Anesth Pain Med.  2024 Jul;19(3):171-184. 10.17085/apm.24075.

Optimizing patient-controlled analgesia: a narrative review based on a single center audit process

• Oh C
• Chung W
• Hong B

• KMID: 2563557
• DOI: http://doi.org/10.17085/apm.24075

Abstract

Intravenous patient-controlled analgesia (PCA) is valuable for delivering opioids in a flexible and timely manner. Although it is designed to offer personalized analgesia driven by the patients themselves, users often report insufficient pain relief, which can be addressed by optimizing its settings and multimodal analgesia. We adopted a systematic approach to modify PCA protocols by utilizing a serial audit process based on institutional PCA data. This review retrospectively examined the process, encompassing data from 13,230 patients who had used PCA devices. The two modifications to the fentanyl-based PCA protocols resulted in three distinct phases. In the first phase, high opioid consumption and unintended PCA withdrawal were the common issues. These were addressed in the second phase by omitting the routine use of basal infusion. However, this led to increased delivery-to-demand ratios, mitigated in the third phase by increasing the bolus dose from 15 μg to 20 μg. These serial protocol changes have produced varied outcomes across different surgical departments, underscoring the need for careful and gradual adjustments and thorough impact assessments. Drawing insights from this audit process, we incorporated findings from the literature on PCA settings and multimodal analgesic approaches. This review underscores the significance of iterative feedback and refinement of analgesic protocols to achieve optimal postoperative pain management. Additionally, it discusses critical considerations regarding the postoperative audit processes.

Keyword

Patient-controlled analgesia; Post-operative pain; Clinical audit; Analgesia; Multimodal analgesia; Pain management

Figure

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  Fig. 1. Cumulative use over time of patient-controlled analgesia devices for 48 h postoperatively in patients who have undergone urologic procedures.Each line indicates the cumulative dose of fentanyl administered to each patient. Data from a single department are presented as an example. Total n = 583.

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  Fig. 2. Correlation between maximum pain score (NRS) and the ratio of delivery/demand on the day of surgery (POD 0). The boxplot represents the 24 h delivery/demand ratio (median [1Q, 3Q]) stratified by the maximum NRS on POD 0 (left). The ratio of delivery/demand in the plots indicates the proportion of delivered bolus doses among the attempted bolus doses during the first 24 h postoperatively. This ratio is an indicator of the adequacy of the PCA system, demonstrating the effectiveness of the device in meeting patient requirements. A negative correlation (ρ = –0.182) was observed between the maximum NRS on the day of surgery and the 24 h delivery/demand ratio. Each blue dot represents the mean value (upper right) or the rate (lower right) calculated for each NRS category. Total n=7,689. NRS: numerical rating scale, POD: postoperative day, PCA: patient-controlled analgesia.

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  Fig. 3. Maximum pain scores (NRS; 0–10) on the day of surgery (POD 0). Each dot represents the maximum NRS score recorded for each patient on the day of surgery. Boxplot represents the median (1Q, 3Q) values. These scores were assessed during the evening postoperative rounds conducted by nurses dedicated to the PCA management team. NRS: numerical rating scale, POD: postoperative day, CS: cardiothoracic surgery, GS: general surgery, GY: gynecologic surgery, NS: neurosurgery, OS: orthopedic surgery, UR: urologic surgery. Total n = 8,759.

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  Fig. 4. PCA withdrawal within 24 h stratified by department and protocol (phase 1, routine basal infusion, n = 4,472; phase 2, without routine basal infusion, n = 6,098). The bar represents the rate of PCA withdrawal within 24 h in each department stratified by phase. PCA: patient-controlled analgesia, CS: cardiothoracic surgery, GS: general surgery, GY: gynecologic surgery, NS: neurosurgery, OS: orthopedic surgery, UR: urologic surgery. *P < 0.05.

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  Fig. 5. Rates of total bolus delivery/demand ratio < 70% stratified by surgical departments and protocols (phase 1, routine basal infusion, n = 4,324; phase 2, without routine basal infusion, n = 6,003). The delivery/demand ratio in the plot indicates the proportion of delivered bolus doses among the attempted bolus doses during the entire period of PCA use. The bar represents the rate of delivery/demand ratio < 70% within each department, stratified by phase. PCA: patient-controlled analgesia, CS: cardiothoracic surgery, GS: general surgery, GY: gynecologic surgery, NS: neurosurgery, OS: orthopedic surgery, UR: urologic surgery. *P < 0.05.

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  Fig. 6. Rates of total bolus delivery/demand ratio < 70% stratified by surgical departments and protocols (phase 2, fentanyl 15 μg bolus, n = 6,003; phase 3, fentanyl 20 μg bolus, n = 2,637). The delivery/demand ratio in the plot indicates the proportion of delivered bolus doses among the attempted bolus doses during the entire period of PCA use. The bar represents the rate of delivery/demand ratio < 70% within each department, stratified by phase. PCA: patient-controlled analgesia, CS: cardiothoracic surgery, GS: general surgery, GY: gynecologic surgery, NS: neurosurgery, OS: orthopedic surgery, UR: urologic surgery. *P < 0.05.

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  Fig. 7. Postoperative opioid consumption (48 h) and bolus delivery/demand ratios stratified by sex and department. The delivery/demand ratio in the plot (lower) indicates the proportion of delivered bolus doses among the attempted bolus doses during the entire period of PCA use. The plots were derived from phases 2 and 3 after excluding patients who underwent gynecological and breast surgeries. PCA: patient-controlled analgesia, CS: cardiothoracic surgery, GS: general surgery, GY: gynecologic surgery, NS: neurosurgery, OS: orthopedic surgery, UR: urologic surgery. *P < 0.05.

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  Fig. 8. Use of intraoperative multimodal agents stratified by year. The intraoperative administration of multimodal agents, including intravenous paracetamol, nonsteroidal anti-inflammatory drugs, nefopam, and magnesium, was stratified based on the number of agents used: none, single, and dual or more. There has been an increasing trend in the use of multimodal analgesia consisting of two or more agents. Conversely, the absence of multimodal agents decreased over time.

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