Post-Op Pain with PCA

SoldierNurse22, BSN, RN · Aug 27, 2014

I can't speak for other facilities, but I've never seen a patient come out of the OR with a PCA. I've never even seen a patient come out of the PACU with a PCA. We have always set up PCAs when the patients arrive to the ward. Most patients in the OR and even in PACU aren't awake enough yet to utilize the bolus function on the PCA, and our providers won't start basal PCA rates until the patient starts to come out from under sedation.

As far as mismanagement, I've seen issues with getting the PCA meds ordered, getting the orders correct, securing patent IV access, and similar issues once the patient arrives to the ward. Is that what you mean?

scrubnurselife · Aug 27, 2014

Have you talked to anyone in the OR there? I agree with above, as far as not seeing PCAs in the OR. That's what we have anesthesia staff for. Most patients are asleep under general anesthesia, so no need for a PCA. Even if you have a patient awake with spinal or regional anesthesia, the CRNA pushes meds IV if needed for pain control, or the surgeon can inject local. I have seen PCAs set up in PACU, so I would focus more in that direction, rather than the OR. If your patients are returning from surgery with PCAs already present, I'd say they were most likely set up in PACU. Not to mention, if they're having pain control issues that soon after surgery, I don't think PCA mismanagement needs to be the only focus. Try to find the common ground. What kinds of procedures are these patients having? Who's the surgeon? Who's the anesthesia provider? Look at the post op orders and protocols. Anyway, I would try the PACU forum, as they would probably offer even more input.

Spiker, ASN, RN, EMT-P · Aug 28, 2014

Our PCA's are set up in PACU, & always approximately 30-40 minutes after we bring them in there. I'd wonder if NOT starting it in a timely fashion could be the reason for breakthrough pain? Our anesthesiologists usually give an IV dose of Fentanyl after the 1st set of vitals, then leave further orders for Morphine, Dilaudid, etc. Once the patient has been stabilized, assessed, & made comfortable, then the PCA is prepared & initiated. As an evening shift OR charge RN, I spent a fair amount of time in PACU, & would often start the PCA if the PACU RN's were busy. I always checked the orders right after coming to PACU, to assure that the MD wrote orders for an adequate bolus dose, but also an appropriate hourly basal dose, which makes a big difference in patient comfort. You need to be a patient advocate, & work to ensure proper dosing & time intervals are ordered: To me, that's the key to successful PCA use.

NurseStelri · Aug 28, 2014

Thanks for the responses!

I do believe in our hospital hooks up (not starts) the PCA in the OR but after reading all of your replies I'm going to go double check this. I was told that they were set up in the OR incorrectly and that attributed to them not being utilized so I will check all the facets you guys gave me to find the issue and keep you posted!

All in all your answers were exactly what I needed! And I will definitely check out the PACU forum.

NurseStelri · Aug 28, 2014

Hi Everyone! (Thanks for reading)

I have recently been approached to possibly guide an assessment and rollout plan for our OR regarding PCAs. I am a graduate student and have been told that there has been an issue with mismanagement PCAs unnecessary post-op pain.

I will be tasked with finding where this error occurs so my question to you all is: have any of you witnessed this? Multiple times or even one case that you remember would be helpful-- what was the mismanagement attributed to (specific surgery, med, etc)? Has your unit experienced a similar issue and how was it addressed?

I don't have much experience yet so before I go in and start my assessment I want to make sure my head is in the right spot and the staff don't resent me for "trying to find their mistake." I'm conducting a literature review right now which seems to be yielding more research on overdosing via PCAs so any insight you all have on post-op pain with PCAs would be invaluable!

TakeTwoAspirin, MSN, RN, APRN · Aug 30, 2014

NurseStrelri I could be wrong, but I think you are getting your terminology mixed up which is why you are getting strange answers to your question.

The devices that are commonly hooked up in the OR are not referred to as PCA pumps, but On-Q Pain Systems. The On-Q system is a localized pain relief system that is intended to be used at the site of a surgical incision to infuse a local anesthetic agent (lidocaine, etc) into the peri-surgical tissue. These are generally fitted and indeed hooked up to begin working in the OR. They provide very specific, localized pain relief.

A PCA pump is more commonly seen on the nursing floor to manage pain resulting from disease processes such as cancer and the pain management is introduced via an IV catheter that allows the patient to press a button to give PRN pain relief systemically with medications such as morphine. They provide on-demand systemic pain relief for hard-to-control pain. These pumps need to be programmed and titrated depending on what PO pain medications the patient is taking, alongside their PCA pump medications. They are meant to help the patient control break-through pain.

From everything I have read that you have posted, I believe you are referring to On-Q pumps rather than PCA's which could explain why you are not getting much feedback.

malestunurse · Aug 31, 2014

What is your actual question? I'm struggling to decipher it.

Editorial Team / Admin · Aug 31, 2014

As patient controlled analgesia, patients under anesthesia are incapable of using PCAs. Our facility policy is that every single medication order is discontinued by having surgery. Therefore, PCAs are discontinued in holding and any remaining medication wasted. The surgeon must reorder a PCA (and every other med) as part of the post op orders. Since each med prior to surgery is in the EMR, the surgeon checks yes or no to renewing each one. PCAs are set up in PACU once the patient is awake enough to utilize it. For pain control in PACU, anesthesia uses three meds and specifies what order to use them. The most common is morphine first, then fentanyl if ineffective and finally dilaudid.

Esme12, ASN, BSN, RN · Aug 31, 2014

multiple threads merged as per the TOS