Anaesthesia and Pain Management : Patient Controlled Analgesia PCA (2023)

This pain management guideline was written by the staff of the Children's Pain Management Service for the Royal Children's Hospital, Melbourne.

This guideline may NOT be suitable for use in other institutions.

  • Nurse competencies
  • Indications
  • Contraindications to PCA
  • Prescription and program of PCA (view prescription)
  • PCA set up
  • PCA delivery
  • Concurrent drugs
  • Precautions
  • Parents and PCA
  • Patient review
  • Observations
  • Complications
  • Ceasing the PCA

Nurse competencies

  • All Registered Nurses caring for patients receiving PCA should complete and pass their opioid competency annually.
  • If Registered Nurses are regularly caring for patients with PCA they should complete the PCA competency also.


  • PCA is used for the management of moderate to severe pain when inadequate analgesia would result from oral analgesia or intermittent IV morphine boluses.
  • The child must have the cognitive ability to understand the conceptPCA and is willing toself-manage analgesia.
  • Lack of normal hand function does not prevent patients from using PCA.A number of alternate handsets areavailable.

Contraindications to PCA

  • If the child is unable to understand the concept of PCA or they do not wish to control their own analgesia, a nurse controlled opioid infusion would be more suitable.

Prescription and program of PCA

  • PCA is a specialised analgesia technique and is managed by CPMS.
  • Most patients are commenced on PCA in the recovery room. For other patients requiring PCA a referral needs to be made to CPMS by paging 5773 (24 hours) and completing an inpatient electronic referral. The referrer needs to ensure that the patient's primary consultant has approved of CPMS involvement.
  • ONLY CPMS and Anaesthesia staff may prescribe PCA. For safety reasons ONLY Recovery or CPMS staff may program the PCA infusion pumps.
  • Please contact CPMS to program the pump during office hours or recovery after hours
  • Morphine is the preferred opioid in most circumstances. Fentanyl or hydromorphone are alternative choices.
  • The PCA infusion is prescribed according to the PCA prescription guidelines .

    Opioid dilution for PCA

    Less than 50kg: 0.5 mg / kg diluted to a total volume of 50 mL with normal saline
    Bolus dose: 2 mL = 20 microgram / kg
    *Background:0.5 mL / hr = 5 microgram / kg / hr

    More than 50kg: 50 mg diluted to a total volume of 50 mL with normal saline
    Bolus dose:1 mL = 1 mg
    *Background: 0.5 mL / hr = 0.5 mg / hr

    Less than 50kg: 15 microgram / kg diluted to a total volume of 50 mL with normal saline
    Bolus dose: 1 mL = 0.3 microgram / kg
    *Background:1 mL / hr = 0.3 microgram / kg / hr

    (Video) Patient Controlled Analgesia

    More than 50kg: 750 microgram diluted to a total volume of 50 mL with normal saline
    Bolus: 1 mL = 15 microgram
    *Background:1 mL / hr = 15 microgram / hr

    Less than 50kg: 0.1 mg / kg diluted to a total volume of 50 mL with normal saline
    Bolus dose:1 – 2 mL = 2 – 4 microgram/kg
    *Background:0.5 – 1 mL / hr = 1 – 2 microgram/kg/hr

    More than 50kg: 6 mg diluted to a total volume of 50 mL with normal saline
    Bolus dose:1 mL = 120 microgram
    *Background:0.5 – 1 mL / hr = 1 – 2 microgram/kg/hr

    Background infusion
    * Rarely required

    OxycodoneLess than 50kg: 0.5 mg / kg diluted to a total volume of 50 mL with normal saline
    Bolus dose:2 mL = 20 microgram / kg
    *Background:0.5 mL / hr = 5 microgram / kg / hr

    More than 50kg: 50 mg diluted to a total volume of 50 mL with normal saline
    Bolus dose:1 mL = 1 mg
    *Background: 0.5 mL / hr = 0.5 mg / hr

PCA set up

  • The PCA syringe must be prepared in accordance with RCH medication policy and labelled clearly with a blueintravenous additives label.
  • PCA infusion pumps (Alaris P5000 PCA) must be used for all PCA infusions.
  • The PCA infusion line should be clearly labelled with a blue IV opioid label at the 3-way-tap where the PCA line meets the maintenance line.
  • 50 mL Braun Omnifix syringes are used for PCA, together with 180 cm minimum volume extension tubing.
  • A 3-way-tap at the syringe end of the opioid infusion line is not required.
  • The two authorised persons who make up each PCA syringe must sign the record of infusion on the Patient Controlled Analgesia prescription.
  • Syringe and lines should be changed every 72 hours or more often depending on individual unit policy or the patient's medical condition.
  • Keys for the PCA infusion pumps are kept with the ward drug keys on every ward. The operating theatre recovery room also has a set of PCA keys.

