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Child Health Guideline Identifier

Pain - IV Oxycodone as per protocol

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Intravenous Oxycodone as per protocol must only be commenced and prescribed by the Paediatric Acute Pain Service

If you feel a patient fits the criteria outlined under Indications, please contact the Acute Pain Service

Indications for use

Morphine remains the 'gold-standard' opioid at Starship Children's Hospital. However, in certain circumstance where children are unable to have Morphine (eg. previous reactions or renal impairment) Oxycodone may be considered as an alternative.

The preferred route of administration is oral as it is convenient and painless. However, many patients with acute pain may initially require Oxycodone by injection if the oral route is contraindicated (eg. vomiting), unavailable, or a rapid response is needed.

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

IV Oxycodone as per protocol

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

Oxycodone

Responsibility

The Paediatric Acute Pain Service will commence and prescribe the initial IV Oxycodone as per protocol.

Once prescribed, by the Acute Pain Service, IV Oxycodone as per protocol can then be managed by the primary team with advice from the Acute Pain Service.

Administration

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

The syringe of IV Oxycodone 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 Oxycodone as per protocol will be prescribed on the As Required (PRN) Medicines section on the patients medication chart. The prescription must have approval from the pain service and should state this with approved by pain service documented.

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 Oxycodone as per protocol

IV Oxycodone as per protocol should be discarded by the end of each shift. This should be done so by two registered nurses witnessing the discard.

Risks

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

Cautions & contraindications

Special considerations should be given to children with an increased risk of respiratory depression before IV Oxycodone is administered.
This includes children with:

  • Neuromuscular disease
  • Sleep apnoea
  • Pre-existing respiratory failure
  • Children receiving other sedating drugs (eg. Diazepam)

Infants less than 6 months have an increased risk of opioid induced respiratory depression. IV Oxycodone 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 IV oxycodone as per protocol. The following should also be observed:

  • Pain Level: currently in (or anticipated) moderate to severe pain (assessed using an age appropriate pain assessment tool - see paediatric pain assessment guideline).
  • 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 Oxycodone as per protocol if patient does not meet the above criteria.

All children less than 6 months of age should have continuous pulse oximetry (with consideration for secondary apnoea monitoring in the younger neonate) post administration of IV Oxycodone as per protocol.

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 less than 60 weeks will require observations 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 IV Oxycodone as per protocol dose.

Additional Analgesia

Regular Paracetamol and NSAID's (if not contraindicated) should be administered whilst a child is receiving IV Oxycodone as per protocol. If not contraindicated they may also have Tramadol. No other opioid (eg. Morphine) should be administered while a patient is receiving IV Oxycodone as per protocol.

References

  1. Kalso, E. (2005) Oxycodone. Proceedings of the Symposium "Updates of the Clinical Pharmacology of Opioids with Special Attention to Long-Acting Drugs". Journal of Pain and Symptom Management. 29(5S), 47-56.
  2. McGrath, J, P., Stevens, B, J., Walker, M, S., & Zempsky, T, W. (2014) Oxford Textbook of Paediatric Pain. Oxford, United Kingdom : Oxford University Press.
  3. Pharmaco (N.Z.) Ltd. (2017) New Zealand Data Sheet. OXYNORM® (solution for injection or infusion)
  4. Oxycodone hydrochloride. Retrieved from: http://www.medsafe.govt.nz/profs/datasheet/o/oxynorminj.pdf

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Document Control

  • Date last published: 04 April 2018
  • Document type: Clinical Guideline
  • Services responsible: ADHB Pharmacy, Paediatric Pain Service
  • Author(s): Andrew Liley, Taryn Mannix
  • Owner: Andrew Liley
  • Editor: Greg Williams
  • Review frequency: 2 years

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