Morphine and Lorazepam Tapering Guidelines in the NICU

[Pages:4]Morphine and Lorazepam Tapering Guidelines in the NICU

University of Iowa Children's Hospital

Morphine/Lorazepam Use

Morphine use < 3 days

No taper necessary.

No withdrawal expected.

Morphine use 4-7 days

Morphine use 8?29 days

Morphine use 30 days

Finnegan scoring q4 hrs. Taper morphine drip by 5 mcg/kg/hr q24 hrs to

off as tolerated.

Finnegan scoring q4 hrs. Taper by 5 mcg/kg/hr q24 hrs until 10 mcg/kg/hr as tolerated.

Finnegan scoring q4 hrs. Taper morphine drip by 5 mcg/kg/hr q24 hrs to 20 mcg/kg/hr than taper by 2-3 mcg/kg/hr

q24 hrs until 10 mcg/kg/hr as tolerated.

Once at < 10 mcg/kg/hr, if tolerated, convert to enteral dose 0.12 mg/kg/dose PO q4 hrs (see page 2), otherwise continue IV, and taper as below.*

Concurrent scheduled lorazepam use with scheduled morphine

Follow

Yes

No

morphine

taper

schedule

Convert to enteral as tolerated, IV:PO is 1:1

Scheduled lorazepam use < 10 days

Scheduled lorazepam use 10 days

Taper over 3-5 days based on clinical status. Also follow morphine taper

schedule.#

Wean patient by ~10-30% daily based on clinical

status. Also follow morphine taper schedule.#

#NOTE: Signs of benzodiazepine withdrawal may not occur for 24-36 hours after a taper dose has been decreased. Refer to Withdrawal Signs and Tapering Guide (p.2) for signs/symptoms of benzodiazepine withdrawal.

Decrease dose every day by ~10-30% as tolerated.

Decrease dose by ~10% every OTHER day as tolerated.

Score > 8 or signs and symptoms of opioid withdrawal.

Finnegan Score

? Treat acute symptoms of withdrawal with morphine 0.05-0.1 mg/kg IV or 0.150.3 mg/kg PO q2 hours PRN.^

? Do not taper for 24-48 hrs. ? Remain at same dose or

increase to previous dose until signs/symptoms are well-controlled and Finnegan < 8 for 12-24 hours. Then continue taper.

*NOTE: Discontinue drip 2 hrs after 1st enteral dose. Refer to Withdrawal Signs and Tapering Guide for dosing (p.2).

Score < 8

Continue taper until complete.

Continue Finnegan scoring q4 hours until taper has been

discontinued for 48 hours.

^NOTE: Signs of opioid withdrawal may not occur for 8-15 hrs after taper. Weaning may progress well for 2-3 days before withdrawal symptoms emerge. Avoid discharge for at least 24 hrs after taper has ended. Refer to Withdrawal Signs and Tapering Guide for signs of opioid withdrawal (p2.).

Written: 06/15/09 Sarah Tierney PharmD, Julie Lindower MD, MPH & Stephanie Stewart RN, MSN Updated: 11/17/09, 3/12/2012 Jonathan Klein, MD and Sarah Tierney, PharmD

2 Withdrawal Signs and Tapering Dose Guide

WITHDRAWAL SIGNS

Central Nervous

Signs

Opioid

High-pitched crying

Withdrawal Hyperactive reflexes

Signs

Increased muscle tone

Tremors

Sneezing

Hiccups

Yawning

Short, non-quiet sleep

Fever

Difficult to comfort

Benzodiazepine Hypertonicity

Withdrawal Tremors

Signs

Irritability

Respiratory Signs

Tachypnea Excess secretions

Gastrointestinal Signs

Disorganized sucking Poor feeding Vomiting Drooling Diarrhea

Disorganized sucking Vomiting Diarrhea

Vasomotor Signs

Stuffy nose Flushing Sweating Mottling

Cutaneous Signs

Skin excoriation (knees, elbows,

buttocks)

DOSE CONVERSION CALCULATIONS AND DOSE TAPERING GUIDE

Conversion from IV to Enteral Morphine Dosing:

Usual starting IV drip at time of conversion to PO: 10 mcg/kg/hr Usual starting dosing interval for oral dosing: q4 hours (ie. 6 doses daily) The dosing conversion used in the calculations for morphine IV:PO = 1:3

1. Calculate starting point for oral morphine dose from morphine drip Patient PO dosing weight MUST be the same weight that was initially used to calculate the drip and not necessarily their current daily weight.

15 mcg/kg/hr IV drip = 0.18 mg/kg/dose PO q4 hours 12 mcg/kg/hr IV drip = 0.14 mg/kg/dose PO q4 hours 10 mcg/kg/hr IV drip = 0.12 mg/kg/dose PO q4 hours 8 mcg/kg/hr IV drip = 0.1 mg/kg/dose PO q4 hours

3 2. Find calculated STARTING oral morphine dose on the appropriate table below based on patient weight (using actual dose, not the mg/kg/dose) and follow the morphine taper schedule from that point.

