This pain management guideline was written by the staff of the Children's Pain Management Service for The Royal Children's Hospital, Melbourne.

This guideline may NOT be suitable for use in other institutions.

Nurse competencies

• All Registered Nurses caring for patients receiving opioid infusions should complete and pass their opioid competency annually

Indications

• Intermittent IV morphine boluses are to be used for the management of moderate to severe pain related to trauma, medical orsurgical conditions OR for the management of anticipated pain due to procedures (for example, dressing changes, chest drain insertion or removal).
• The intermittent IV morphine bolus prescription is intended for patients who do not have an intravenous opioid infusion. It is not meant to replace an opioid infusion or PCA.
• These guidelines may NOT be suitable for premature infants, ex-premature infants or for infants under 3 months of age. If unsure discuss with Neonatal Unit staff.

Prescription of intermittent IV morphine bolus

• Any prescriber can order an intermittent IV morphine bolus according to the guidelines on the Intermittent IV morphine bolus prescription in EMR.
• The prescriber should select the appropriate dose range according to the patient's weight/age.
• The prescriber should thenselect if the prescription is for single use or multiple use and document an end date
• Naloxone (Narcan) order must be completed as per EPIC

Child under 12 months

• Add 0.2 mg / kg of morphine made up
• to 10 mL with normal saline 0.9%
• Recommended bolus size is 1 mL IV
• from the syringe
• 1 mL = 0.02 mg / kg (20 microgram / kg)

Child over 12 months, and under 50kg

• Add 0.2 mg/kg of morphine made up
• to 10mL with normal saline 0.9%
• Recommended bolus size is 2 mL IV
• from the syringe.
• 2 mL = 0.04 mg / kg (40 microgram / kg)

Child weighs over 50kg

• Add 10 mg of morphine made up
• to 10 mL with normal saline 0.9%
• Recommended bolus size is 2 mL IV
• from the syringe
• 2 mL = 2 mg

Precautions

• If the patient is receiving other medication that may cause sedation (for example, antihistamines, benzodiazepines or anticonvulsants), smaller and/or fewer boluses may be required. This does not mean that analgesia should be omitted, however the staff administering the morphine bolus should be aware of the increased risk of sedation and/or respiratory depression.

Administration of intermittent IV morphine bolus

• As per the RCH medication policy two (2) authorised persons must check and administer the IV morphine bolus.
• The two authorised persons that check the morphine must sign for each morphine bolus administered.
• The morphine syringe must be clearly labelled.
• The IV line must be checked for patency prior to delivering the morphine bolus.
• The IV fluid should be checked for compatibility prior to giving the morphine bolus.
• A pulse oximetry monitor must be available and placed on the patient.
• The patient's level of sedation and respiratory rate must be fully assessed as per the checklist on the intermittent IV morphine bolus prescription, prior to giving each morphine bolus
• The prescribed dose of morphine should be administered as a 'push' from the 10 mL syringe via a 3-way-tap. The tap should be turned off to the morphine syringe between boluses.
• The bolus dose must not exceed the recommended bolus size.
• A normal saline flush must be given between morphine boluses to ensure the morphine dose has reached the patient.
• One nurse should continue to observe the patient during administration of IV morphine boluses.
• The nurse administering the morphine bolus is responsible for the morphine syringe, which must not be left unattended or returned to the Drugs of Addiction (DA) safe.
• If no further boluses are required after 15 minutes the syringe should be discarded.
• If the patient requires further morphine boluses after this time, a new syringe should be made up as per the prescription and the same administration process followed.
• The total amount of morphine given and amount discarded must be recorded on the MAR by the two authorised persons that administered and checked the morphine.
• If the pain is unresolved after the permitted boluses have been given a referral to the Children's Pain Management Service (pager 5773) should be considered for ongoing pain management.

Procedural pain

• If procedural pain is anticipated, it is suggested that one to two boluses are given prior to the procedure.
• During the procedure the need for further boluses should be re-assessed according to the patient's level of pain and sedation

Observations

The following observations should be recorded on the clinical observation chart:

University of Michigan Sedation Scale (UMSS)

• Prior to administration of the IV morphine bolus the patient should have a baseline set of observations.
• The patient should be awake or easily roused to voice (UMSSscore of0 to 2)prior to each bolus.
• Heart rate, respiratory rate, oxygen saturation, pain score and sedation score every 5 minutes during boluses.
• After the last bolus has been given, two further sets of observations at5 minute intervals should be completed.
• The effectiveness of the analgesia should be recorded in the patient's medical record and/or on theclinical observation chart.

Complications

IF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:

• CEASE administering morphine bolus
• CEASE any other infusion(s) that could contribute to sedation
• Attempt to rouse the patient
• Call 22 22 (MET team) if appropriate
• If apnoeic: administer bag and mask ventilation with 100% oxygen
• If breathing: maintain airway, monitor oxygen saturation and administer oxygen via face mask at 8 L/min
• Check circulation. If pulseless: commence chest compressions
• Administer naloxoneper the guidelines on the MAR if opioid toxicity is suspected
• Notify medical team for urgent review

First version written June 2002, Updated Feb 2023