(Video) 7. Patient Controlled Analgesia

PCA delivery

  • To avoid the IV occluding between PCA tries, the patient should have maintenance IV fluids (with a minimum infusion rate of 5 mL/hr) running through an infusion pump (IVAC or similar). No anti-reflux valves are required if an infusion pump is used.
  • The volume infused should be checked every hour and documented on the fluid balance chart.
  • The treatment for opioid overdose is the opioid antagonist naloxone (Narcan). Naloxone is available in the ward/unit drug cupboard and on the ward/unit resuscitation trolley.
  • The naloxone dose is available in3 dose ranges: 1 microgram/kg for opioid induced pruritusand urinary retention, 2 microgram/kg for excess sedation and 10 microgram/kg for resuscitation.

Concurrent drugs

  • When opioid infusions are used, NO ORAL/ RECTAL/ INTRAVENOUS opioids or sedative agents should be given without prior consultation with CPMS or an anaesthetist.
  • Paracetamol, ketamine, local anaesthetics, tramadoland NSAIDs may be used concurrently with PCA infusions and may help to reduce opioid consumption and associated side effects.


  • If the patient is receiving other medication that may cause sedation (e.g. antihistamines, benzodiazepines or anticonvulsants), the patient may be at increased risk of sedation and respiratory depression.
  • Prolonged administration of opioid infusions and impaired liver and/or renal function may alter drug elimination with ALL opioids and possibly result in drug accumulation and toxicity.
    • The morphine metabolite M3G causes CNS disturbances (including myoclonus and tremor) and the morphine metabolite M6G is a potent analgesic. Both these metabolites may accumulate in patients receiving long-term morphine infusions or patients with renal impairment.
    • The hydromorphone metabolite H3G may accumulatein patients receiving long-term hydromorphone infusions orpatients with renal impairment. H3G can cause CNS disturbances (including confusion, tremor and agitation).
    • Prolonged fentanyl infusion may result in drug accumulation and potential increase in opioid related side effects.
  • Development of opioid tolerance with long-term administration of opioids may require the opioid dose to be increased.
  • Careful tapering of doses is important when weaning long-term opioids to avoid opioid withdrawal.

Parents and PCA

  • It is important that the child's parents understand the concept of PCA, so they can support their child in its use.
  • The child's parents must NOT push the PCA button for their child, but may encourage their child to use it as required.

Patient review

  • CPMS reviews patients twice daily on week days and once daily on weekends and public holidays.
  • If analgesia is inadequate or the patient is experiencing side-effects, CPMS must be called to review the patient.
  • CPMS can be contacted at all times on pager 5773.


The following observations should be recorded on the general observation chart:

  • Sedation score, respiratory rate and heart rate: 1hourly until the PCA is ceased. [The need for less frequent observations for patients receiving long-term PCA should be discussed with CPMS.]It is important to accurately assess sedationduring wakeand sleepperiods
  • Pain score: 1hourlywhile awake (using developmentally appropriate scale e.g. Wong-Baker Faces scale, Numeric scale, FLACC scale or PAT score).
  • Vomiting score:1 hourly for the first 12 hours, then4 hourly as indicated.
  • Pulse oximetry: if indicated

Indications for pulse oximetry:

Pulse oximetry MUST BE implemented and used continuously in high-risk patients with:

  • University of Michigan Sedation Scale (UMSS)

    0Awake and alert
    1Minimally sedated: may appear tired/sleepy, responds to verbal conversation and/or sound
    2Moderately sedated: somnolent/sleeping, easily aroused with light tactile stimulation or simple verbal command
    3Deep sedation: deep sleep, arousable only with deep or significant physical simulation
    SPatient is sleeping
    UMSS sedation score> 2
  • Significant cardiorespiratory impairment
  • Sleep apnoea, snoring or airway obstruction
  • Spot oximetry less than 94% SaO2

or patients receiving:

(Video) How to set-up an adult PCA

  • Supplementary oxygen
  • Concurrent sedative agents

Clinical indicators for 'spot' pulse oximetry are:

  • Tachypnoea or bradypnoea
  • Respiratory distress
  • Pallor or cyanosis or impaired oxygenation
  • Confusion or agitation
  • Hypotension
  • Nurse concern
  • PCA use: good and bad tries and total mg, recordedhourly on the PCA flowsheet
  • The effectiveness of the analgesia should be recorded in the Nursing Progress notes.

CPMS should be called if pain relief is inadequate after more than 5 good tries per hour for three hours.

Any observations outside normal values for age should be reported to CPMS +/- the primary treating team.



Ceasing the PCA

  • The decision to cease the PCA should ideally be made in consultation with CPMS.
  • Most patients self-wean off PCA, using it less as their pain decreases.
  • Oral opioids may be administered immediately after the PCA is ceased.
  • The date and time of ceasing the PCA must be recorded on thePatient Controlled Analgesia prescription
  • Any remaining opioid must be disposed of according to the RCH Drugs of Addiction policy.
  • The PCA infusion pump must be returned to Recovery when it is no longer required.

