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In order to ensure adequate analgesia in the opioid tolerant patients or those patients who use more analgesia a more concentrated opioid solution should be used allowing higher four hour limits to be selected.Common Four-hour Limits Examples: The four-hour limit ranges from 0 to 30 mls of the opioid solution selected.

Accumulation of normeperidine, a metabolite of meperidine, can precipitate seizures.

Seizures have occurred after less than twenty-four hours of meperidine with less than 400mg Loading Dose The loading dose accelerates attainment of an effective blood level of the opioid at the initiation of therapy or for procedures.

Patient weight is a useful on which to base the PCA dose, even though the correlation between analgesic requirement and weight is poor.

The volume of distribution of a drug is often weight-related and thus a useful guide to prevent over-or under-dosing.

The default limit four-hour limit is 30 mls of the solution, so the concentration of the selected agent will determine the mcg or mg amount of opioid.

Although no four hour limit can be selected it is advisable to have a warning of high opioid use ensure repeated patient assessment. For acute pain, which is subject to rapid change, the continuous infusion rate should be approximately one-third of the average hourly usage. cancer, mucositis), up to two-thirds of the average hourly usage is appropriate.

This period of time is a "moving window" that accounts for drug intake during the four hours preceding any given moment.

Given large inter-patient variations, it is not feasible to predict an appropriate four-hour limit.

Therefore, the speed of agent onset should be accounted for when determining the lockout interval.

Long lockout reduces the patient's ability to obtain an effective analgesic level if they fall behind, i.e. Lockout Intervals Examples: Morphine 8 minutes Fentanyl 6 minutes Hydromorphone 8 minutes Four-hour Limit (Abbot PCA Pumps) This safety feature prevents a patient from receiving more than a pre-determined amount of opioid within a four-hour period.

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