Follow this chart for patients' 2 kg:

Morphine use 8-29 days

decrease dose DAILY

Actual Dose Frequency % change from

previous dose

0.7 mg PO

q4 hrs

0.6 mg PO 0.5 mg PO 0.4 mg PO 0.3 mg PO 0.2 mg PO 0.1 mg PO 0.1 mg PO 0.1 mg PO 0.1 mg PO 0.1 mg PO

q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q6 hrs q8 hrs q12 hrs q24 hrs Taper Completed

14 % 16 % 20 % 25 % 33 % 50% 33% 50 % 33 % 50 %

Morphine use 30 days

decrease dose EVERY OTHER day

Actual Dose Frequency % change from

previous dose

0.7 mg PO

q4 hrs

0.6 mg PO 0.55 mg PO 0.5 mg PO 0.45 mg PO 0.4 mg PO 0.35 mg PO 0.3 mg PO 0.25 mg PO 0.2 mg PO 0.2 mg PO 0.1 mg PO 0.1 mg PO

q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q6 hrs q6 hrs q8 hrs

14 % 8 % 9 % 10 % 11 % 12 % 14 % 16 % 23% 33 % 50 % 25 %

0.1 mg PO

q12 hrs

33 %

0.1 mg PO

q24 hrs

50 %

Taper Completed

Follow this chart for patients' > 2 kg:

Morphine use 8-29 days

decrease dose DAILY

Actual Dose Frequency % change from

previous dose

0.7 mg PO

q4 hrs

0.6 mg PO 0.5 mg PO 0.4 mg PO 0.3 mg PO 0.2 mg PO 0.2 mg PO 0.2 mg PO 0.2 mg PO 0.2 mg PO

q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q6 hrs q8 hrs q12 hrs q24 hrs Taper Completed

14 % 16 % 20 % 25 % 33 % 33 % 25 % 33 % 50 %

Morphine use 30 days

decrease dose EVERY OTHER day

Actual Dose Frequency % change from

previous dose

0.7 mg PO

q4 hrs

0.6 mg PO 0.55 mg PO 0.5 mg PO 0.45 mg PO 0.4 mg PO 0.35 mg PO 0.3 mg PO 0.25 mg PO 0.2 mg PO 0.2 mg PO 0.2 mg PO

q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q4 hrs q6 hrs q8 hrs

14 % 8 % 9 % 10 % 11 % 12 % 14 % 16 % 23% 33 % 25 %

0.2 mg PO

q12 hrs

33 %

0.2 mg PO

q24 hrs

50 %

Taper Completed

4 Finnegan Scoring System

System

Symptoms

Points

Score

Central Nervous System

Excessive high pitched (or other) cry (< 5 min)

2

Continuous high pitched (or other) cry (> 5 min)

3

Sleep < 1 hour after feeding

3

Sleep < 2 hours after feeding

2

Sleep < 3 hours after feeding

1

Hyperactive Moro reflex

2

Moderately hyperactive Moro reflex

3

Mild tremors when disturbed

1

Moderate-severe tremors when disturbed

2

Mild tremors when undisturbed

3

Moderate-severe tremors when undisturbed

4

Increased muscle tone

1

Excoriation (eg. Chin, knees, elbows, toes, nose)

1

Myclonic jerks (twitching/jerking of limbs)

3

Generalized convulsions

5

Sweating

1

Hyperthermia (37.2 ? 38.2?C)

1

Hyperthermia ( 38.4?C)

2

Frequent yawning (>3-4/interval)

1

Metabolism Vasomotor Respiratory

Molting

1

Nasal stuffiness

1

Frequent sneezing (> 3-4/interval)

1

Nasal flaring

2

Respiratory rate > 60/min

1

Respiratory rate > 60/min with retractions

2

Excessive sucking

1

Gastrointestinal

Poor feeding (infrequent/uncoordinated suck)

2

Regurgitation (2 times during/past feed)

2

Projectile vomiting

3

Loose stool

2

Watery stool

3

TOTAL SCORE

References: 1. Berens RJ, Meyer MT, Mikhailov TA, et al. A Prospective Evaluation of Opioid Weaning in OpioidDependent Pediatric Critical Care Patients. Anesth Analg. 2006; 102:1045-50. 2. Committee on Drugs. Neonatal Drug Withdrawal. Pediatrics. 1998; 101:1079-1088. 3. Dominguez KD, Lomako DM, Katz RW, Kelly HW. Opioid Withdrawal in Critically Ill Neonates. Ann Pharmacother. 2003; 37: 473-7. 4. Dunbar III AE, Sharek PJ, Mickas NA, et al. Implementation and Case-Study Results of Potentially Better Practices to Improve Pain Management of Neonates. Pediatrics. 2006; 118; S87-S94. 5. Finkel JC. Opioid Tolerance and Dependence in Infants and Children. Lecture at George Washington University Medical Center. Date unknown. 6. Franck LS, Vilardi J, Durand D. Opioid Withdrawal in Neonates after Continuous Infusions of Morphine or Fentanyl during ECMO. American Journal of Critical Care. 1998; 7(5): 364-369. 7. McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. Reproductive Toxicology. 1994; (8)6:461-75. 8. Osborn DA, Jeffery HE, Cole M. Opiate treatment for opiate withdrawal in newborn infants. Cochrane Database Syst Rev. 2005 Jul 20; (3): CD002059. Review. 9. Ostrea EM et al. The Infant of the Drug-Dependent Mother. Avery's Neonatology. 2005; 6th edition. 10. Suresh S, Anand KJS. Opioid tolerance in neonates: a state-of-the-art review. Paediatric Anaesthesia. 2001; 11: 511-521. 11. Vitali SH, Camerota AJ, Arnold JH. "Anesthesia and Analgesia in the Neonate." Avery's Neonatology. 6th Edition. 2005. Chapter 57. Page 1563.

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