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Definition of Terms
Opioid analgesia is indicated for the treatment of moderate to severe pain. An opioid is a medication that relieves pain by binding to opioid receptors in the central nervous system spinal cord and peripheral nervous system. This guideline does not cover opioid delivery via patient controlled analgesia (PCA) delivery.
To provide medical and nursing staff at the Royal Children’s Hospital with a clear outline for assessment and management of a patient receiving opioids as an inpatient, including administration and adverse events associated with administration.
There are three main types of opioid receptors, these receptors have multiple actions:
Mu (m) receptors are primarily responsible for analgesia and side effects of opioids and are associated with analgesia and side effects (Table 1). Side effects occur regardless of which opioid is used and are generally dose related. Mu receptors subtyped: mu-1 & mu-2
Delta (d) receptors are involved with modulation of mu receptors. Primarily responsible for spinal analgesia
Kappa (k) receptors are associated with miosis, spinal analgesia and sedation
Opioids are metabolised in the liver and excreted via the kidneys. Morphine is the most commonly used opioid of choice, and has two main metabolites M3G and M6G. M3G (morphine -3 glucuronide) has no analgesic action, but can cause neurotoxic effects such as tremor and myoclonus. M6G (morphine – 6 – glucuronide) is a powerful analgesic.
Table 1: Side effects of opioids
*Fentanyl primarily on the face, Morphine generalised
**Acute effect of IV fentanyl
Table 2: List of opioid medications
Regular observations (Table 3) of patients are indicated during the time a patient receives an opioid infusion to monitor the efficacy of pain management.
Pain assessment and measurement as per the clinical nursing guideline, and to recognise and prevent adverse effects such as sedation and respiratory depression. More frequent observations should be undertaken in patients receiving an administration of an opioid bolus. Patients receiving opioid infusions in the high risk category (Table 3) are ideally admitted to a room that supports line of sight by nursing staff (e.g. close to the central desk in each pod). Patients in Table 5 require continuous pulse oximetry while for the duration of their opioid infusion due to their high risk of an adverse event. Effectiveness of the analgesia and any bolus administration should be recorded in the patient’s EMR progress notes
Table 3: Observations required for documentation for a patient receiving an opioid infusion
Table 4: Observations required for documentation for a patient following administration of a bolus
Table 5: Patients considered at high risk of an adverse event
Table 6: Criteria for post-operative monitoring in intensive care
Who are undergoing a surgical procedure and are likely to require a
narcotic infusion or oral opioid in the post-operative period, are at high risk
for apnoea and deterioration on the wards. This can occur because of the
combination of anaesthesia, opioid analgesia, pain and diaphragm splinting,
fluid overload, and late identification of under-ventilation. These
infants should be monitored in PICU for the first 24 hours, then when stable
returned to the ward. Monitor these infants with oximetry, respiratory rate
monitoring, no oxygen unless hypoxaemic, and monitor analgesia requirements and
A continuous opioid infusion can provide continuous analgesia without the peaks and troughs of intermittent bolus only administration
Table 7: Intravenous preparation of opioids for infusion
0.5mg/kg in 50mL 0.9% saline or 5% dextrose
Initial bolus 5mL (50mcg/kg) PRN
For pain or painful procedures 1-2 mL (10-20mcg/kg) at intervals no less than 10 minutes
15 mcg/kg in 50mL 0.9% saline or 5% dextrose
Initial bolus 2mL (0.6mcg/kg)
No initial bolus
Initial bolus 5mL (50mcg/kg)
4mg/kg in 50mL 0.9% saline or 5% dextrose
Patient receiving an opioid infusion may be at risk of adverse effects including pruritus, urinary retention, and respiratory depression or over sedation. The treatment of intolerable opioid side effects is the opioid antagonist naloxone. The half-life of Naloxone is 30-60 minutes, therefore if a patient is given Naloxone for sedation or respiratory depression they must be monitored for 4 hours. Naloxone is available in the ward impress drug cupboard and on the ward resuscitation trolley.
Table 8: Naloxone doses for side effects
Figure 1: Response to over sedation or respiratory depression events
Evidence table for the Management of the paediatric patient receiving opioids nursing guideline.
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read the disclaimer.
The development of this nursing guideline was coordinated by Grace Larson, CNC, Rosella, approved by the Nursing Clinical Effectiveness Committee. Published December 2018.