Mosby's 2014 Nursing Drug Reference (276 page)

• Adult ≥50 kg:
Initially, 10–30 mg every 3–4 hr as needed

• Adult <50 kg/geriatric patients:
Might require lower doses and/or extended dosing intervals; doses should be titrated carefully

• Child/infant ≥6 mo:
0.2–0.5 mg/kg every 4–6 hr as needed

• Infants <6 mo/neonate:
PO
0.1 mg/kg every 3–4 hr

• Adult ≥50 kg:
2.5–15 mg every 2–6 hr as needed, titrate; or a loading dose of 0.05–0.1 mg/kg IV, followed by 0.8–10 mg/hr IV, titrate

• Adult <50 kg/geriatric patients:
Might require lower doses and/or extended dosing intervals 0.1 mg/kg every 3–4 hr, titrate

• Child/infant ≥6 mo:
0.05–0.2 mg/kg every 2–4 hr, titrate to relief; max initial dose 15 mg/dose

• Infants <6 mo/neonate:
0.03–0.05 mg/kg every 3–8 hr, titrate to relief

• Adult:
Initially, 5 mg in the lumbar region; if pain relief does not occur in 1 hr, give 1–2 mg epidurally; max 10 mg/24
hr;
continuous epidural infusion
2–4 mg/24 hr; may give another 1–2 mg

• 
Do not inject >2 ml of the 0.5 mg/ml or 1 ml of the 1 mg/ml ampule

• Adult:
0.2–1 mg in the lumbar area as a single dose or to establish dosage for continuous intrathecal infusion; repeated injections are not recommended

• Adult:
PR
10–20 mg every 4 hr, as needed

• Child:
Individualize

• Adult:
15–30 mg every 12 hr (tabs); 10 mg bid or 20 mg every day (Kadian); or 30 mg every day (AVINza), titrate; AVINza should be adjusted in increments ≤30 mg every 4 days; Kadian should be increased ≤20 mg every 1–2 days, taper gradually; to discontinue, gradually decrease AVINza and Kadian every 2–4 days

• Child (unlabeled):
0.3–0.6 mg/kg every 12 hr (tabs)

• Adult:
IV
2–10 mg loading dose, then 0.8–10 mg/hour IV, titrate; maintenance 0.8–80 mg/hour IV

• Children/infants ≥6 mo:
IV
Initially, 0.04–0.07 mg/kg/hr (range: 0.025–2.6 mg/kg/hr)

• Infants <6 mo/neonate:
IV
0.01 mg/kg/hour initially; infusion rates max 0.015–0.02 mg/kg/hour IV

• Adult/child:
The dose is usually 1/4 to 1/3 the 8- to 12-hour extended-release dose every 4–6 hr as needed

• Adult/child:
For PCA, intermittent dosage is usually 25%–30% of the hourly rate IV/SC every 6–15 min as needed; intermittent IV injection dosage is 25%–30% of the hourly rate given IV/SC every 1–2 hr as needed

• 
Give with food or milk to minimize GI effects

• 
Begin with immediate-release products and titrate to correct dose and convert to a sustained-release product

• 
Immediate-release cap:
May swallow whole, or cap may be opened and contents sprinkled on cool food (pudding or applesauce) or added to juice; give immediately or delivered via gastric or NG tube by either adding to or following with liquid

• 
Extended-release and controlled-release tabs:
Swallow whole; do not crush, break, dissolve, or chew

• 
The use of MS Contin 100 mg or 200 mg tabs should be limited to opioid-tolerant patients requiring oral doses equivalent to ≥200 mg/day; use of the 100 mg or 200 mg tablet is only recommended for patients who have already been titrated to a stable analgesic regimen using lower strengths of MS Contin or other opioids

• 
Sustained-release caps:
Swallow; do not chew, crush, or dissolve; caps may be opened and contents sprinkled on applesauce (at room temperature or cooler) immediately before ingestion; do not chew, crush, or dissolve the pellets/beads inside the cap; the applesauce should be swallowed without chewing; if the pellets/beads are chewed, an immediate release of a potentially fatal morphine dose may be delivered; rinse mouth to ensure all the pellets/beads have been swallowed; do not separate applesauce into separate doses; the entire portion should be taken; discard unused portion

• 
Kadian caps:
may be given through a 16-F gastrostomy tube; flush with water, and sprinkle the cap contents into 10 ml of water; using a funnel and a swirling motion, pour the pellets and water into the tube; rinse the beaker with 10 ml of water, and pour the water into the funnel; repeat until no pellets remain in the beaker.
Do not administer AVINza tabs through a gastrostomy tube;
do not
administer Kadian or AVINza through a nasogastric tube

• 
Avoid concurrent administration of AVINza with prescription or nonprescription medications that contain alcohol; Consumption of alcohol while taking the extended-release capsules can result in the rapid release and absorption of a potentially fatal dose of morphine

• 
AVINza ≥90 mg or Kadian 100 mg, 130 mg, 150 mg, or 200 mg caps are given only to opioid-tolerant patients

• 
Check dose before use because many concentrations of oral solution are available; may be diluted in fruit juice, protect from light

• 
Visually inspect for particulate matter, discoloration before use, do not use if a precipitate is present after shaking, do not use the Duramorph solution if a precipitate is present or if the color is darker than pale yellow

• 
Inject, taking care not to inject intradermally

• 
Continuous SC infusion
Morphine is not approved by the FDA for subcut use; dilute to an appropriate concentration in D
₅
W, give using a portable, controlled, subcut device; adjust rate based on patient response and tolerance; max subcut rate is 2 ml/hour/site

 
Morphine sulfate injection is not interchangeable with morphine sulfate extended-release liposome injection (DepoDur); DepoDur is only for epidural administration

 
Do not use Infumorph (10 mg/ml or 25 mg/ml) for single-dose neuraxial injection because lower doses can be more reliably administered with Duramorph (0.5 mg/ml or 1 mg/ml

• 
Moisten the suppository with water before insertion; if suppository is too soft, chill in the refrigerator for 30 min or run cold water over it before removing the wrapper

• 
Before use, an opiate antagonist and emergency facilities should be available

 
Do not use the highly concentrated morphine injections (i.e., 10–25 mg/ml) for IV, IM, or SC administration of single doses; these injection solutions are intended for use via continuous, controlled microinfusion devices

• 
Direct IV route
Dilute dose with ≥5 ml of sterile water for injection or NS injection; inject 2.5–15 mg directly into a vein or into the tubing of a freely flowing IV solution over 4–5 min, do not give rapidly

• 
Continuous IV infusion
Dilute in 5% dextrose, use a controlled-infusion device; adjust dosage and rate based on patient response

• 
Patient-controlled analgesia (PCA)
A compatible patient-controlled infusion device must be used; dilute solutions to obtain a concentration of 1 or 10 mg/ml for ease in calculations and programming of PCA pumps; adjust dosage and rate based on patient response; consult the patient-controlled infusion device manual for directions on rate of infusion