Engaging Best Practice in Opioid-based Intravenous Patient-Controlled Analgesia After Surgery

Abstract

Opioid-based intravenous patient-controlled analgesia (IV-PCA) has been used extensively to relief acute postoperative pain for several decades. Recently, PCA has just been accepted and widely used in Thai hospital context. Here, using PCA is a relatively new method of opioid administration for nurses which specific knowledge and complex skills are required. The purpose of this review was to summarize the best practices in the administration of IV-PCA for patients after surgery. An integrative review method was employed using the search terms and the following databases: PubMed, CINAHL, Cochrane Library, and ThaiJo. Thirteen clinical practice guidelines, a literature review, and a retrospective study published between 2001 and 2021 which met the inclusion criteria were included in the final analysis. The quality of evidence and risk of bias of 13 articles were evaluated by AGREE II and the Joanna Briggs (JBI) institute critical appraisal tools which revealed good data extraction from the 15 included studies was done using the evidence table in accordance to the purpose of this review. Content analysis and narrative synthesis were employed for data analysis and synthesis. This review indicated that administration of IV-PCA best practice involved 5 phases. Phase I before implanting PCA, this phase focused on capability development and accreditation for staff involved in caring for the patients receiving IV-PCA after surgery, readiness of relevant resources, including clinical practice guideline, standard for practices, and policy. Phase II, prior to administration of IV-PCA, this phase involved patient selection, patient education, and opioid risk assessment. Phase III, patients’ pre-commencement of IV-PCA, this phase included verification and validation of PCA prescription, PCA devices, and equipment. Phase IV, patients receiving IV-PCA, this phase highlighted the provision of adequate analgesia, adequate pain relief, prevention of medication error, assessment and management of opioid-induced side effects and complication, including patient monitoring and documentation. The last phase, before and after discontinuation of IV-PCA, assessment of patients’ readiness to discontinue IV-PCA as the certain criteria, receiving new prescription of oral analgesia, ongoing patients’ evaluation, and documentation at least 4 hours after ceasing the IV-PCA. Capability development as well as accreditation of nursing practices are the first step maintaining safety and efficacy of IV-PCA. In-service training in conjunction with contextually-sensitive clinical nursing practice guideline for Thai hospitals are the foreseeable benefits of this review.