First version written July 1998, last UpdatedSep 2021


Who can use PCA? ›

PCA can be used in the hospital to ease pain after surgery. Or it can be used for painful conditions like pancreatitis or sickle cell disease. It also works well for people who can't take medicines by mouth. PCA can also be used at home by people who are in hospice or who have moderate to severe pain caused by cancer.

What is a PCA procedure? ›

Patient-controlled analgesia (PCA) is a method of pain control that gives patients the power to control their pain. In PCA, a computerized pump called the patient-controlled analgesia pump, which contains a syringe of pain medication as prescribed by a doctor, is connected directly to a patient's intravenous (IV) line.

What are the nurse's responsibilities when placing a patient on a PCA? ›

Nurses are responsible for the placement of peripheral intravenous lines, setup of PCA pumps, insertion of medication into the pumps, and monitoring of the patient's pain, sedation, and respiration.

What drug is in PCA? ›

Despite a variety of medication options, morphine remains the gold standard medication for intravenous PCA. Local anesthetics are primarily used for epidural catheter and indwelling nerve catheter PCA. They include the sodium channel blockers (bupivacaine, levobupivacaine, and ropivacaine).

Can oxycodone be given with PCA? ›

Conclusions: PCA with oxycodone is a suitable method for pain control after craniotomy. No progressive hypoventilation, desaturation or excessive sedation were encountered.

What are the disadvantages of patient-controlled analgesia? ›

Furthermore, IV PCA has drawbacks, such as device programming errors, system errors, medication errors, limitations in patient mobility, and potential for IV tubing kinks, clogging, and transmission of infection.

Who is not a good candidate for a PCA? ›

Patients who are confused, critically ill, lacking manual dexterity or under the age of 5 are not considered good candidates. The effectiveness of treatment relies on patient understanding of the principle behind PCA and compliance with prescribed regimen.

When do you apply for PCA? ›

Fresh PCA applications can only be submitted for an entry date 90 days after the employee's previous entry into Singapore.
Payment Matters
  1. My employee is unable to enter Singapore on the date indicated in the application. ...
  2. My employee was diagnosed with COVID-19 upon entry into Singapore.

How do you perform patient-controlled analgesia? ›

Patient Controlled Analgesia - YouTube

What observations are required when caring for a patient with a PCA? ›

Patients with PCA need regular observations of pain, nausea, sedation and respiratory rate, in addition to the conventional postoperative recording.
Monitoring PCA Infusions
  • Pain score must be recorded on the observation chart. ...
  • Sedation scores and respiration rate must be recorded on the observation chart.

What patient teaching should the patient receive regarding the use of the PCA patient controlled analgesia pump? ›

The PCA pump is safe to use because you receive medication by pressing the button when you feel pain, but the pump won't give you the drug if it's not time to receive another dose yet. Remember, no one should press the button on the PCA pump except you. When the pump is empty, an alarm lets the nursing staff know.

Can a nurse administer PCA? ›

PCA/NCA modalities must only be prescribed by Anaesthetists or the Acute Pain Service (APS) and managed by the APS.

When do you stop PCA? ›

Both intravenous and epidural PCA are started after your operation and are stopped when you are able to take pain medicine by mouth (pills). Once the PCA is stopped, please ask your nurse for pain pills when you need them.

What are the advantages of PCAS? ›

Among the advantages of PCA over traditional administration of analgesics, either orally or via intramuscular (IM) injection, include improved pain relief, greater patient satisfaction, less sedation, and possibly fewer postoperative complications.

What is the most common method of patient-controlled analgesia? ›

Morphine is the most studied and most commonly used intravenous drug for PCA. In spite of the fact that it is the 'first choice' for PCA, other opioids have been successfully used for this option.

Can tramadol given with a PCA? ›

Paracetamol, ketamine, local anaesthetics, tramadol and NSAIDs may be used concurrently with PCA infusions and may help to reduce opioid consumption and associated side effects.

What should the nurse assess in a patient who is receiving patient controlled analgesia? ›

Monitoring requirements should be developed for patients who are receiving PCA. At a minimum, the patient's level of pain, alertness, vital signs, and rate and quality of respirations should be evaluated every four hours. The staff must be alert for signs of oversedation.

How often must a PCA syringe be changed? ›

12. Pre-filled syringes are good for 24 hours. Date and time the syringe only if you anticipate (based on dosage) that the syringe will not completely infuse within the 24 hours. Nurse should record time, date, and initials when initiating as medications compounded by pharmacy are good for only 24 hours.

