morphine

Disclaimer to the Online Edition

This Manual has been designed for use in the NICU at London Health Sciences Centre (LHSC), London, Ontario, Canada, and represents clinical practice at this institution. The information contained within the Manual may not be applicable to other centres. If users of this Manual are not familiar with a drug, it is recommended that the official monograph be consulted before it is prescribed and administered. Any user of this information is advised that the contributors, Editor and LHSC are not responsible for any errors or omissions, and / or any consequences arising from the use of the information in this Manual.

morphine

Indication

  • Narcotic analgesic used for pain relief and sedation
  • Management of neonatal opioid withdrawal syndrome (NOWS)

Dosage Guidelines

  • Anglgesia/Sedation: Titrate to response or side effects

    50-200 microgram/kg/dose IV/IM/SUBCUT/rectal 

    200-500 microgram/kg/dose ORAL q4 hours prn

    5-20 microgram/kg/hr IV continuous infusion 

  • Neonatal Opioid Withdrawal Syndrome (follow NOWS algorithm and maximize non-pharmacologic interventions first) 

    May consider a one-time dose of 50 microgram/kg to settle infant on admission. If additional doses are needed, order 50 microgram/kg/dose q4 hours PRN. If 3 doses are needed in a 24-hour period, switch to standing doses (50-100 microcgram/kg/dose q4 hours).

    Weaning is based on clinical symptoms and success in the ESC framework. Wean by 10-15% q48 hours as tolerated.

Administration

  1. ORAL
  2. IV direct over 3-5 minutes

  3. IV continuous infusion

    For patients 2 kg or less: Use morphine [0.04 mg/mL]

    To make 25 mL of morphine [0.04 mg/mL] [1 mg/25 mL] solution:

    1) Add 0.5 mL (1 mg) of morphine [2 mg/mL] to 24.5 mL of solution

    For patients over 2 kg to 4 kg: Use morphine [0.08 mg/mL]

    To make 25 mL of morphine [0.08 mg/mL] [2 mg/ 25 mL] solution:

    1) Add 1 mL (2 mg) of morphine [2 mg/mL] to 24 mL of solution

    For patients over 4 kg to 10 kg: Use morphine [0.2 mg/mL]

    To make 25 mL of morphine [0.2 mg/mL] [5 mg/25 mL] solution:

    1) Add 2.5 mL (5 mg) of morphine [2 mg/mL] to 22.5 mL of solution

Side Effects

  • Decreased gastric emptying, constipation, nausea, vomiting, urinary retention, narcotic dependence
  • Dose dependent effects: respiratory and CNS depression, bradycardia, hypotension, miosis

Comments

  • IV onset: within 10 minutes.  Half-life is 10 to 20 hours in preterm infants
  • When converting from IV to oral dosing, the total daily dose of IV morphine should be multiplied by 2-3 due to the decreased bioavailability of oral morphine
  • Monitor cardiovascular and respiratory status, abdominal distention or loss of bowel sounds, level of sedation, NPASS score as per protocol
  • Taper dose after prolonged use to prevent withdrawal

Supplied As

  • 1 mg/mL oral syrup (0.25 mL and 0.5 mL)
  • 2 mg/mL ampoule for injection

  • Nurse to prepare syringes based on patient weight

    For patients 2 kg or less: morphine [0.04 mg/mL]

    For patients over 2 kg to 4 kg: morphine [0.08 mg/mL]

    For patients over 4 kg to 10 kg: morphine [0.2 mg/mL]

  • At LHSC, standard concentration reference charts are available on the NICU Intranet site

References

LexiComp Sick Kids, LexiComp Pediatric and Neonatal