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Child Health Guideline Identifier

Pain - Morphine intermittent IV administration

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Introduction

Morphine is considered the 'gold standard' opioid analgesic for management of acute pain in children unless contraindicated.

The preferred route of administration is oral as it is convenient and painless. However, many patients with acute pain will initially require morphine by injection if the oral route is contraindicated (e.g. vomiting or fasting) or a rapid response is needed.

Intravenous (IV) morphine is preferred over intramuscular or subcutaneous injection as the effect is more rapid and reliable and less traumatic for the patient.

IV Morphine as per protocol (IV morphine APP)

Intermittent IV morphine is given as IV morphine APP on the wards at Starship. This allows small boluses of morphine to be administered every 5 minutes, making it possible to titrate pain relief whilst observing for side effects.

See the below chart for further details.

IV Morphine as Per Protocol Flow Chart

IV morphine protocol

Responsibility

The primary team should manage patients receiving IV Morphine as per protocol.

All registered nursing staff that have completed the competency for intravenous administration of Morphine and who are currently assessed as competent for IV medication administration can administer IV Morphine as per protocol.

Administration

All registered nursing staff that have completed their intravenous administration competency and attended the paediatric pain study can administer IV Morphine as per protocol.

The syringe of IV Morphine as per protocol should be prepared by two registered nurses. A medication additive label should be applied to the syringe with the details of the medication, date, time and the two registered nurses signatures.

The first initial dose should be administered with these two registered nurses in attendance, following the medication administration guidelines. All subsequent doses for that shift may be administered by either of the registered nurses that prepared the syringe.

Documentation

IV Morphine as per protocol will be prescribed on the As Required (PRN) Medicines section on the patients medication chart.

On administration the registered nurse will document on the medication chart the date, time, dose and route. The dose should be documented in mg. The two registered nurses that prepared the syringe should sign the initial dose. All subsequent doses require only the signature of the registered nurse that administered that dose.

Discarding IV Morphine as per protocol

IV Morphine as per protocol should be discarded by the end of each shift. This should be witnessed by two registered nurses.

Risks

Side effects will occur more rapidly with IV morphine over oral, such as the risk of respiratory depression. The use of standardised protocol morphine minimises this.

Cautions & Contraindications

Caution in children with renal impairment.

Children with renal or hepatic impairment have the potential to accumulate morphine metabolites and therefore have increased risk of respiratory depression and sedation with repeated doses. Consultation with the primary team/renal consultant should occur prior to administration of morphine. Please see Renal - acute pain management in children with renal impairment guideline for further information.

Special consideration should be given to children with an increased risk of respiratory depression before IV morphine protocol is administered.

This includes children with:

  1. Neuromuscular disease
  2. Sleep apnoea
  3. Pre-existing respiratory failure
  4. Children receiving other sedating drugs (eg. Diazepam)

Infants less than 6 months have an increased risk of opioid induced respiratory depression. Morphine IV as per protocol should be administered to these patients with caution and close respiratory monitoring.  

Observations

All patients should have baseline observations prior to administering morphine IV as per protocol. The following should also be observed;

  • Pain Level: Currently in (or anticipated) moderate or severe pain.
  • Sedation Level: Awake or easily roused.
  • Respiratory rate: >26/min in under 12 months

                                >20/min in 12 months to 4 years

                                >18/min in 5 to 11 years

                                >12/min in over 12 years

Do not administer IV as per protocol if the patient does not meet all these criteria.

All children under 6 months of age should have continuous pulse oximetry (with consideration for secondary apnoea monitoring in the younger neonate) post administering Morphine IV as per ptotocol.

The period of observation for these patients should be:

  • Infants < 1 month = 9 hours
  • Infants > 1 month to 6 months = 4 hours
  • Ex-premature infants with a post conceptual age of less than 60 weeks will require observation until they have a 12 hour "apnoea free" period.

Children over 6 months of age should be closely monitored for signs of respiratory distress with an oximetry and sedation check 10 minutes post administration of Morphine IV as per protocol dose.

Additional Analgesia

Regular paracetamol and NSAID's (if not contraindicated) should be administered whilst a child is receiving IV Morphine APP.

Initial Morphine Bolus Administration PICU/CED/OR

The larger doses below may initially be administered to children over 6 months of age as prescribed by medical staff on an individual basis in the Paediatric Intensive Care Unit (PICU)/ Children's Emergency Department (CED)/ and Operating Rooms (OR) where there is the immediate availability of personnel and equipment for advanced airway intervention. 

  • For children over 6 months and less than 50kg the initial administration dose may be 0.1mg/kg.
  • For children less than 6 months a usual initial dose would be 0.05mg/kg (50mcg/kg).
  • For children over 50kg the initial administration dose may be a standard bolus of 5mg. Further doses may then be administered as per IV Morphine protocol.
  • Smaller doses are advisable under some circumstances.

References

  • McGrath, J, P., Stevens, J, B., Walker, M, S., & Zempsky, T, W. (2014) Oxford Textbook of Paediatric Pain. Oxford, United Kingdom: Oxford University Press.
  • Twycross, A., Dowden, S., & Stinson, J. (2014) Managing Pain in Children. A Clinical Guide for Nurses and Healthcare Professionals (2nd ed). United Kingdom: Wiley Blackwell

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Document Control

  • Date last published: 02 March 2018
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department, Paediatric Pain Service
  • Owner: Paediatric Pain Service
  • Editor: Greg Williams
  • Review frequency: 2 years

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