Intravenous patient controlled analgesia (PCA) regimens for opioid naïve children*: Commonly prescribed dose ranges

Drug	Concentration	Initial demand dose^¶	Lockout interval	Clinician bolus dose	Continuous infusion^Δ	Suggested initial 4 hour maximum (PCA demand doses and continuous infusion, if used)
Morphine	1 mg/mL; may use 0.5 mg/mL for patients <15 kg	0.015 mg/kg (range 0.01 to 0.03 mg/kg)	10 minutes	0.02 mg/kg (range 0.02 to 0.03 mg/kg), every 20 minutes up to 3 to 4 doses within a 4 hour period, if needed	Starting dose 0.01 mg/kg/hour	0.3 mg/kg
Hydromorphone	0.2 mg/mL	0.003 mg/kg (range 0.002 to 0.006 mg/kg)	10 minutes	0.005 mg/kg (range 0.002 to 0.006 mg/kg) every 20 minutes up to 3 to 4 doses within a 4 hour period, if needed	Starting dose 0.002 mg/kg/hour	0.06 mg/kg
Fentanyl	10 mcg/mL	0.2 mcg/kg (range 0.1 to 0.4 mcg/kg)	10 minutes	0.3 mcg/kg (range 0.1 to 0.4 mcg/kg) every 20 minutes up to 3 to 4 doses within a 4 hour period, if needed	Starting dose 0.1 to 0.2 mcg/kg/hour; maximum 0.5 mcg/kg/hour up to a maximum of 25 mcg/hour^◊	5 mcg/kg

Doses are based on actual weight, or for obese patients, ideal body weight.
These settings apply to opioid naïve children with post-procedural pain. Distinct order sets may be required for patients who are known to be opioid tolerant or who require high doses and concentrations for palliation.
If the patient is on a demand PCA dose only order profile, the maximum number of demand PCA doses allowed in 1 hour is set by the lock-out interval, hence a 10 minute lock-out implies that a maximum of 6 doses of drug may be self-administered hourly. That is the de facto 1-hour limit. Some PCA pumps specify a limit for the number of demand doses allowed per hour while maintaining the same lockout interval. As an example, with a 10 minute lockout period, one might chose a maximum of 4 demand PCA doses per hour.
Some institutions choose to impose a 4 hour total dosing maximum, pump design permitting, and we have included some recommended limits in that regard.
For patients who are receiving a continuous PCA infusion (CI), it is important to understand that the hourly dose that the patient can potentially receive is the maximum number of demand PCA doses permitted by the prescriber plus the amount administered as an infusion (total hourly dose = CI + maximum number of PCA demand doses). This must be taken into consideration when writing an order for a continuous infusion.
To reduce the total hourly dose that the patient is receiving either:
- Decrease the demand PCA dose or increase the lockout interval;
- Further limit the number of demand doses that are allowed in 1 hour beyond that defined by the lockout interval;
- Do not order a continuous infusion or, if ordered, decrease the rate or eliminate it entirely from the prescription.
Clinician bolus dosing is based on patient need and physiologic assessment and is independent of the hourly limits imposed by PCA demand dosing +/– the continuous infusion.

* For children over 60 kg, adult PCA dose ranges may be used.
¶ Demand dosing is generally limited to children who are capable of understanding the relationship of pain relief and pressing the PCA button, usually children who are >8 years of age.
Δ Continuous infusions violate a basic principle of safe PCA use, that sedation most often precedes respiratory depression; a sedated patient cannot press the demand dose button. Continuous infusion is optional and not routinely used, and requires intensive monitoring and nursing surveillance.
◊ Continuous infusions of fentanyl at rates of ≥0.5 mcg/kg/minute are usually limited to opioid tolerant patients.

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Intravenous patient controlled analgesia (PCA) regimens for opioid naïve children*: Commonly prescribed dose ranges