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Patient- and Nurse-Controlled Analgesia: 22-Year Experience in a Pediatric Hospital
Carolina Donado1,2, Jean Solodiuk1,2, Shawn J Rangel3,4
1Departments of Anesthesiology, Critical Care, Pain Medicine.
Insights
Pediatric patient-controlled analgesia (PCA) and nurse-controlled analgesia (NCA) use declined significantly after 2007, despite increased hospital procedures. Adverse events (AEs) were rare, but improvements are needed, especially with opioid medications.
Area of Science:
- Pediatric Anesthesiology
- Pain Management
- Pharmacology
Background:
- Pediatric pain management practices have evolved significantly over the past two decades.
- Patient-controlled analgesia (PCA) and nurse-controlled analgesia (NCA) have been key methods for managing pain in children.
Purpose of the Study:
- To analyze trends in PCA/NCA utilization over a 22-year period in a pediatric hospital.
- To identify and characterize adverse events (AEs) associated with PCA/NCA in pediatric patients.
Main Methods:
- Retrospective data collection from 1994 to 2016 at a single tertiary-care pediatric hospital.
- Analysis of annual PCA/NCA orders, patient demographics, treatment duration, length of stay, and AE frequencies.
- Subgroup analysis for surgical versus medical pediatric cases.
Main Results:
- Over 32,000 PCA/NCA orders were recorded; initial orders increased until 2006, then rapidly decreased, despite rising hospital admissions.
- Peripheral nerve blocks saw a tenfold increase between 2007 and 2012.
- A total of 146 AEs (1.0%) were reported after 2002, with a low rate of preventable events.
Conclusions:
- PCA/NCA remains a common, though declining, method for pediatric pain management, coexisting with newer analgesia techniques.
- The overall incidence of adverse events associated with PCA/NCA is low.
- Continuous quality improvement is necessary to minimize medication errors, particularly with high-risk drugs like opioids.
Objectives:
Pediatric pain management has rapidly changed over the last 2 decades. In this study, we describe the changing practices and adverse events (AEs) related to patient-controlled analgesia (PCA) and/or nurse-controlled analgesia (NCA) over a 22-year period.
Methods:
After institutional review board approval, retrospective data from a single tertiary-care pediatric hospital were collected between 1994 and 2016. Subgroup analyses were done for surgical and medical case patients. We reported the number of times that PCA and/or NCA was ordered annually, the median and interquartile ranges for age, PCA and/or NCA duration and length of stay, and AE frequencies.
Results:
Over 22 years, 32 338 PCAs and/or NCAs were ordered in this institution. Morphine and hydromorphone were used most commonly. Between 1994 and 2006, initial orders for PCA and/or NCA increased 2.5-fold. After 2007, initial orders for PCA and/or NCA rapidly decreased; after 2013, the decrease continued at a slower rate, with a total of 1007 orders in 2016. This decrease occurred despite increased hospital admissions and surgeries. Between 2007 and 2012, peripheral nerve blocks rapidly increased (10-fold). After 2002, 146 AEs were reported (1.0%). Of those, 50.5% were nonintercepted, and 20.6% were intercepted AEs; 5.5% and 6.2% were preventable and nonpreventable AEs, respectively.
Conclusions:
PCA and/or NCA usage continues to be common in pediatric patients, although usage has declined and stabilized in the setting of other emerging methods of analgesia and increases in the number of minimally invasive surgical procedures. The overall rate of AEs was extremely low. However, improvements to eliminate all errors are needed, especially with medications with a great risk of harm (such as opioids).
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