This is the Patient Controlled Epidural Analgesia protocol at Al Razi Hospital. This presentation was done before initiating the PCEA as a pain control modality in the hospital.

1. PATIENT CONTROLLED
EPIDURAL ANALGESIA
DEPARTMENT PROTOCOL
FARAH JAFRI

2. Topics
Review of literature
Department protocol
Our experience

3. ESRA GUIDELINES FOR PCEA -
This technique produces high patient
satisfaction.
Reduced dose requirements compared with CI.
Sophisticated pumps are required and accurate
catheter position is important for optimal efficacy.
Knowledge is Reassuring....

4. ESRA - Guidelines
“There are many possible variations in
local anaesthetic/opioid concentration
yielding good results, the example given
here should be taken as a guideline;
higher concentrations than the ones
mentioned here are sometimes required
but cannot be recommended as a routine
for postoperative pain relief.”

5. ESRA- Guidelines for PCEA
Dosage for patient controlled infusion
(lumbar or thoracic):
Background 4-6 ml/h infusion
Bolus dose 2 ml (2-4 ml)
Lockout interval 10-30 min,
We have kept 30 min.
Recommended max hourly dose
(bolus + Background) 12 ml/hr

6. Other opinions......
Bonica- Management of Pain-
Ballentyne, Fishman, Rathmell
“ PCEA allows individualization of patients
pain therapy.”
“Less consumption of drug” .
“ Data of over a 1000 patients shows that
90% of patients with PCEA receive
adequate analgesia.”

7. COMPARING PCEA & CI
CONT. EPIDURAL
INFUSION
PCEA
PRURITIS 1.8- 16.7% 10-22%
NAUSEA 3.8-14.8% 2-22%
SEDATION 13.2% 7.4%
HYPOTENSION 4.3% 0.7-6.6%
MOTOR BLOCK 0.1-2% 3%
RESP DEPRESSION 0.25% 0.1-1.6%

8. OTHER OPINIONS.......
National Guideline Clearinghouse
A public resource for evidence-based clinical practice
guidelines from the US Dept of Health
Patient Controlled Epidural Analgesia (PCEA)
is safe to use in selected older adults.
(Acute pain management in older adults. 2006)

9. National Guideline Clearinghouse
“Studies have demonstrated effective
pain relief, decreased opioid use, and
increased patient satisfaction with pain
relief with PCEA (opioid and local
anesthetics).”
(APS, 2003; Gopinathan et al., 2000; Lebovits et al., 2001;
Mann et al., 2000; Mann, Pouzeratte, & Eledjam, 2003;
Silvasti & Pitkanen, 2001).
Evidence Grade = B

10. OTHER OPINIONS....
Randomized, double-blind comparison of patient-controlled
epidural infusion vs nurse-administered epidural infusion for
postoperative analgesia in patients undergoing colonic
resection
J. J. Nightingale et al. BJA. 2007 98(3):380-384;
CONCLUSIONS: PCEA provides greater
analgesic efficacy than CEI for post-op
analgesia after major intra-abdominal
surgery, and a decreased requirement for
physician or nurse intervention.

11. ASA guidelines for PCEA in obs.
• Solution 0.0625% bupiv + opioid
• Continuous infusion 08-15 ml/h (most use12)
• Bolus 10-12 ml (most use12)
• Lockout 12 min (it takes the
pump almost 8 min
to get the dose in).
• Air sensitivity OFF
• 1 hour maximum 3-4 boluses.

12. ASA GUIDELINES-- CONTD
• Instruct patient to request physician
evaluation and bolus if no relief after 2 self-
administered boluses within 40 min.
• Rescue Meds: Supplement with bolus of
bupivacaine ± opioid (e.g. 7 to 10 ml of
0.125% bupivacaine 10 ml, or 7 to 10 ml of
0.25% bupivacaine) and increase infusion rate
and hourly maximum if necessary.

13. DEPARTMENT PROTOCOL
 Prerequisite
 Preoperative orientation of patient
 Safety
 PCA initiation
 Pump programming
 Drug regimes
 Monitoring

14. PRE-REQUISITES
Patent IV line, I/V Fluid
Available O2,
Knowledge of Basic Life Support,
Professional Accountability,
Staff trained to use equipment and drugs,
Adequate ward staffing levels.

15. Pre-op orientation for PCEA
All patients must have—
Explanation pre-operatively about technique
How to press the button, with help of prop,
pictures or actual pump.
And should be told to hear the soft beep which
would indicate the have received a dose.
They should know that the dose is within safe
limit but they must not press when there is no
pain.

