Vol. 49 No.

5 May 2015 Journal of Pain and Symptom Management 923

Clinical Note

Patient-Controlled Analgesia for Children at Home

Martha F. Mherekumombe, MBChB, MMED, FRACP, FACHPM, and
John J. Collins, MBBS, PhD, FRACP, FACHPM
The Children’s Hospital at Westmead, Sydney, New South Wales, Australia

Abstract
Context. Pain is a common and significant symptom experienced by children with advanced malignant disease. There is
limited research on pain management of these children at home.
Objectives. To describe and review the indications for using patient-controlled analgesia (PCA) in the form of a
Computerized Ambulatory Drug Delivery device (CADDÒ) in the home setting.
Methods. A retrospective chart review was conducted in children discharged home with opioid infusions using a CADD.
Charts from January 2008 to February 2012 were surveyed.
Results. Thirty-seven CADDs were dispensed during the study period, and of these, 33 were prescribed for patients with
cancer-related pain. A third of the CADDs were commenced at home and almost all PCA CADDs were used for end-of-life care.
Hydromorphone was the most commonly prescribed opioid. Patients remained at home and pain control was achieved by
either increasing the opioid dose or switching the opioid and using adjuvant therapy. Sixteen patients were readmitted to
hospital from home and three admissions were related to pain. The median duration on a PCA CADD at home was 33.7 days
(range, 1e150 days), and the mean morphine equivalent dose was 2.13 mg/kg/day.
Conclusion. PCA with a CADD can be used to manage pain in the home setting. Dose adjustments and opioid switches
were performed with no adverse incidents. J Pain Symptom Manage 2015;49:923e927. Ó 2015 American Academy of Hospice and
Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Key Words
PCA, CADD, palliative care, analgesia, cancer, morphine, hydromorphone, fentanyl, end-of-life care

Introduction has been shown to be safe and with infrequent occur-

rence of complications.5,7
Pain is a major complaint in many pediatric pallia-
Children at the end of life treated with PCA are re-
tive care patients and, in particular, children with can-
ported to have variable and increasing need of
cer. More than 75% of children dying from cancer
opioids.8,11e13 Research also describes pain manage-
experience pain, with some children having subopti-
ment during the end of life in some cases to be satis-
mal pain control.1e4 Opioids are recommended to
factory in only 20% of patients and others report up
effectively manage severe pain and can be adminis-
to 95% satisfaction.2e4,10,14 Portable PCA exists in
tered as an infusion in the form of patient-
the form of a computerized ambulatory drug device
controlled analgesia (PCA). PCA is known to be an
(CADDÒ) and there are few published reports, pre-
effective and safe modality, with children from the
dominantly in adult patients, regarding CADD use in
age of five able to self-administer ‘‘rescue’’ doses of an-
the outpatient setting.10,15e18
algesics for either breakthrough or incidental pain
This study describes and reviews the indications for
and have control over their pain management.5e10
using PCA with a CADD in the home setting for pedi-
In children who are either too young or unable to
atric palliative care patients during end-of-life care and
use PCA, their parents can use PCA by proxy, which
in advanced disease.

Address correspondence to: Martha F. Mherekumombe, Street, Westmead, Sydney, NSW, Australia. E-mail:
MBChB, MMED, FRACP, FACHPM, The Children’s Hos- Martha.mherekumombe@health.nsw.gov.au
pital at Westmead, Corner Hainsworth and Hawkesbury Accepted for publication: October 22, 2014.

Ó 2015 American Academy of Hospice and Palliative Medicine. 0885-3924/$ - see front matter
Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpainsymman.2014.10.007
924 Mherekumombe and Collins Vol. 49 No. 5 May 2015

