PRESCRIPTION ORDER FOR PATIENT CONTROLLED ANALGESIA (PCA) PUMP
PATIENT INFORMATION
Name:
Date of Birth:
(Last Name, First Name)
Male
Gender:
(dd-mmm-yyyy)
Female
Address:
City:
Postal Code:
**Patient Identifier is required upon delivery under Narcotics Safety and Awareness Act **
(http://www.health.gov.on.ca/en/public/programs/drugs/ons/)
Health Card Number (Recommended):
or
Check One Identifier:
Driver’s License
Passport
Birth Certificate
Citizenship Card
Military
Other:
No. on Identifier:
or
Exempt/Unable to Supply Identification to Prescriber
Specify Reason:
Note: If patient is unable to supply identification, the medication must be received/delivered to person directly
Allergies:
Discontinue all previous narcotic orders
Medication:
Morphine
Concentration:
Hydromorphone
Other:
mg/mL
(The higher the concentration, the smaller the infusion volume for subcutaneous so site will last)
Route:
Subcutaneous
Other:
(If intravenous, basal rate volume must be minimum 0.5mL/hr)
Infusion Rate: Minimum
mg/hr; Maximum
Breakthrough Bolus Doses: Minimum
mg/hr; Starting
mg; Maximum
Breakthrough Bolus Interval: Every
min prn Maximum:
mg/hr
mg; Starting
mg
doses/hr
May increase both basal and bolus rates of infusion by
mg each for pain greater than
or greater than
breakthrough used over 24 hour period AND notify MD/NP
Reservoir Size:
100 mL
Other:
Total Quantity of Reservoirs:
Dispense at each time:
mL
10 (ten)
2 (two)
/10
Other:
Other:
PHYSICIAN
(Prescriber, please sign and date prescription)
Name (PRINT):
CPSO No. (Required):
Address:
Tel:
After Hours Tel:
Fax:
Signature:
Date:
(dd-mmm-yyyy)
Prescription Order for Patient Controlled Analgesia (PCA) Pump
November 2015
Page 1 of 2
How-To-Guide – Starting a Continuous Subcutaneous Infusion
Step 1:
Step 2:
Step 3:
Determine the 24-hour oral dose of narcotics by adding up the amount of controlled-release per
24-hour and the average amount of breakthroughs used in a 24 to 48 hour period
Determine which subcutaneous (subcut) medication you want to use (hydromorphone vs.
morphine)
Convert all current oral (PO) opioids to your drug of choice (in PO form first)
Drug
PO dose
Ratio to morphine*
Morphine
10 mg
-Codeine
100 mg
10 : 1
Oxycodone
5 mg
1:2
Hydromorphone
2 mg
1:5
*When switching from one opioid to another, reduce dose by 20% - 50% for incomplete cross tolerance
(30% reduction generally used)
Morphine dose mg PO/24 hr**
Transdermal (TD) fentanyl dose mcg/hr every 72 hr
25 – 59
12
60 – 134
25
135 – 179
37
180 – 224
50
225 – 269
62
270 – 314
75
315 – 359
87
360 - 404
100
**Does not require 30% reduction as already done in table
**When switching from TD fentanyl to subcut infusion, discontinue patch and start pump 12 hr later. Rely
on breakthrough doses to get patient through
**Start PCA pump when next long acting opioid is due
Example:
Patient on 6 mg HydromorphCONTIN BID + Morphine 5 mg Breakthrough x2/day – switching to
Hydromorphone
= 12 mg Hydromorphone PO/24 hr + 10 mg Morphine PO/24 hr
= 12 mg Hydromorphone PO/24 hr
+ 10 mg Morphine = 2 mg Hydromorphone = 1.4 mg Hydromorphone PO/24 hr (30% for cross tolerance)
= 13.4 mg Hydromorphone PO/24 hr total daily dose
Step 4:
Step 5:
Step 6:
Step 7:
Convert the 24 hour oral dose into equivalent subcut dose. This is a 2 : 1 ratio (PO : Subcut).
Divide the total daily PO dose by 2 to get the subcut dose/24 hour.
Divide the 24 hour subcut dose by 24 hours to get the hourly dose. The pump infuses hourly
doses in milligrams per hour.
Determine the breakthrough dose. The breakthrough dose is 10% of the total daily subcut dose.
The breakthrough can be infused every hour, or alternatively broken into intervals of every 15 or
30 minutes
Determine the concentration on the subcut medication you are using. The appropriate drug
concentration is dependent on the dose being used. (Minimum infusion rate: 0.1 mL/hr;
Maximum: 1 mL/hr)
Standard Concentrations
1 mg/mL
2 mg/mL
10 mg/mL
50 mg/mL
Recommended Subcutaneous Rates
0.1 – 2 mg/hour
2 – 5 mg/hour
2 – 30 mg/hour
10 – 150 mg/hour
Adapted from: Pallium Canada. (2013). The Pallium Palliative Pocketbook: A peer-reviewed, referenced resource.
Prescription Order for Patient Controlled Analgesia (PCA) Pump
November 2015
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