Opioids used for Patient Controlled Analgesia (PCA)
- Morphine
- HYDROmorphone (Dilaudid)
- Fentanyl
How to Write Patient Controlled Analgesia (PCA) Orders
To write PCA orders, you need to make certain choices. First, choose the medication you want to use and its concentration. Frequently used concentrations are:
- Morphine 1mg/mL
- Hydromorphone 1mg/mL
- Fentanyl 10mcg/mL OR 50mcg/mL
Next, the physician must determine the following parameters.
Loading Dose (initial bolus dose): Decide if you want to give a loading dose (bolus). Consider a loading dose (bolus) if the patient is in moderate or severe pain at the time of orders. The loading dose is a dose you give before the PCA starts. If you don’t want to give a loading dose, you will enter zero in the field for loading dose in the EHR.
Patient-administered bolus dose (PCA dose): This is the dose of medication you want to the patient to give themselves every time they click the button.
Lockout interval (min): This is the time the patient must wait after giving themselves a PCA dose before their click can deliver another PCA dose of medication. If the Lockout interval is 15 minutes, it means, the patient may click when it’s not 15 minutes from their last dose. However, no medication will be delivered. But when that 15 minutes have expired, the next click by the patient will dispense medication. But if the patient doesn’t click after the 15-minute mark has passed, no medication is dispensed.
Basal rate (continuous IV infusion basal rate): This is a dose of medication that is given continuously, like a drip, to the patient to control their pain. At my institution, when we use PCA, we often set this to zero.
One Hour Limit: This is the maximum total dose of medication you want the patient to receive in one hour. It is the sum of the basal rate and the patient-administered bolus dose (PCA dose).
You will need the above information to write your PCA order in your EHR.
The following image from when I was in medical school shows suggested parameters for morphine, hydromorphone, and fentanyl.
Discontinue PRN opioid analgesics while the patient is using PCA
Monitoring
After initiating PCA or changing the dose of PCA medication, monitor the patient’s pain, RR, respiratory quality, and level of consciousness as follows:
Q15min x 1 hour, then Q30min x 1 hour, then Q1H x 2 hours, then Q2hr thereafter.
IF RR drops below 12, check RR q30 minutes x 2, then q1hr x 4
Monitor BP and HR q4h
Continuous pulse oximetry by nursing.
Education: Instruct patient and visitors that ONLY the patient is allowed to push the PCA button