GUIDELINES FOR NURSE CONTROLLED AND PATIENT

CONTROLLED ANALGESIA
MORPHINE INFUSION
PATIENT CONTROLLED ANALGESIA
PCA STANDARD INFUSION Children aged ≥ 8years, Weight >5kg to 50kg Children weight ≥ 50kg

Opioid Dilution 1mg/kg Morphine made up to a total of 50 ml in 50mg Morphine made up to a total of 50ml in
Sodium Chloride 0.9% or 5% Glucose Sodium Chloride 0.9% or 5% Glucose

Concentration 20 microgram/kg/ml 1mg/ml

Loading Dose 50 or 100microgram/kg** (2.5 or 5ml) 50 or 100microgram/kg** (max 5mg) (2.5 or 5ml)
Zero, 0.2, 0.5, 1ml/hr Zero, 0.2, 0.5 or 1ml/hr
Background Infusion (Zero, 4, 10, or 20 microgram/kg) (Zero , 0.2mg, 0.5mg or 1mg/hr)
Criteria for increasing Need for 3 or more PCA boli in 2 consecutive Need for 3 or more PCA boli in 2 consecutive hours
background infusion hours, and sedation level <2 and sedation level <2
10 or 20 microgram/kg
Bolus Dose (0.5 or 1ml)
1 or 2ml ( 1mg or 2mg)

PCA Bolus time 2 to 5 minutes 2 to 5minutes

Lockout time 5 to 10 minutes 5 to 10 minutes

Maximum 4 hourly Dose 400 microgram/kg (20ml) 20mgs (20ml)

NURSE CONTROLLED ANALGESIA

NCA STANDARD Neonates & Infants <5KG* Children> 5kg to 49kg Children >50kg
INFUSION

Opioid Dilution 0.5mg/kg Morphine made up to 1mg/kg Morphine made up to 50mg Morphine made up to total
total of 50 ml in glucose 5% or total 50 ml in Sodium chloride 0.9% 50ml in Sodium chloride 0.9% or
Sodium chloride 0.9% or Glucose 5 % Glucose 5 %

Concentration 10microgram/kg/ml 20microgram/kg/ml 1mg/ml

Loading Dose 20-100microgram/kg** 50 or 100microgram/kg** 50 or 100microgram/kg** (max

Max dose 100microgram/kg (2.5 to 5ml) 5mg) (2.5 or 5ml)
Zero, 0.5 or 1ml/hr 0.2, 0.5, 1ml/hr Zero, 0.5 or 1ml/hr
Background Infusion (4, 10, or 20 microgram/kg) (Zero, 0.5mg or 1mg/hr)
(0 , 5 or 10 microgram/kg/hr)
Criteria for increasing Need for 3 or more NCA boli in 2 Need for 3 or more NCA boli in 2 Need for 3 or more NCA boli in 2
background infusion consecutive hours and sedation consecutive hours and sedation consecutive hours and sedation
level <2 level <2 level <2
Bolus Dose 0.5 to 1ml 0.5 to 1ml 1 or 2ml
(5 to 10microgram/kg) (10 or 20 microgram/kg ) ( 1 or 2mg)

NCA Bolus time 2 to 5 minutes 2 to 5minutes 2 to 5minutes

Lockout time 20 minutes 15 or 20 minutes 15 or 20 minutes

Maximum 4 hour dose 200 microgram/kg (20ml) 400 microgram/kg (20ml) 20mg (20ml)

*Babies (birth-12 weeks) undergoing multiple surgeries may require more morphine than their age suggests
** Administered over 5mins with Respiratory & SaO2 monitoring if not already given in theatre.
NB: This guide is intended for use in children who are opioid naïve. Children who have been on oral or IV opioids including
opioid transdermal patch or children with conditions associated with severe pain, (major surgery, sickle cell disease, cancer,
and severe burn injury) may have higher opioid requirements.
Infusion rates higher than this guideline is at the discretion of the Pain service, consultant anaesthetist, Consultant PICU.
• Paracetamol, NSAID and Clonidine can be given along with IV opioids if there are no contraindications.
• An Anti-emetic should be prescribed for patients receiving opioid infusions.
• An Antihistamine or Low dose Naloxone can be given to treat opioid induced Itch.
When pain is not controlled, seek support from CNS Acute Pain, bleep 8300 or Anaesthetist on call, bleep 8528.

CNS Acute Pain. 1/7/15.

 GUIDELINES FOR NURSE CONTROLLED AND PATIENT
CONTROLLED ANALGESIA
MORPHINE INFUSION

General Instructions
• No supplementary opiates unless ordered by the Anaesthetist, palliative care or Pain service
• Line for IV opiates should be exclusive or an anti-reflux valve ( protect-a-line 2) must be used
• Maintain IV access during pain management.
• Treatment of:
• Inadequate analgesia Call Pain service on bleep 8300 or 8528 out of hours
• Nausea and Vomiting Antiemetic’s, Ondansetron as prescribed
• Itching Anti-histamine or low dose naloxone
• Over Sedation ≥ 3 See sedation scale
• Respiratory depression Stimulate child, give oxygen, stop infusion, call medical team /anaesthetist.
Give naloxone 2 microgram/kg IV prn. Repeat every 1-2 minutes (max 5 doses)
• Resuscitation: (minimal respirations, sedation score ≥4, cardiorespiratory arrest):
Naloxone: 10 microgram/kg IV PRN. Repeat every 1-2minutes (maximum
200microgram or 5 doses) N .B. Naloxone has a relatively short half-life
respiratory rate may drop again even though infusion has been stopped.
• Urinary retention Naloxone low dose > 1month: 1microgram/kg stat (max daily dose 200microgram).
If this fails insert urinary catheter

Sedation
Sedation score > 3 (University of Michigan Sedation Scale BJA, 2002; 88(2): 241-5
Sedation score > 3 (University of Michigan Sedation Scale BJA, 2002; 88(2): 241-5
 0 = Awake and alert
 1 = Minimally sedated ("drowsy” may appear tired/sleepy, responds to verbal conversation and/or sounds)
 2 = Moderately Sedated (sleepy, moves spontaneously, easily aroused to stimulation or verbal command)
 3= Deep sedation (deeply asleep, arousable only with deep or significant physical stimulation).
o Stop infusion until level returns to 2.
 4 =Unrousable to stimulation. Stop infusion, stimulate patient, administer oxygen, Call 2222
 S= patient sleeping

Analgesic Interventions
0: No Pain
1-3: Mild Pain NCA: Give bolus 10 minutes before activity. PCA: encourage bolus 10 minutes before activity
4-6: Moderate Pain NCA: Give Bolus. PCA: encourage bolus
7-10: Severe Pain NCA or PCA: Pain uncontrolled with 3 boli/hr & adjunctive analgesia. Contact Pain Service

Nausea and Vomiting ITCH

0: No vomit 0: No Itch
1: Nausea 1: slight
2: Vomit 2: Moderate
3: Vomit more than 3 in last hour 3: Severe

Sample prescription child weight 35kg

PCA Morphine 35mgs made up to total of 50mls in Glucose 5%
1ml=700microgram (20microgram/kg/ml) 35x1000÷50=700
PCA: 1ml (20microgram/kg)
Lockout 6 to 12 minutes
Continuous infusion: zero to 1ml/hr. Start at: 0.2ml/hr (4microgram/kg/hr)
Maximum 4 hourly dose: 400microgram/kg 20mls

CNS Acute Pain. 1/7/15.