Pain - Oxycodone intermittent IV administration
Intravenous Oxycodone as per protocol must only be commenced and prescribed by the Paediatric Acute Pain Service.
Indications for use
Morphine remains the ‘gold-standard’ opioid at Starship Children’s Hospital. However, in certain circumstances, oxycodone may be considered as an alternative.
Oxycodone is used to relieve moderate to severe pain. It works by altering the way the brain and central nervous system respond to pain. The preferred route of administration is oral because this route is convenient and painless. However, many patients with acute pain may initially require intravenous oxycodone if the oral route is impractical (e.g. vomiting), unavailable, or a rapid response is needed.
Intravenous (IV) oxycodone is preferred over intramuscular or subcutaneous injection as the effect is more rapid and reliable and less traumatic for the patient.
Intravenous oxycodone as per protocol
Intermittent IV oxycodone may only be given as IV oxycodone "as per protocol" on the wards at Starship. This allows small bolus doses of oxycodone to be administered every 5 minutes, making it possible to titrate pain relief whilst observing for adverse effects.
Responsibility
Intravenous oxycodone, administered as per protocol, must only be commenced and prescribed following approval by the Paediatric Acute Pain Service.
Once approved by the Acute Pain Service, IV oxycodone as per protocol can then be managed by the primary team.
Administration
All registered nursing staff that have completed their intravenous administration competency and attended the Paediatric pain study can administer IV oxycodone as per protocol.
The syringe of IV oxycodone as per protocol should be prepared by two registered nurses. A medication additive label should be applied to the syringe with the details of the medicine name, dose, date, time and the two registered nurses signatures.
The first initial dose should be administered with these two registered nurses in attendance, following the Medication Administration Guidelines. All subsequent doses for that shift may be administered by either of the registered nurses that prepared the syringe.
Documentation
Intravenous oxycodone as per protocol will be prescribed on the As Required (PRN) Medicines section on the patient's medication chart. The prescription must have approval from the pain service and should state this with "approved by pain service" documented.
On administration the registered nurse will document on the medication chart the date, time, dose and route. The dose should be documented in mg. The two registered nurses that prepared the syringe should sign the initial dose. All subsequent doses require only the signature of the registered nurse that administered that dose.
Discarding IV oxycodone as per protocol
Any IV oxycodone remaining in the syringe should be discarded by the end of each shift. This should be done by two registered nurses witnessing the discard.
Risks
Side effects will occur more rapidly with IV oxycodone over oral, such as the risk of respiratory depression. The use of a standardised protocol with oxycodone minimises this risk.
Cautions and contraindications
Special considerations should be given to children with an increased risk of respiratory depression before IV oxycodone is administered.
This includes children with:
Neuromuscular disease
Sleep apnoea
Pre-existing respiratory failure
Children receiving other sedating drugs (e.g. benzodiazepines)
Infants less than 6 months have an increased risk of opioid induced respiratory depression. Intravenous oxycodone as per protocol should be administered to these patients with caution and close respiratory monitoring.
Observations
All patients should have baseline observations before administering IV oxycodone as per protocol. The following should also be observed:
Pain level: currently in (or anticipated) moderate to severe pain (assessed using an age appropriate pain assessment tool - see paediatric pain assessment guideline).
Sedation level: awake or easily roused
Respiratory rate:
>30 breaths/min in under 12 months
>20 breaths/min in 12 months to 4 years
>20 breaths/min in 5 to 11 years
>15 breaths/min in over 12 years.
Do not administer IV Oxycodone as per protocol if patient does not meet the above criteria.
All children less than 6 months of age should have continuous pulse oximetry (with consideration for secondary apnoea monitoring in the younger neonate) after administration of IV oxycodone as per protocol.
The period of observation for these patients should be:
Infants < 1 month = 9 hours
Infants > 1 month to 6 months = 4 hours
Ex-premature infants with a post conceptual age less than 60 weeks will require observations until they have a 12 hour "apnoea free" period.
Children over 6 months of age should be closely monitored for signs of respiratory distress with an oximetry and sedation check 10 minutes after administration of IV oxycodone as per protocol dose.
Additional analgesia
Regular paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs e.g. ibuprofen, celecoxib, diclofenac, if not contraindicated) should be administered whilst a child is receiving IV oxycodone as per protocol. If not contraindicated they may also have tramadol. No other opioid (e.g. morphine) should be administered while a patient is receiving IV oxycodone as per protocol.