Morphine Sulfate
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morphine sulfate (mor' feen) Immediate-release tablets:
MSIR Timed-release:
Kadian, M-Eslon (CAN), MS Contin, Oramorph SR Oral solution:
MSIR, Rescudose, Roxanol, Roxanol T Rectal suppositories:
RMS Injection:
Astramorph PF, Duramorph, Epimorph (CAN) Preservative-free concentrate for microinfusion devices for intraspinal use:
Infumorph Pregnancy Category C Controlled Substance C-II Drug class
Opioid agonist analgesic Therapeutic actions
Principal opium alkaloid; acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same as those mediating the effects of endogenous opioids (enkephalins, endorphins). Indications
• • • • • •
Relief of moderate to severe acute and chronic pain Preoperative medication to sedate and allay apprehension, facilitate induction of anesthesia, and reduce anesthetic dosage Analgesic adjunct during anesthesia Component of most preparations that are referred to as Brompton's cocktail or mixture, an oral alcoholic solution that is used for chronic severe pain, especially in terminal cancer patients Intraspinal use with microinfusion devices for the relief of intractable pain Unlabeled use: Dyspnea associated with acute left ventricular failure and pulmonary edema
Contraindications and cautions
•
Contraindicated with hypersensitivity to opioids; diarrhea caused by poisoning until toxins are eliminated; during labor or delivery of a premature infant (may cross immature blood–brain barrier more readily); after biliary tract surgery or following surgical anastomosis; pregnancy; labor (respiratory depression in neonate; may prolong labor).
•
Use cautiously with head injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale, preexisting respiratory depression, hypoxia, hypercapnia (may decrease respiratory drive and increase airway resistance); lactation (wait 4– 6 hr after administration to nurse the baby); acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, renal or hepatic dysfunction.
Available forms
Injection—0.5, 1, 2, 4, 5, 8, 10, 15, 25, 50 mg/mL; tablets—15, 30 mg; CR tablets—15, 60, 100, 200 mg; ER tablets—30, 60, 100 mg; soluble tablets—10, 15, 30 mg; oral solution—10, 20, 100 mg/5 mL; concentrated oral solution—20 mg/mL, 100 mg/5 mL; suppositories—5, 10, 20, 30 mg; capsules—15, 30 mg; SR capsules—20, 30, 50, 60, 100 mg Dosages ADULTS Oral
One-third to one-sixth as effective as parenteral administration because of first-pass metabolism; 10–30 mg q 4 hr PO. Controlled-release: 30 mg q 8–12 hr PO or as directed by physician; Kadian: 20–100 mg PO daily–24-hr release system; MS Contin: 200 mg PO q 12 hr. SC and IM
10 mg (5–20 mg)/70 kg q 4 hr or as directed by physician. IV
2.5–15 mg/70 kg of body weight in 4–5 mL water for injection administered over 4–5 min, or as directed by physician. Continuous IV infusion: 0.1–1 mg/mL in 5% dextrose in water by controlled infusion device. Rectal
10–30 mg q 4 hr or as directed by physician. Epidural
Initial injection of 5 mg in the lumbar region may provide pain relief for up to 24 hr. If adequate pain relief is not achieved within 1 hr, incremental doses of 1–2 mg may be given at intervals sufficient to assess effectiveness, up to 10 mg/24 hr. For continuous infusion, initial dose of 2–4 mg/24 hr is recommended. Further doses of 1–2 mg may be given if pain relief is not achieved initially. Intrathecal
Dosage is usually one-tenth that of epidural dosage; a single injection of 0.2–1 mg may provide satisfactory pain relief for up to 24 hr. Do not inject > 2 mL of the 5 mg/10 mL ampule or > 1 mL of the 10 mg/10 mL ampule. Use only in the lumbar area. Repeated intrathecal injections are not recommended; use other routes if pain recurs. For epidural or intrathecal dosing, use preservative-free morphine preparations only. PEDIATRIC PATIENTS
Do not use in premature infants. SC or IM
0.05–0.2 mg/kg (up to 15 mg per dose) q 4 hr or as directed by physician.