Who orders PCA after surgery? ›

The physician orders the narcotic analgesic dose to be given, the interval between doses, and the total amount of analgesic to be delivered over 4 hours. The patient simply presses a button connected to the analgesic infuser, which delivers a predetermined intravenous dose of the particular analgesic.

What is the meaning of patient controlled analgesia? ›

A method of pain relief in which the patient controls the amount of pain medicine that is used. When pain relief is needed, the person can receive a preset dose of pain medicine by pressing a button on a computerized pump that is connected to a small tube in the body. Also called PCA.

How much does PCA cost? ›

After acknowledgement of the above is sought from employees, companies can proceed to apply for the PCA. As part of the application process, companies need to pay an upfront fee of $200 each employee for the mandatory COVID-19 PCR test.

What is the purpose of PCA? ›

PCA helps you interpret your data, but it will not always find the important patterns. Principal component analysis (PCA) simplifies the complexity in high-dimensional data while retaining trends and patterns. It does this by transforming the data into fewer dimensions, which act as summaries of features.

What should I do after PCA? ›

Your Answer
  1. Asking for help, clarification, or responding to other answers.
  2. Making statements based on opinion; back them up with references or personal experience.
Jul 20, 2012

How do you start a PCA? ›

Loading Dose: PCA should be initiated after an initial bolus dose of morphine 5 – 20 mg (2-3 mg every 5 minutes up to 20 mg) to attain adequate plasma morphine concentrations. Doses should be reduced in patients over 70 years, and in patients with severely compromised physical status.

Why do you need oxygen with PCA? ›

The administration of oxygen is effective in preventing/treating hypoxaemia in the early post-operative period. Oxygen therapy will be prescribed by the anaesthetist and should be administered for the duration of the PCA.

Can a patient overdose on a PCA? ›

It is set so that once a small amount of pain killer is delivered, no more can be given within a pre-set time limit of five minutes, even if you press the button again. Therefore it is highly unlikely that you overdose as a result of using the machine.

Who can press the PCA pump? ›

It is very important to remember that only YOU are allowed to push the button on the PCA pump. Family members and/or friends should NEVER press the control button for you.

When can PCA be used? ›

When/Why to use PCA. PCA technique is particularly useful in processing data where multi-colinearity exists between the features/variables. PCA can be used when the dimensions of the input features are high (e.g. a lot of variables). PCA can be also used for denoising and data compression.

When should you not use a PCA? ›

While it is technically possible to use PCA on discrete variables, or categorical variables that have been one hot encoded variables, you should not. Simply put, if your variables don't belong on a coordinate plane, then do not apply PCA to them.

Can we use PCA for supervised learning? ›

A: PCA is great for exploring and understanding a data set. For pipelines where PCA is followed by a supervised learning algorithm, they are not suitable for model iterations for reasons listed above. However, they are handy for tasks such as quickly construct model performance benchmarks.

What is PCA good for? ›

The most important use of PCA is to represent a multivariate data table as smaller set of variables (summary indices) in order to observe trends, jumps, clusters and outliers. This overview may uncover the relationships between observations and variables, and among the variables.

What should I do after PCA? ›

Your Answer
  1. Asking for help, clarification, or responding to other answers.
  2. Making statements based on opinion; back them up with references or personal experience.
Jul 20, 2012

Which one of the following are drawbacks of PCA? ›

Principal Components are not as readable and interpretable as original features. 2. Data standardization is must before PCA: You must standardize your data before implementing PCA, otherwise PCA will not be able to find the optimal Principal Components.

Is PCA always necessary? ›

If the limitations outweigh the benefit, one should not use it; hence, pca should not always be used. IMO, it is better to not use PCA, unless there is a good reason to. You can have a linear relationship between variables and still not have a very meaningful compression by maximizing variance retained.

What are the key assumptions of PCA? ›

Principal Components Analysis. Unlike factor analysis, principal components analysis or PCA makes the assumption that there is no unique variance, the total variance is equal to common variance. Recall that variance can be partitioned into common and unique variance.

Can you do PCA twice? ›

Ordered by the dimension explaining the most variance of the original dataset. So you still could do a few PCA on a disjoint subset of your features. If you take only the most important PC, it will make you a new dataset on wish you could do a pca anew. (If you don't, there is no dimension reduction).

Does PCA have any assumptions? ›

The assumptions in PCA are: There must be linearity in the data set, i.e. the variables combine in a linear manner to form the dataset. The variables exhibit relationships among themselves.

What does PCA mean in medical terms? ›

A method of pain relief in which the patient controls the amount of pain medicine that is used. When pain relief is needed, the person can receive a preset dose of pain medicine by pressing a button on a computerized pump that is connected to a small tube in the body. Also called patient-controlled analgesia.

Whats PCA stand for? ›

Patient Care Assistants (PCA) can work in a variety of settings including; hospitals, medical clinics/offices, nursing care facilities, homes, assisted living facilities, and rehabilitation centers.


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