16. Safety
Epidural infusion lines should be clearly
identified.
Pump & cartridge must be labeled “ for
epidural connection only”.
All patients must have a patent iv cannula
during & for 12 hr after cessation of
epidural.

17. Safety
 Ensure that the patient is not fluid depleted
before insertion of epidurals- e.g. due to:
 bowel prep,
 fasting/starvation
 insensible per-operative loss from evaporation – up to
10ml/kg/hr)
Ensure hydration during the initial post-op
period, with iv fluids and later by good oral
intake.

18. PCEA- Initiation
In Recovery, program the Cadd Legacy
pump,
Set an base line infusion of 5ml/hr
initially.
Possibly raising up to 8 ml/hr:
if analgesia proves inadequate,
after the patient is settled and
is using the PCEA satisfactorily.

19. PCEA- Initiation
Bolus dose 2-3 ml.
Lockout 30 min.
Basal infusion 6-8 ml/ hr
Normal epidural care
Regular analgesic and
Side effect assessments.

20. ADMINISTRATION OF DRUGS
A ‘test’ dose of drug will be given by the
anaesthetist prior to commencement of
infusion.
The infusion will be commenced in the
Theatre or Recovery and patient monitored
prior to transfer to ward.
Instructions for drug doses and infusion rates
will be clearly written on the patient’s drug
and epidural analgesia chart.

21. ADMINISTRATION OF DRUGS
• Regimes
• Patients admitted to ICU
• Inj Bupivacaine 0.1% and inj Sufentanil 0.16 mcg/ml
• Patients admitted to ICU
• Inj bupivacaine 0.1% and inj Fentanyl 1-2 mcg/ml
• All ward patients:
• Inj Bupivacaine 0.125%

22. Drug dilutions
Simple formula--
actual conc x actual vol. = desired conc. x
desired vol.
To make bupiv. 0.1% with suf. 0.16 ug/ml, 100
ml
For bupivacaine-
0.5 x ? = 0.1% x 100, we need 20 ml that is 1
amp
For sufent. 5 ug/ml
5 x ? = 0.16 x 100, we need 3.2 ml of the vial.

23. Drug dilutions
So putting it all together...
For sufentanil+ L.A PCEA cartridge
20 ml marcaine + 3.2 ml of sufentanil from 10 ml
vial + 76.8 ml = 100 ml cartridge.
Similarly for fentanyl + LA PCEA cartridge
20 ml marcaine + 4ml fentanyl + 76 ml saline =
`100 ml cartridge

24. Drug dilutions
Continuing in the same way
For plain L.A solutions
0.125% x 100 = 0.5 x ?
We need 25 ml of 0.5% solution.
Just remember the formula and you can
calculate if in doubt!

25. ADMINISTRATION OF DRUGS
The epidural catheter will be clearly
labeled and screwed tightly into the
bacterial filter.
The filter will be anchored to the
patient’s skin to avoid traction on the
giving set and unnecessary disconnection.

26. ADMINISTRATION OF DRUGS
Bolus doses of drugs outside of
Theatre,Recovery Unit and ITU will only
be administered by an anaesthetist
On discontinuation of epidural infusion,
the amount of controlled drug remaining
in the syringe must be checked by two
nurses, or the pain tech. and doctor
The discarded amount must be recorded,
i.e., in the patient’s notes, care plan
and/or on the epidural observation chart.

27. Check & Record before starting the
epidural infusion:
Temperature
Pulse
BP
Respiratory rate
Pain score
Sedation level
Movement & Sensation

28. Items recorded every 6 hrs by nursing
staff
BP
Pulse
Respiration rate
Sedation level
Pain scores (on movement & deep
breathing)
Nausea and vomiting
Movement and Sensation

29. Urine output
If not catheterized:
 Check & record UOP q 4 hr,
 Observe for bladder distension.

30. OUR EXPERIANCE
STILL IN PRELIMINARY STAGE
10 cases till date
Mostly TKRS, 1 femur, 1 tibial ilizhorov
PATIENT SATISFACTION IS GOOD
Median Pain Score of 2.5/10

31. OUR EXPERIANCE
Complications No of Patients
Hypotension 2
Itching 2
Nausea - Vomiting 2
Constipation 1
Breakthrough pain because of
cartridge change over time
Most Patients

32. WAYS TO IMPROVE
Prepare 2 cartridges at same time with
identical solution.
Put patient label and send to ward.
They can be used alternatively, the
anesthetist attending the cartridge
change can refill and keep the other for
next change.
Ward teaching and awareness of
complications.

33. Thanks