How to administer Patient-Controlled Analgesia (PCA) in the operating room (OR)?

From the Guidelines

To give PAM in the operating room, it is not applicable as PAM is used for organophosphate poisoning, however, for postoperative pain management, opioids such as fentanyl or oxycodone can be used through intravenous patient-controlled analgesia (PCA) with a strong recommendation and moderate quality evidence 1.

Postoperative Pain Management

When considering postoperative pain management, it is essential to prioritize the use of opioids, such as fentanyl or oxycodone, through intravenous PCA, as they have been shown to be effective in managing moderate-to-severe pain 1.

• The initial infusion of opioids using intravenous PCA should be avoided in opioid-naïve patients, with a strong recommendation and moderate quality evidence 1.
• Sedation levels, respiratory status, and the possible development of adverse events in patients on systemic treatment with opioids must be regularly assessed, with a strong recommendation and weak quality evidence 1.

Opioid Administration

The use of PCA with major opiates after emergency general surgery is effective and useful, with no clear evidence about which opiate drug should be preferred 1.

• Fentanyl and oxycodone are alternatives, with oxycodone providing slightly better postoperative pain relief and less sedation, but also associated with more side effects than fentanyl 1.
• The sublingual sufentanil tablet system has been compared to PCA, with sufentanil seeming to be an appropriate choice due to its high affinity for the μ opioid receptor and high therapeutic index 1.

Route of Administration

Oral administration of analgesic drugs should be preferred over the intravenous route whenever feasible, with a strong recommendation and moderate quality evidence 1.

• The intramuscular route should be avoided in postoperative pain management, with a strong recommendation and moderate quality evidence 1.
• Epidural and regional anesthesia is recommended in emergency general surgery, whenever feasible and if not delaying the emergency procedures, with an intermediate recommendation and intermediate quality evidence 1.

From the Research

Administration of PAM in the Operating Room

There are no direct studies on the administration of PAM in the operating room. However, some studies provide information on ventilation strategies and medication administration in the operating room:

• The use of noninvasive positive pressure ventilation (NPPV) modes such as average volume-assured pressure support (VAPS) and bilevel positive airway pressure (BPAP) in acute and chronic respiratory failure is discussed in 2.
• Medication administration in the operating room is addressed in 3, which recommends standardizations, barcode medication administration, and the use of prefilled or premixed syringes to increase patient safety.
• Mechanical ventilation strategies that allow unsupported spontaneous breathing activity are discussed in 4, which suggests considering the use of techniques that maintain spontaneous ventilatory effort in patients with severe pulmonary dysfunction.
• Perioperative pharmacology and medication safety are discussed in 5, which emphasizes the importance of understanding the medication-use process and recognizing threats to patient safety.
• The use of Airway Pressure Release Ventilation (APRV) as a rescue strategy in COVID-19 patients is evaluated in 6, which suggests that APRV may improve oxygenation, alveolar ventilation, and CO2 clearance in patients with refractory hypoxemia.

Key Considerations

• The administration of PAM in the operating room requires careful consideration of ventilation strategies and medication administration protocols.
• Standardizations, barcode medication administration, and the use of prefilled or premixed syringes can help increase patient safety.
• Mechanical ventilation strategies that allow unsupported spontaneous breathing activity may be beneficial in patients with severe pulmonary dysfunction.
• Understanding the medication-use process and recognizing threats to patient safety are crucial in ensuring the safe use of pharmacological agents in perioperative clinical practice.