GERIATRIC PATIENTS OR IMPAIRED ADULTS
Use caution. Respiratory depression may occur in the elderly, the very ill, those with respiratory problems. Reduced dosage may be necessary. Epidural
Use extreme caution; injection of < 5 mg in the lumbar region may provide adequate pain relief for up to 24 hr. Intrathecal
Use lower dosages than recommended for adults above. Pharmacokinetics Route Oral TPR SC IM IV
Onset Varies Rapid Rapid Rapid Immediate
Peak 60 min 20–60 min 50–90 min 30–60 min 20 min
Duration 5–7 hr 5–7 hr 5–7 hr 5–6 hr 5–6 hr
Metabolism: Hepatic; T1/2: 1.5–2 hr Distribution: Crosses placenta; enters breast milk Excretion: Urine and bile IV facts
Preparation: No further preparation needed for direct injection; prepare infusion by adding 0.1–1 mg/mL to 5% dextrose in water. Infusion: Inject slowly directly IV or into tubing of running IV, each 15 mg over 4–5 min; monitor by controlled infusion device to maintain pain control. Incompatibilities: Do not mix with aminophylline, amobarbital, chlorothiazide, heparin, meperidine, phenobarbital, phenytoin, sodium bicarbonate, sodium iodide, thiopental. Y-site incompatibilities: Do not give with minocycline, tetracycline. Adverse effects
•
• • • • • •
CNS: Light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, drowsiness, lethargy, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, seizures, miosis, visual disturbances, suppression of cough reflex CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, chest wall rigidity, hypertension, hypotension, orthostatic hypotension, syncope Dermatologic: Pruritus, urticaria, laryngospasm, bronchospasm, edema GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm; increased colonic motility in patients with chronic ulcerative colitis GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria, antidiuretic effect, reduced libido or potency Local: Tissue irritation and induration (SC injection) Major hazards: Respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest
•
Other: Sweating, physical tolerance and dependence, psychological dependence
Interactions
Drug-drug • Increased likelihood of respiratory depression, hypotension, profound sedation or coma in patients receiving barbiturate general anesthetics Drug-lab test • Elevated biliary tract pressure (an effect of opioids) may cause increases in plasma amylase, lipase; determinations of these levels may be unreliable for 24 hr Nursing considerations Assessment
•
•
History: Hypersensitivity to opioids; diarrhea caused by poisoning; labor or delivery of a premature infant; biliary tract surgery or surgical anastomosis; head injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale, preexisting respiratory depression; acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, renal or hepatic dysfunction; pregnancy; lactation Physical: T; skin color, texture, lesions; orientation, reflexes, bilateral grip strength, affect; P, auscultation, BP, orthostatic BP, perfusion; R, adventitious sounds; bowel sounds, normal output; urinary frequency, voiding pattern, normal output; ECG; EEG; thyroid, liver, kidney function tests
Interventions
• • • • • •
Caution patient not to chew or crush controlled-release preparations. Dilute and administer slowly IV to minimize likelihood of adverse effects. Tell patient to lie down during IV administration. Keep opioid antagonist and facilities for assisted or controlled respiration readily available during IV administration. Use caution when injecting SC or IM into chilled areas or in patients with hypotension or in shock; impaired perfusion may delay absorption; with repeated doses, an excessive amount may be absorbed when circulation is restored. Reassure patients that they are unlikely to become addicted; most patients who receive opioids for medical reasons do not develop dependence syndromes.
Teaching points
• • •
Take this drug exactly as prescribed. Avoid alcohol, antihistamines, sedatives, tranquilizers, over-the-counter drugs. Swallow controlled-release preparation (MS Contin, Oramorph SR) whole; do not cut, crush, or chew them. Do not take leftover medication for other disorders, and do not let anyone else take your prescription.
•
•
These side effects may occur: Nausea, loss of appetite (take with food, lie quietly); constipation (use laxative); dizziness, sedation, drowsiness, impaired visual acuity (avoid driving or performing tasks that require alertness and visual acuity). Report severe nausea, vomiting, constipation, shortness of breath or difficulty breathing, rash.
Adverse effects in Italic are most common; those in Bold are life-threatening.