Methods Table 1
Patient Demographics (N ¼ 33)
A retrospective chart review of pediatric oncology
n Percentage
patients discharged home with PCA in using a
CADD device between January 2008 and February Age (yrs), mean (range) 10 (0.6e23)
Sex
2012 was conducted at the Children’s Hospital at West- Male 22 67
mead (CHW), Sydney. The patient population, indica- Female 11 33
tion and duration of PCA CADD use, opioid type, and Cancer type
Neuroblastoma 10 30
dose used were reviewed. The audit was submitted and Leukemia 7 21
approved by the Sydney Children’s Hospital Network Soft tissue tumors and sarcomas 7 21
(SCHN/CHW Quality Improvement Ethics Review Brain tumors 5 15
Bone tumors 4 12
Process. Ethics approval number: QIE-2012e08-10). Weight (kg), mean (range) 20.45 (5e106)
The CADD-LegacyÒ PCA Ambulatory Infusion Place of residence
Pump, Model 6300 was used. A 100 mL cassette is Metropolitan 33 100
Language
loaded with the opioid and attached securely to the English-speaking background 26 79
device. The cassettes were ordered through the hospi- Non-English-speaking backgrounda 7 21
tal’s Pharmacy Department and supplied by Baxter Place of death
Home 16 50
Australia preloaded with the prescribed opioid. All Hospital 10 31
dose alterations required a new prescription and sup- Bear Cottage b
6 19
ply. The CADDs were programmed with either a five- a
Non-English speaking background was defined as a person whose first lan-
minute lockout time for children able to use the guage is not English or whose cultural background is derived from a none
English-speaking country.
device for PCA or a 10-minute lockout time when b
Bear Cottage is a Pediatric Inpatient Hospice, a unit of the Sydney Children’s
the device was used by proxy for children who were Hospital Network.
unwell or unable to comprehend usage. A preset hour-
ly maximum dose that could be delivered was set by severe abdominal pain in 14%, and for severe head-
the palliative care team. The CADDs begun in hospital ache in 8%. The remainder was prescribed for end-
were observed as per departmental policy using an of-life care or pain that was unspecified.
age-appropriate pain scale. At home, the reported Approximately one-third of the patients required an
pain scores were documented using a verbal rating opioid switch to effectively manage pain and in the
scale during the consultations with children capable presence of difficult side effects. Hydromorphone
of estimating their pain. was prescribed in more than half of the children;
The record of patients dispensed CADD cassettes be- the rest received fentanyl, morphine, or methadone.
tween January 2008 and February 2012 was obtained The treatment characteristics are listed in Table 2.
from the Pharmacy Department. The list was verified The side effects reported were itch, sedation,
in the imaged medical records on Power Chart, a hospi- nausea, and urinary retention. Safety issues encoun-
tal multi-entity electronic medical record software tered were depleted batteries in two cases and a deliv-
program. The patient medical charts and electronic en- ery problem as a result of the infusion line kinking.
tries were reviewed. The data obtained were transferred Thirty-nine percent of PCA CADD infusions were
onto a spread sheet file (Microsoft Excel 2010, Micro- commenced at home and the remainder in hospital
soft, Inc., Redmond, WA) after it was cross-checked. a few days before discharge. These opioid infusions
Opioid doses other than morphine were converted to were continued until death in 97% of the patients.
intravenous morphine equivalent doses referenced to
body weight.19 Missing data were excluded. Discussion
Approximately 40% of children with progressive
malignant disease referred to the Palliative Care Ser-
Results vice at CHW each year will require opioid analgesia
Study Patients via a PCA CADD.
Thirty-seven PCA CADDs were dispensed in the The indications for PCA CADD use at home include
study period, and of these 33 were prescribed to 1) an opioid is required for pain management or ter-
oncology patients. Patient demographics are summa- minal dyspnea; 2) patient requires opioid therapy and
rized in Table 1. the oral route is not tolerated; 3) family’s desire to be
or remain at home and the child has already
Opioid Consumption commenced intravenous opioids in hospital; 4) inade-
The total opioid consumption is illustrated in Fig. 1. quate analgesia using oral medications; and 5) inci-
The PCA CADDs were prescribed mostly for bone pain dent or breakthrough pain inadequately treated with
from metastatic disease in 61% of the patients, for oral opioid analgesia.
Vol. 49 No. 5 May 2015 PCA for Children at Home 925

Fig. 1. Opioid consumption. MED ¼ Mean IV morphine equivalent dose.

