Parenteral Manual

Morphine sulfate

Disclaimer: Official controlled document is the CHEO online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Classification: 
Narcotic analgesic
Original Date: 
August 2005
Revised Date: 
December 2019
Indications: 
  • Symptomatic relief of moderate to severe acute and chronic pain
  • Sedation
Reconstitution and Stability: 
  • Clear, colourless solution. Stable at room temperature, protect from light
  • Diluted solutions of 0.04-0.4 mg/mL in D5W, NS stable 7 days at room temp or in fridge
  • Diluted solutions of 5 mg/mL in NS or D5W stable for 30 days at room temperature
Compatibility: 

- Solutions Compatible: dextrose up to D20W, 0.9% NaCl, dextrose-saline combinations, RS, RL

- Additives/Above Cassette Compatible: atropine, bupivicaine, chlorpromazine, dimenhydrinate, diphenhydramine, fentanyl, glycopyrrolate, hydroxyzine, ketamine, ranitidine, milrinone, midazolam, metoclopramide

- Y-site Compatible: amiodarone, clindamycin, digoxin, dobutamine, dopamine, epinephrine, esmolol, erythromycin, fat emulsion (intralipid),  fluconazole, granisetron, heparin, ketorolac, labetalol, KCl (up to 40 mmol/L), magnesium sulfate, metronidazole, metoclopramide, meropenem, midazolam, nitroglycerin, norepinephrine, propanolol, nitroprusside sodium, ticarcillin, TPN (amino acids/dextrose), vancomycin, zidovudine

Incompatible: acyclovir, azithromycin, phenytoin, meperidine

Administration: 

(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)

SC YES
SC Infusion YES
IM YES
Usual dilution: 0.5-5 mg/mL
IV Direct

YES
Usual dilution: 0.5-5 mg/mL (1 mg/mL preferred)
Infusion time: 4-5 minutes
Infusion rate: do not exceed 3 mg/minute

IV Intermittent Infusion

YES
Usual dilution: 1 mg/mL
Infusion time: 15-30 minutes

IV Continuous Infusion

YES
Standard concentrations: 0.2 mg/mL or 1 mg/mL

Continuous Epidural Infusion   YES, use epidural morphine only, (preservative free)

Click here to access SDC Drug Infusion Sheet

Dosage: 

(For neonatal dosages, refer to Neonatal IV Drug Manual.)

NOTE:     1000 mcg  =  1 mg

Pediatric
- IV/IM/SC:

  • 0.1-0.2 mg/kg/dose Q 2-4 hours PRN.  May initiate at 0.05 mg/kg/dose
  • Maximum: 5 mg/dose

- IV/SC Continuous Infusion:

  • Sickle cell/Cancer pain: Initial dose- 0.03 mg/kg/hour
  • Postoperative pain: 0.01-0.04 mg/kg/hour

- Sedation/Analgesia for Procedures:

  • 0.05-0.1 mg/kg IV 5 minutes before procedure, may repeat x 1 in 15 minutes PRN
  • Adolescents (>12 years): 3-4 mg IV, may repeat in 5 minutes if necessary
  • 0.05-0.2 mg/kg/dose IM 30-60 minutes pre-op

- Epidural (preservative free morphine):

  • 0.03-0.05 mg/kg
  • Maximum: 0.1 mg/kg/dose or 5 mg/24 hours

- NCA

  • Continuous rate: 0.01 - 0.03 mg/kg/hr
  • Bolus dose: 0.02 - 0.05 mg/kg/dose

- PCA

  • Continuous rate: 0.004 - 0.15 mg/kg/hr
  • Bolus dose: 0.02 mg/kg/dose

- Sickle cell PCA

  • Continuous rate: 0.02 - 0.04 mg/kg/hr
  • Bolus dose: 0.02 - 0.04 mg/kg/dose

Adults:
IM/SC:

  • 2.5 - 20 mg/dose Q 2-6 hours PRN         Usual: 10 mg/dose Q4H PRN

IV:

