Morphine sulphate is the first line opioid used in RHC Glasgow.
However there may be occasions to use a different opioid, for example when there is an increase in morphine side effects or when switching opiates are appropriate.
Oxycodone is the second line of opioid choice in RHC Glasgow.
Oxycodone is known to have a better side effect profile, with less itch, less nausea/vomiting, and less gastric stasis (ileus risk). It may therefore be chosen in preference to morphine in certain patients. Oxycodone is slightly more potent (between 1.5-2x) than morphine, but can be prescribed using the same dosing regimen as morphine, and titrated to effect.
Titration
Intravenous morphine/oxycodone infusion
Dedicated anti-syphon/reflux infusion lines with maintenance fluids to ensure patency of cannula.
Morphine/Oxycodone syringe should be prepared as 1mg/kg in 50mls 0.9%saline º20micrograms/kg/ml; maximum 50mg in 50mls
Infusion only opiates are used almost exclusively in PICU and NICU. The settings below can also be used as a guide to initial background infusions for PCA/NCAs
Morphine / oxycodone PCA or NCA
PCA (patient controlled analgesia) work well for children around 8 years and over, who can understand when and how to press the button. For children under 8, or for children with cognitive impairment/developmental delay an NCA is more appropriate. This is a guide only and there may be children under 8 who would be able to use a PCA effectively.
Dedicated anti-syphon/reflux infusion lines with maintenance fluids to ensure patency of cannula.
Morphine / Oxycodone syringe should be prepared as
1mg/kg in 50mls 0.9% Saline
20micrograms/kg/ml; maximum 50mg in 50mls (1mg/ml)
Please refer to this document (Sharepoint link) for practical guide to setting up NCA in neonatal population.
Troubleshooting/changing settings
- In pain
- Side effects – itch/n&v/ileus
- Resp depression/sleepiness
Children on PCA/NCA should have hourly pain scores documented on their PEWS chart or on PCA/NCA chart. A trend of escalating pain scores should trigger a call to APRS (84319).
Other things to check/consider include:
- Patency of IV access
- Is PCA/NCA pump programmed correctly and working?
- Has the patient had adjuvant analgesia (should be prescribed regularly)?
- Do they need a loading dose/titration?
- Consider increasing background, increasing bolus dose or reducing lockout – this should only be done by the APRS/on call anaesthetist
- Low threshold for re-review by surgical/parent team if pain out of proportion or new.
All patients with NCA/PCA should be prescribed at least PRN anti-emetics. Anti-emetic guidance is provided later in this document.
Itch can be managed with either low dose naloxone (1mcg/kg) or piriton (250mcg/kg – max dose 2.5mg IV)
Ileus is commonly seen following abdominal surgery and use of post op opiates can compound this. We advise early conversion to Oxycodone as this is associated with a lower incidence of ileus. Conversion to oxycodone may also effective for children with nausea/vomiting and/or itch.
If a child on an opiate infusion is excessively sleepy, or with a RR <10, the infusion should be stopped and the ward/parent team should be called to review. As part of the standard ABC assessment of an unwell child, naloxone should be administered.
Dose:
- For Severe (life threatening) respiratory depression = 400mcg
- For sedation/mild respiratory depression/itch = 1mcg/kg
This can be repeated at 5 minute intervals for 5 doses, maximum dose 2mg. Ideally given IV but can be given IM or SC if these routes are available. By IM and SC routes, both the dose and the frequency are the same as above.
Consider smaller dosing initially in children at risk of withdrawal, or in children who will continue to need opiates (post-operative care, palliative care, mucositis, sickle cell crisis).
