Patient-controlledversus nurse-controlled analgesia after cardiac surgery — a meta-analysis

Abstract

Background: Patient-controlled analgesia (PCA) has been advocated as superior to conventional nurse-controlled analgesia (NCA) with less risk to patients. This systematic review and meta-analysis sought to determine whether PCA improves clinical and resource outcomes when compared with NCA. Methods:A comprehensive search was undertaken to identify all randomized controlled trials of PCA vs NCA. Medline, Cochrane Library, Embase, and conference abstract databases were searched from the date of their inception to August 2005. The primary postoperative outcome was defined as mean visual analogue scale (VAS) scores. Secondary postoperative outcomes included cumulative morphine equivalents, intensive care unit (ICU) and hospital length of stay, postoperative nausea and vomiting, sedation, respiratory depression, and all-cause mortality. Odds ratios or weighted mean differences (WMD) and their 95% confidence intervals (CI) were calculated for discrete and continuous outcomes, respectively.Results: Ten randomized trials involving 666 patients were included. Compared to NCA, PCA significantly reduced VAS at 48 hr (WMD -0.73, 95% CI -1.19, -0.27), but not at 24 hr (WMD -0.19, 95% CI -0.61, 0.24). Cumulative morphine equivalents consumed were significantly increased at 24 hr (WMD 6.84 mg, 95% CI 0.97, 12.72 mg), and at 48 hr (WMD 10.46 mg 95% CI 2.02, 18.9 mg) for PCA compared with NCA. Ventilation times, length of ICU stay, length of hospital stay, patient satisfaction scores, sedation scores, and incidence of postoperative nausea and vomiting, respiratory depression, severe pain, discontinuations, and death were not significantly different between groups, but these outcomes were generally under-reported. Conclusions:In postcardiac surgical patients, PCA increases cumulative 24 and 48 hr morphine consumption, and improves 48-hr VAS compared with NCA. Objectif

Locked out and still knocking: predictors of excessive demands for postoperative intravenous patient-controlled analgesia

“…3 In addition, caregivers are freed up to attend to other patient needs and patients value not having to request pain medication from caregivers. 4 Although the total dose of drug is greater when patients self administer the agent than when it is nurse administered, 4,5 with the exception of pruritus, PCA is not associated with a greater incidence of adverse effects. 3 In spite of these advantages of PCA, we know very little about the factors that govern its effective use.…”

Teaching From Catastrophe: Using Therapeutic Misadventures From Hydromorphone to Teach Key Principles in Clinical Pharmacology

“…32 Therefore, when a PCA system is available in a hospital setting, its exclusive use is strongly recommended for opioids by non-anesthesiologists outside of the operating suite, emergency department, and intensive care unit for reasons of patient safety and effectiveness. 33,34 Figure 1 demonstrates a pedagogical tool to correlate the relationships between pharmacokinetics and pharmacodynamics by comparing 2 hypothetical drugs with identical clearances given by a single intravenous bolus. The use of such figures that superimpose the pharmacodynamic concept of minimum effective concentration overlying a pharmacokinetic graph effectively demonstrates the central impact that redistribution has on duration of drug action while simultaneously counteracting the common misperception of the importance of half-life in terminating the drug effect following a single bolus dose.…”

Nurse‐Led Strategies to Improve Patient Safety in Acute Pain Management

“…The use of PCA has been shown to increase patient satisfaction when compared to conventional analgesia (Chumbley 2009) whilst a meta-analysis revealed higher morphine consumption but lower pain scores at 24 and 48 hours after cardiac surgery (Bainbridge et al 2006). Early equipment was cumbersome and practical only for high-care clinical areas.…”