Morphine Administration of very small doses

preemieRNkate, RN · May 24, 2008

We do a serial dilution. 0.1 ml of the med, 0.9 ml of NS (or whatever diluent is compatible). If your dose is 0.05, you would give 0.5 ml of your dilution.

We have 2 mg/ml morphine as well, so in this case the you would be giving 0.025 ml. After the serial dilution you would be giving 0.25 ml, not 0.5 like I originally said.

SteveNNP, MSN, NP · May 25, 2008

We used tuberculin syringes and "eyeballed" it. 2mg/ml Mso4 is what we stock.

dance45 · May 26, 2008

To Preemie RN Kate and Steve. Thanks for the input. I came up with 0.25 cc for the dose if diluted out to 0.2 mg morphine/ml. Because if you draw up 0.1 ml of the 2 mg/ml concentration and add 0.9 ml NS, you still have 0.2 mg/ml. It's not a 1:1 mix. Does that make sense?? I tend to be a bit anal and check and recheck my calculations.

I've only ever done NICU during my nursing career. I wouldn't even consider any other area. And I know the margin for error is non-existent with the little micros. I want to make sure I'm doing everything correctly, and do what's best for the babies.

preemieRNkate, RN · May 26, 2008

I don't know if I'm really explaining myself clearly, but doing a serial dilution the way we do it where I work is making a tenfold dilution. Anytime we have to give a med where it works out to be less than 0.1 ml, we serial dilute. If your order says to give 0.05 mg of morphine, and you have 2 mg/ml on hand, you are going to be giving 0.025 ml. We don't eyeball it. So by drawing up 0.1 ml of the med and mixing with 0.9 ml NS, you're making a tenfold dilution and you will then give 0.25 ml. Does anyone else do this? I hope I am making sense, but maybe someone else can explain it better than me.

SteveNNP, MSN, NP · May 26, 2008

I don't know if I'm really explaining myself clearly, but doing a serial dilution the way we do it where I work is making a tenfold dilution. Anytime we have to give a med where it works out to be less than 0.1 ml, we serial dilute. If your order says to give 0.05 mg of morphine, and you have 2 mg/ml on hand, you are going to be giving 0.025 ml. We don't eyeball it. So by drawing up 0.1 ml of the med and mixing with 0.9 ml NS, you're making a tenfold dilution and you will then give 0.25 ml. Does anyone else do this? I hope I am making sense, but maybe someone else can explain it better than me.

So you guys are OK with witnessing a waste done this way? It makes sense. To be honest I'd never thought about doing it that way.

elizabells, BSN, RN · May 26, 2008

We don't do the serial dilution, but I will often draw up whatever my teensy amount is in the tuberculin syringe and then draw up some NS behind it to make a bigger volume going into the kiddo. In my head it makes it more likely the baby will get the med and it won't just get stuck in the hub. It's probably no more effective than a really good flush, but it makes me feel better.

BittyBabyGrower, MSN, RN · May 26, 2008

Our pharmacy dilutes our narcotics for us. Our morphine is diluted 9ml to 1ml morphine for a final concentration of 1mg/ml. We draw up what we need, for instance the 0.05ml in a TB syringe. We use a closed med/flush system in which we have an extension tubing always hooked up with a flush on the end. We would push the 0.05ml into this tubing then hook up the flush to infuse over 1 minute, usually about 0.5ml since our med tubing is 0.2ml and the connector is 0.2 ml and 0.1 to clear the end of the cath. This way we can control how much fluid each kid gets.

preemieRNkate, RN · May 27, 2008

So you guys are OK with witnessing a waste done this way? It makes sense. To be honest I'd never thought about doing it that way.

Yeah, we draw up what we need (the 0.1 ml) and then do the dilution and then waste the rest of the med and the extra of the dilution in front of each other.

texas2007, BSN, RN · May 28, 2008

Hmm...we don't dilute at my hospital. Usually the amount is so little, we push it into the med line tubing which is usually long enough so that it doesn't reach the patient, and then put a flush on. But I guess if you're busy you push in the flush as well. Hmm....:stone

ymm123 · Jun 1, 2008

Our hospital has a policy where if your giving something in a sryinge, the given volume in the syringe has to be greater or equal to 20% of the syringe's capacity. I think its for accuracy purposes.

So because of this we always first have to draw up 0.2 mls in our TB syringe. Dilute that to 1 ml and waste whatever the extra would be. Hopefully its not less than 0.2mls because then we'd have to dilute again.

I did the numbers out with your 2mg/ml concentration of morphine for our way and ended up with 0.625 mls to get 0.05mgs. But my math could be off and i'm pretty sure our on hand is 1mg/ml so we dont get too many wacky numbers when we dilute morphine. With the 2:1 concentration you have to dilute twice for this method.

justjenny · Jun 3, 2008

Not sure if this helps or not.

At my old job our management decided that these types of situations were unsafe and therefore (after much arguing and number crunching) came up with the following solution:

the example I am using is Fentanyl- we would have to calculate and dilute a large amount of fentanyl to a tiny dose and that left room for math error, etc. so our pyxis med machines now have a couple of prediluted syringes from the pharmacy (trying to remember.....) I think it was diluted down to 1 mcg/ml in a 5ml syringe. Much easier to give a baby 2 mcgs of fentanyl this way vs. calculating and diluting from a 50 mcg vial and risk overdosing.

Because it is premixed it is only good for 24 hours and pharmacy refills Q24. Yes, there were cost concerns, etc. but after some of the news on babies getting lethal doses of heparin, our management decided it was worth the cost.

I am wondering if a similar scenario could be implemented at your hospital?

Jenny