Intermittent IV Morphine Bolus

  • 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.

    Goto Top

    Indications

    • Intermittent IV morphine boluses are to be used for the management of moderate to severe pain related to trauma, medical or surgical 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 chart is intended for patients who donot 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.

    Goto Top

    morphine bolus admin

    Download the form 
    (PDF 100 KB)

    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 attachment. This attachment is only valid if attached to a current medication chart (MR52). 
       
    • There are two prescription options available:
      • The single use prescription is valid for 24 hours after the first bolus is given
      • The multiple use prescription is valid for 6 days after the first bolus is given
    • The prescriber should select the appropriate dose range according to the patient's weight/age. 
       
    • The prescriber should then select if the prescription is for single use or multiple use.
       
    • For the prescription to be valid, the dose of morphine (mg/kg), the bolus size and the naloxone (Narcan) order must be completed followed by the prescriber's signature, date and full name.

    Goto Top

    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.

    Goto Top

    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 attachment, prior to giving each morphine bolus.

    Check patient BEFORE administering IV morphine bolus:

    Moderate or severe pain OR anticipated pain

    AND

    Sedation Level: awake or easily roused to voice

    AND

    Respiratory rate:>20/min if under 12 months
    >15/min if under 50 kg
    >12/min if over 50 kg

    DO NOT ADMINISTER BOLUS IF PATIENT DOES NOT MEET ALL THESE CRITERIA

    • 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 Intermittent IV morphine bolus attachment and signed 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.

    Goto Top

    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 as per the intermittent IV morphine bolus administration chart.

    Goto Top

    Observations

    The following observations should be recorded on the general observation chart (MR77):

    University of Michigan Sedation Scale (UMSS)

     0Awake and alert
     1Minimally sedated: may appear tired/sleepy, responds to verbal conversation and/or sound 
     2Moderately sedated: somnolent/sleeping, easily aroused with light tactile stimulation or simple verbal command
     3Deep sedation: deep sleep, arousable only with deep or significant physical simulation
     4Unarousable
     SPatient is sleeping
    • 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 (UMSS score of 0 to 2prior to each bolus. 
       
    • Heart rate, respiratory rate, oxygen saturation, pain score & sedation score every 5 minutes during boluses. 
       
    • After the last bolus has been given, two further sets of observations at 5 minute intervals should be completed. 
       
    • The effectiveness of the analgesia should be recorded in the patient's medical record and/or on the general observation chart.

    Goto Top

    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 777 [MET team] if appropriate
    • If apnoeic: administer bag & 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 naloxone per the guidelines on the attachment chart if opioid toxicity is suspected
    • Notify medical team for urgent review

    Goto Top

    First version written June 2002, Updated October 2010