MSIR Timed-release:
Kadian, M-Eslon (CAN), MS Contin, Oramorph SR Oral solution:
MSIR, Rescudose, Roxanol, Roxanol T Rectal suppositories:
RMS Injection:
Astramorph PF, Duramorph, Epimorph (CAN) Preservative-free concentrate for microinfusion devices for intraspinal use:
Infumorph Pregnancy Category C Controlled Substance C-II Drug class
Opioid agonist analgesic Therapeutic actions
Principal opium alkaloid; acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same as those mediating the effects of endogenous opioids (enkephalins, endorphins). Indications
• • • • • •
Relief of moderate to severe acute and chronic pain Preoperative medication to sedate and allay apprehension, facilitate induction of anesthesia, and reduce anesthetic dosage Analgesic adjunct during anesthesia Component of most preparations that are referred to as Brompton's cocktail or mixture, an oral alcoholic solution that is used for chronic severe pain, especially in terminal cancer patients Intraspinal use with microinfusion devices for the relief of intractable pain Unlabeled use: Dyspnea associated with acute left ventricular failure and pulmonary edema
Contraindications and cautions
•
Contraindicated with hypersensitivity to opioids; diarrhea caused by poisoning until toxins are eliminated; during labor or delivery of a premature infant (may cross immature blood–brain barrier more readily); after biliary tract surgery or following surgical anastomosis; pregnancy; labor (respiratory depression in neonate; may prolong labor).
•
Use cautiously with head injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale, preexisting respiratory depression, hypoxia, hypercapnia (may decrease respiratory drive and increase airway resistance); lactation (wait 4– 6 hr after administration to nurse the baby); acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, renal or hepatic dysfunction.
Available forms
Injection—0.5, 1, 2, 4, 5, 8, 10, 15, 25, 50 mg/mL; tablets—15, 30 mg; CR tablets—15, 60, 100, 200 mg; ER tablets—30, 60, 100 mg; soluble tablets—10, 15, 30 mg; oral solution—10, 20, 100 mg/5 mL; concentrated oral solution—20 mg/mL, 100 mg/5 mL; suppositories—5, 10, 20, 30 mg; capsules—15, 30 mg; SR capsules—20, 30, 50, 60, 100 mg Dosages ADULTS Oral
One-third to one-sixth as effective as parenteral administration because of first-pass metabolism; 10–30 mg q 4 hr PO. Controlled-release: 30 mg q 8–12 hr PO or as directed by physician; Kadian: 20–100 mg PO daily–24-hr release system; MS Contin: 200 mg PO q 12 hr. SC and IM
10 mg (5–20 mg)/70 kg q 4 hr or as directed by physician. IV
2.5–15 mg/70 kg of body weight in 4–5 mL water for injection administered over 4–5 min, or as directed by physician. Continuous IV infusion: 0.1–1 mg/mL in 5% dextrose in water by controlled infusion device. Rectal
10–30 mg q 4 hr or as directed by physician. Epidural
Initial injection of 5 mg in the lumbar region may provide pain relief for up to 24 hr. If adequate pain relief is not achieved within 1 hr, incremental doses of 1–2 mg may be given at intervals sufficient to assess effectiveness, up to 10 mg/24 hr. For continuous infusion, initial dose of 2–4 mg/24 hr is recommended. Further doses of 1–2 mg may be given if pain relief is not achieved initially. Intrathecal
Dosage is usually one-tenth that of epidural dosage; a single injection of 0.2–1 mg may provide satisfactory pain relief for up to 24 hr. Do not inject > 2 mL of the 5 mg/10 mL ampule or > 1 mL of the 10 mg/10 mL ampule. Use only in the lumbar area. Repeated intrathecal injections are not recommended; use other routes if pain recurs. For epidural or intrathecal dosing, use preservative-free morphine preparations only. PEDIATRIC PATIENTS
Do not use in premature infants. SC or IM
0.05–0.2 mg/kg (up to 15 mg per dose) q 4 hr or as directed by physician.