Nine patients were receiving oral opioids and one a It was difficult to quantify parent or child satisfac-
transdermal opioid patch before commencing the tion of pain management in this study. Evidence
PCA CADD opioid infusion. Patients begun on the would suggest that pain was adequately managed at
PCA CADD infusion in hospital before discharge home, with only three patients readmitted for pain
were continued on the same infusion on discharge. management. The PCA CADDs enabled many chil-
The choice of opioid also depended on previous dren to die at home; this may correlate to parental
opioid side effects. Patients were generally started on satisfaction regarding supporting the preferred place
a morphine infusion but were switched to an alterna- of death. A prospective study will need to be per-
tive opioid in the context of inadequately treated formed to assess parent satisfaction of pain manage-
pain and intolerable side effects. ment at home.
Documentation did report that of the patients Successful pain management requires patient and
managed at home, dose adjustments and opioid carer education on pain assessment as well as the risks
switches were performed safely. Opioid switching in and side effects of opioids.6,30 Pain assessment should
children is strongly recommended in the presence of
inadequate analgesic effect and intolerable side-
effects.19e23 The dose conversions are calculated using Table 2
age-appropriate dose conversion tables and are done Treatment Characteristics
by a pediatric pain specialist or palliative clinician.19 N %
The factors considered when switching opioids
Adjuvant analgesics
include the bioavailability of the formulation, possible Gabapentin 11
drug interactions, renal and hepatic clearance, and Pregabalin 2
previously used opioid analgesics.9,18,20,24 The patients Dexamethasone 1
Minimum morphine equivalent 0.5
with metastatic neuroblastoma had severe nerve- (mg/kg/day)
mediated pain that was difficult to control, requiring Maximum morphine equivalent 24
higher opioid doses and in some instances an opioid (mg/kg/day)
Mean morphine equivalent 2.13
switch to methadone.25e27 (mg/kg/day)
Drowsiness was reported in one patient and opioid Duration of PCA CADD therapy
toxicity may have played a role because the child had Therapy days at home 1e150 (mean, 33.7)
Readmissions for pain 3/16
recently been switched to methadone. Dose switching Route of opioid administration
to methadone is complex and should only be done by Central venous access device 29 87.9
practitioners experienced with its use. Methadone has Subcutaneous 4
Side effects 7
wide inter-individual variation in its pharmacokinetics Safety issues 3
and titration should be carried out with close clinical Occasions of service, n ¼ 615 1e115
observation of the patient over several days.21,23,28,29 Mean 18.6
Average (range) pain scores 5 (2e10)
Greater monitoring is recommended to improve the Pain score documentation 8
safety of PCA CADDs at home especially when doses Occasions of service ¼ any examination, consultation, treatment, or other
are altered or opioids are changed. service provided in a non-admitted setting to a patient.
926 Mherekumombe and Collins
be integrated into outpatient clinical care. A pain
assessment was probably performed when the CADD
history was reviewed (but not documented) because
opioid doses were subsequently amended. In one
study, PCA for pain control in dying children reported
stable pain scores; opioid doses varied with high bolus
demand, which was reported as a reflection of the
child’s actual opioid requirement, supporting the
need for mandatory pain scoring.8 Research will
need to be conducted on parental pain assessment us-
ing appropriate assessment tools in children on PCA
CADDs at home.
The strengths of this study include the ability to
define the number of days the children spent at
home with an opioid infusion. It also demonstrated
that children can be managed with PCA using a
CADD, and various opioids could be adequately
administered at home.
There were several limitations to the study. The level
of pain control was difficult to quantify, and a closer
review of pain management at home needs to be as-
sessed, along with the reasons children remained at
home. Analgesic requirements in the home and hospi-
tal will need to be compared and the study extended
to children with nonmalignant conditions.
Conclusion
The results of the study indicate that opioid infu-
sions can be managed at home and a PCA CADD pro-
vides effective and timely analgesia. The study also
demonstrated that dying children were able to remain
at home with their families with good pain control
even after an opioid switch. A prospective study is
needed to verify the outcome of this study, including
parental satisfaction.
Disclosures and Acknowledgments
John J. Collins has no conflicts of interest to declare.
Martha Mherekumombe declares receiving a past
grant from Mundipharma Australia and has no
ongoing relationship with the company.
The authors acknowledge the assistance of Peter
Barclay, Acting Director of the Department of Phar-
macy at the Children’s Hospital at Westmead, in
providing the CADD patient records.
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