pain intensity were identified. Morphine use was not different between groups: PCA 61.8 +/- 35.0 and PCACI 74.2 +/- 54.9 mg (p =0.394). A trend toward an increased 12-hour I/A ratio was evident in the PCACI group: PCA 0.73 +/- 0.18 and PCACI 0.86 +/- 0.17 (p =0.073). Patient-reported adverse effects, sedation, and inability to sleep secondary to pain occurred similarly. Eight of 18 PCACI patients required discontinuation of either the continuous infusion mode or of PCA therapy entirely secondary to adverse effects. CONCLUSIONS: When compared with PCA therapy, PCACI was not associated with improved pain control and more patients receiving PCACI required discontinuation of therapy secondary to adverse effects.

Patient-controlled analgesia versus intramuscular analgesic therapy.

The pharmacy and nursing time requirements, quality of postoperative pain control, and cost of patient-controlled analgesia (PCA) and intramuscular (i.m.) analgesic therapy were studied. All timings were conducted with a stopwatch on a single nursing unit that primarily receives gynecologic surgery patients. The various work elements involved in each type of therapy were timed individually. Both quality of analgesia and cost were evaluated in a prospective, randomized study in hysterectomy patients. I.M. patients received meperidine hydrochloride 75-100 mg every three to four hours as needed. PCA patients had access to morphine sulfate 1 mg or meperidine hydrochloride 10 mg, with a six-minute lockout period. The patients scored their pain every four hours. Direct costs for PCA were calculated as drug cost plus tubing cost plus form cost plus maintenance cost plus depreciation cost. Direct costs for i.m. therapy consisted of the cost of drugs. The total mean nursing time per patient was 16.9 minutes for PCA and 10.7 minutes for i.m. therapy. Pharmacy time per patient was 5.1 minutes longer for PCA than for i.m. therapy. Thirty-six hysterectomy patients (17 i.m. and 19 PCA) were enrolled in the study of pain control and cost. Among i.m. patients, 64% of the pain scores were mild or worse, compared with 40% for PCA patients. The median pain scores were moderate for i.m. patients and mild for PCA patients. Scores tended to be lower for PCA patients at 16 and 20 hours. Although equal numbers of patients in the two groups experienced nausea, i.m. patients needed more doses of antiemetics than PCA patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective patient-controlled analgesia quality assurance: one year's experience.

The goal of this project was to develop a prospective patient-controlled analgesia (PCA) quality assurance (QA) program and evaluate its impact on patient care. Initial elements selected for inclusion into the QA were: patient satisfaction, pain relief, clarity of instructions, respiratory rate, and nausea and vomiting. Standards were initially set at 100% with the exception of nausea and vomiting, which was 90%. Preliminary evaluation in 26 patients indicated initial standards were unrealistically high. Standards were revised to 90% for all elements except respiratory rate, which was left at 100%. Nausea and vomiting were eliminated from the QA because it was difficult to establish a cause and effect relationship with narcotic. Data were collected through patient interviews and chart reviews on a bimonthly basis. Cumulative data on 297 patients revealed standards were met in all categories. Two systematic problems identified early in the QA were that there was no recording of respiratory rate and there was a high incidence of unclear instructions. As a result of pharmacist interventions, outcomes improved. Patient outcomes with PCA therapy can be improved using a prospective PCA QA program. Pharmacy Department's without resources for daily monitoring of PCA patients should consider implementing a prospective PCA QA program.

Retrospective evaluation of patient-controlled analgesia use in a large teaching institution.

Because of a significant increase in the number of patients receiving patient-controlled analgesia (PCA) therapy at our institution, we conducted a review of PCA use. Our objectives were to determine if a PCA recording document (monitoring form) could be used to identify potential problems associated with PCA therapy and to identify measures that could be taken to improve analgesic therapy with this method of administration. The PCA recording document for each patient was reviewed retrospectively to identify patients suspected of having problems with the therapy. Three criteria addressing duration of therapy, change in prescribed narcotic, and respiratory rate were used to evaluate PCA therapy. The standard was set at 100 percent. Complete patient records were reviewed for those patients not meeting the standard to determine whether problems actually existed. PCA recording documents were reviewed for 518 patients. Sixty-one patients did not meet the standard. Of these 61 patients, 41 (67.2 percent) were found to have problems with PCA therapy. Suspected adverse reactions occurred in 27 of these 41 patients and 14 experienced inadequate pain control. Nausea and vomiting were the most prevalent adverse reactions. Our results indicate that PCA therapy is discontinued in many patients because of inadequate pain relief and suspected narcotic-induced nausea and vomiting. To improve analgesic therapy, clinicians should be reeducated regarding ways to optimize analgesic therapy, and a prospective PCA monitoring service should be considered.

Patient-teaching program for home intravenous antimicrobial therapy.

The development of a home i.v. antimicrobial therapy program and associated procedures for patient teaching are described. The pharmacy department at a 940-bed, acute-care, general medical-surgical teaching hospital participated with four other departments in the development of standardized teaching methods for a home i.v. antimicrobial therapy program. The pharmacy and nursing departments each developed sections of a home antimicrobial therapy manual. Over a 16-month period, i.v. antimicrobial therapy was prescribed for 37 patients who were discharged from the hospital. Most patients or their care-givers were able to prepare and administer the medications. After the patient was discharged, the pharmacy department offered services such as supplying medications, coordinating pharmacokinetic dosing, providing drug information, and acting as a patient contact. Hospitals that provide home i.v. antimicrobial therapy should coordinate the resources of the various departments involved to develop standardized patient-teaching methods.

Recycled unused piggyback admixtures through the use of tamper-proof safety caps.

The purpose of the project was to develop and implement a method whereby unused intravenous preparations could be redispensed for a subsequent dose to another patient. Even if the stability and sterility of the solution can be assured, since the admixture has left the controls of the Pharmacy, it cannot be reused because of the possibility that further additions have been made. If the pharmacy could assure that an admixture has not been altered in any way, it could be redispensed. Tamper-Proof Safety Caps have been placed over the additive port of Viaflex minibags after preparation, thereby rendering it impossible for further additions to be made, and therefore these admixtures can be reused for a different patient. The Department of Pharmaceutical Services has begun to recycle admixtures and has experienced an annual cost savings in 1981 of $64,512. The cost of the program for the protective caps was $17,810. This cost savings has been accomplished without further additions to the staff.