  • 2.5 - 15 mg/dose Q 2 - 6 hours PRN       Usual: 10 mg/dose Q4H PRN

IV/SC Continuous Infusion:

  • 0.8-10 mg/hour, may increase depending on pain relief/adverse effects
  • Usual range: up to 80 mg/hour, although higher doses (e.g. 150 mg/hr) have occasionally been required

Epidural (preservative free morphine):

  • Initial: 5 mg in lumbar region
  • If inadequate pain relief within 1 hour, give 1-2 mg
  • Maximum: 10 mg/24 hours

 

                      MORPHINE CALCULATION

   Morphine 1000 mcg = 1 mg

                 ______________mcg   ÷ 1000 = ____________mg

 

 

 

Potential hazards of parenteral administration: 
  • CNS depression
  • Respiratory and circulatory depression (hypotension).  Antidote: Naloxone (see naloxone monograph)
  • Orthostatic hypotension with rapid IV injection
  • Bradycardia (Antidote: atropine)
  • Increased intracranial pressure
  • Nausea, vomiting, dizziness, constipation, increased biliary pressure (common), urinary retention
  • Pruritus, rash
Notes: 
  • Caution in patients with convulsive disorders, cranial injuries, respiratory insufficiency, cardiac arrhythmias and reduced blood volume
  • Only use preservative free injections for epidural administration

NURSING MONITORING GUIDELINES:

  • Check physician's order against guidelines; question dosage if higher.
  • Safely prepare and administer medication as per Medication Administration Policy.
  • Continuous infusion must be on a pump.
  • 02 and suction must be available at bedside
  • Patient may need to be on a respiratory monitor (or Oximeter) if there are concerns
  • IV solution without the added narcotic must be available at bedside with tubing primed, ready to be hooked to patient in case of an emergency.

 MONITOR:

for first dose- Baseline vital signs including sedation score (level of consciousness), HR,RR,BP, oxygen saturation and pain score

-   10 & 20 minutes after start of IV direct- repeat sedation score,HR,RR,BP,oxygen saturation, and pain score

- Monitor oxygen saturation continuously for 30 minutes post start of IV direct

for subsequent dose(s) -HR, RR, pain score, and oxygen saturation 15 minutes post dose x 1

  • Naloxone must be available in the patient care area as ward stock

-Morphine monitoring for first time dose and subsequent doses is not required in the critical care areas (PICU/NICU) as all patients are continuously monitored and the contextual differences allow for greater patient surveillance.

SIGNS & SYMPTOMS OF COMPLICATIONS:

  • Respiratory depression (RR <10 breaths/minute)
  • Somnolence, difficulty in arousing
  • Orthostatic hypotension with bradycardia
  • Nausea and vomiting
  • Allergic reaction.

ACTIONS:     Notify physician if:

  1. Respiratory rate below 10 breaths per minute
  2. Blood pressure decreased by 25% from baseline
  3. Patient difficult to rouse
  4. Allergic reaction
  • Stop infusion of narcotic and start plain IV solution.  Notify physician.
  • Maintain patient airway and administer O2 as indicated.
  • Contact Pharmacy, Anesthesia, or Poison Information Centre if after hours, for appropriate dose of naloxone (Narcan).

EXAMPLES of RATES for INFUSIONS

Using solution of  Morphine 0.2 mg/mL (200 mcg/mL)

WEIGHT (kg)

Dose ordered:  10 mcg/kg/hr

IV Rate: mL/hr

Dose ordered:  20 mcg/kg/hr

IV Rate: mL/hr

5                   0.25                   0.5
10                   0.5                    1

 

 Using solution of Morphine 1 mg/mL  (1000 mcg/mL)

WEIGHT (kg)

Dose ordered:  10 mcg/kg/hr

IV Rate: mL/hr

Dose ordered:  20 mcg/kg/hr

IV Rate: mL/hr

15                  0.15                  0.3
20                  0.2                  0.4
25                  0.25                  0.5
30                  0.3                  0.6
50                  0.5                  1
70                  0.7                  1.4

 

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