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

Area of Science:

• Anesthesiology
• Pharmacology
• Pain Management

Background:

• Intravenous patient-controlled analgesia (PCA) offers flexible opioid delivery but often results in inadequate pain relief.
• Optimizing PCA settings and incorporating multimodal analgesia are key to improving patient outcomes.
• Systematic audits of institutional PCA data are crucial for refining analgesic protocols.

Purpose of the Study:

• To review a systematic approach to modifying fentanyl-based PCA protocols using a serial audit process.
• To analyze the impact of protocol modifications on opioid consumption, PCA withdrawal, and pain management.
• To identify best practices for optimizing PCA settings and postoperative pain management strategies.

Main Methods:

• Retrospective review of institutional PCA data from 13,230 patients.
• Implementation of two serial modifications to fentanyl PCA protocols over three distinct phases.
• Analysis of opioid consumption, PCA withdrawal rates, and delivery-to-demand ratios following protocol changes.

Main Results:

• Initial phase: High opioid consumption and PCA withdrawal issues identified.
• Second phase: Omitting basal infusion reduced PCA withdrawal but increased delivery-to-demand ratios.
• Third phase: Increasing the bolus dose from 15 μg to 20 μg mitigated increased delivery-to-demand ratios, showing varied departmental outcomes.

Conclusions:

• Iterative refinement of PCA protocols, informed by audit data and literature, is essential for optimal postoperative pain management.
• Careful, gradual adjustments and thorough impact assessments are necessary when modifying PCA protocols.
• The study highlights the importance of continuous quality improvement in patient-controlled analgesia delivery.