GERIATRIC PATIENTS OR IMPAIRED ADULTS
Use caution. Respiratory depression may occur in the elderly, the very ill, those with respiratory problems. Reduced dosage may be necessary. Epidural
Use extreme caution; injection of < 5 mg in the lumbar region may provide adequate pain relief for up to 24 hr. Intrathecal
Use lower dosages than recommended for adults above. Pharmacokinetics Route Oral TPR SC IM IV
Onset Varies Rapid Rapid Rapid Immediate
Peak 60 min 20–60 min 50–90 min 30–60 min 20 min
Duration 5–7 hr 5–7 hr 5–7 hr 5–6 hr 5–6 hr
Metabolism: Hepatic; T1/2: 1.5–2 hr Distribution: Crosses placenta; enters breast milk Excretion: Urine and bile IV facts
Preparation: No further preparation needed for direct injection; prepare infusion by adding 0.1–1 mg/mL to 5% dextrose in water. Infusion: Inject slowly directly IV or into tubing of running IV, each 15 mg over 4–5 min; monitor by controlled infusion device to maintain pain control. Incompatibilities: Do not mix with aminophylline, amobarbital, chlorothiazide, heparin, meperidine, phenobarbital, phenytoin, sodium bicarbonate, sodium iodide, thiopental. Y-site incompatibilities: Do not give with minocycline, tetracycline. Adverse effects
•
• • • • • •
CNS: Light-headedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, drowsiness, lethargy, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, seizures, miosis, visual disturbances, suppression of cough reflex CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, chest wall rigidity, hypertension, hypotension, orthostatic hypotension, syncope Dermatologic: Pruritus, urticaria, laryngospasm, bronchospasm, edema GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm; increased colonic motility in patients with chronic ulcerative colitis GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria, antidiuretic effect, reduced libido or potency Local: Tissue irritation and induration (SC injection) Major hazards: Respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest
•
Other: Sweating, physical tolerance and dependence, psychological dependence
Interactions
Drug-drug • Increased likelihood of respiratory depression, hypotension, profound sedation or coma in patients receiving barbiturate general anesthetics Drug-lab test • Elevated biliary tract pressure (an effect of opioids) may cause increases in plasma amylase, lipase; determinations of these levels may be unreliable for 24 hr Nursing considerations Assessment
•
•
History: Hypersensitivity to opioids; diarrhea caused by poisoning; labor or delivery of a premature infant; biliary tract surgery or surgical anastomosis; head injury and increased intracranial pressure; acute asthma, COPD, cor pulmonale, preexisting respiratory depression; acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, seizure disorders, acute alcoholism, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, kyphoscoliosis, Addison's disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, renal or hepatic dysfunction; pregnancy; lactation Physical: T; skin color, texture, lesions; orientation, reflexes, bilateral grip strength, affect; P, auscultation, BP, orthostatic BP, perfusion; R, adventitious sounds; bowel sounds, normal output; urinary frequency, voiding pattern, normal output; ECG; EEG; thyroid, liver, kidney function tests
Interventions
• • • • • •
Caution patient not to chew or crush controlled-release preparations. Dilute and administer slowly IV to minimize likelihood of adverse effects. Tell patient to lie down during IV administration. Keep opioid antagonist and facilities for assisted or controlled respiration readily available during IV administration. Use caution when injecting SC or IM into chilled areas or in patients with hypotension or in shock; impaired perfusion may delay absorption; with repeated doses, an excessive amount may be absorbed when circulation is restored. Reassure patients that they are unlikely to become addicted; most patients who receive opioids for medical reasons do not develop dependence syndromes.
Teaching points
• • •
Take this drug exactly as prescribed. Avoid alcohol, antihistamines, sedatives, tranquilizers, over-the-counter drugs. Swallow controlled-release preparation (MS Contin, Oramorph SR) whole; do not cut, crush, or chew them. Do not take leftover medication for other disorders, and do not let anyone else take your prescription.
•
•
These side effects may occur: Nausea, loss of appetite (take with food, lie quietly); constipation (use laxative); dizziness, sedation, drowsiness, impaired visual acuity (avoid driving or performing tasks that require alertness and visual acuity). Report severe nausea, vomiting, constipation, shortness of breath or difficulty breathing, rash.
Adverse effects in Italic are most common; those in Bold are life-threatening.
