Download Patient Controlled Analgesia Order Form

Patient Controlled Analgesia Orders
Please contact a pharmacist to discuss alternative concentrations.
For Opioid Tolerant patients, patients on previous opioid therapy, or patients who have multiple opioid
allergies please contact a pharmacist or the Supportive Care service for an appropriate conversion from prior
therapy.
Basal Rates should be used cautiously, if at all, for elderly or opioid naïve patients
1.) Discontinue all other intravenous opioid medications while receiving PCA.
[] check one of the following standardized PCA medication concentrations
2.)
HYDROmorPHONE (Dilaudid®) IV PCA Standard
[ ] Sodium Chloride 0.9% 100 mL + HYDROmorphone 20 mg (0.2 mg/mL) Standard Concentration
3.)
Basal Rate:
_______
mg/hour
(0 - 0.2 mg recommended)
On-Demand Amount:
_______
mg per dose
(0.1 - 0.2 mg recommended)
Lockout Interval:
_______ minutes
(10 – 15 minutes recommended)
Loading Dose:
_______
(0.4 - 0.8 mg recommended)
mg
MorPHINE IV PCA Standard
[ ] Sodium Chloride 0.9% 150 mL + MorPHINE 150 mg (1 mg/mL) Standard Concentration
4.)
Basal Rate:
_______
mg/hour
(0 – 1 mg recommended)
On-Demand Amount:
_______
mg per dose
(0.5 - 1 mg recommended)
Lockout Interval:
_______ minutes
(10 - 15 minutes recommended)
Loading Dose:
_______ mg
(2 - 4 mg recommended)
FENTanyl IV PCA Standard recommended if patient experiences intolerable side effects from morphine
or hydromorphone, in elderly patients, and is considered first line opioid for BMT patients due to ongoing
metabolic complications.
[ ] Sodium Chloride 0.9% 150 mL + FENTanyl 1,500 mcg (10 mcg/mL) Standard Concentration
5.)
Basal Rate:
_______
mcg/hour
(0 - 20 mcg recommended)
On-Demand Amount:
_______
mcg per dose
(5 - 20 mcg recommended)
Lockout Interval:
_______ minutes
(5 - 10 minutes recommended)
Loading Dose:
_______
(20 - 40 mcg recommended)
mcg
PRN for respiratory rate less than 8 breaths per minute:
1. Stop PCA and all other opioids (e.g MorPHINE, HYDROmorPHONE, SUFENTA, etc).
2. Administer Naloxone 400 mcg (0.4 mg) with 9 mL of 0.9% of Normal Saline PRN for RR less than
8/minute. Comment: Give 1 mL(0.04 mg) IV q 1 minute via central line or q 2 minutes via peripheral
line until respiratory rate improves.
3. Call Prescriber.
Physician signature:_____________________________________________ Time:____________ Date:_____________
Physician name printed:__________________________________________ Pager number:_____________________
PATIENT NAME:
_____________________________________
*16980-2-012* 01/11
EMR: Physician’s Orders
White-Patient Chart, Yellow-Pharmacy
DATE OF BIRTH: ______________________
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MR#: ________________________________