Why morphine in peds?

[Dantrolene FC]

I’ve noticed at my institution that people give hydromorphone for adults but morphine for peds. Is there a reason for this?

Morphine had active metabolites. Is it just because people are less likely to change their peds practice as fast as their adult practice? Is there an advantage to morphine?

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[drmwvr]

Morphine has gone the way of dopamine in our practice...for peds and adults...

 

[nimbus]

Timely article.


“Meissner et al. found “that the relationship between analgesia and respiratory depression differed between the two drugs, with morphine having “less analgesia” for any given degree of respiratory depression as well as a delayed onset and longer duration of respiratory depression. The authors suggest that hydromorphone may, as a result, have advantages in the clinical setting.”1 Further, the “onset, magnitude, and duration of miotic, analgesic, and ventilatory effects of hydromorphone were characterized by temporal coincidence”, that is, they matched. This was not the case with morphine in which the ventilatory effects of morphine were greater than the magnitude of analgesia and was temporally delayed. Thus, ventilatory depression occurred later than the peak of analgesia and lasted longer than analgesia. Miosis and analgesia also did not match temporally, with miosis occurring earlier than analgesia and faded sooner making the use of pupillometry questionable.

All we can say is “WOW”! As the authors conclude: “at the doses studied, hydromorphone compared with morphine had a faster onset of effects and greater analgesia relative to respiratory depression, and morphine respiratory depression was delayed relative to analgesia. These results suggest that hydromorphone may have clinical advantages compared with morphine for treating acute pain in perioperative, emergency department, and other acute care settings.”1

Morphine v Hydromorphone

Myron Yaster MD and Lynne G. Maxwell MD

open.substack.com

 

[Onefellswoop87]

Morphine has gone the way of dopamine in our practice...for peds and adults...

So . . . you renal-dose it?

 

[Mehd School]

Have always wondered this as well. The big time childrens hospital I rotated at in residency didn't even have hydromorphone as an option for peds in the OR or pacu. I figured they knew something I didn't. At my current practice we do occasional healthy peds and I got dilaudid added to our pacu order set but I'm the only one that actually orders it instead of morphine.

 

[unkemptmiso]

Wondered this at my pedi hospital as well. The answer I got was that morphine is easier to draw up and dose weight based, less prone to error with new residents rotating through. Comes in a 5mg/5cc syringe here, and most kids get 1-3mg standard.

 

[Morzh]

100% peds guy here. I always had the same questions during training and never really got a straight answer. Ultimately I realized it was a combination of institutional culture, familiarity/comfort with "the way things have always been", and the pharmacy practicalities of what volume and concentrations the vials come in. For example, at one of our big hospitals hydromorphone comes in 2mg/ml 1ml vials. So if I'm wanting to give 5-10mcg/kg then I'm frequently doing dilutions or drawing up something like 0.05ml (0.1mg) in a 1ml syringe. A lot more room for errors there. Morphine at the same hospital comes in 2ml 2mg/ml vials so for the same size child I can just give the full 1ml (2mg) and call it a day.

I don't have a strong preference for most kids. If dilaudid is in my Pyxis/Omnicell I will use it 90% of the time. If I'm at a surgery center and they only have morphine I'm fine with that, it's not worth making a stink about it. Teenagers I definitely prefer dilaudid because I feel like once you are going above 4-5mg of morphine you are far more likely to see some of the dirty side effects like excessive pruritis and vomiting. Although you get that with any narcotic sometimes.

I'm glad to see the study cited above. Their findings seem to match my general anecdotal experiences, although I think for otherwise healthy kids it's probably fine to use either one.

 

[GravelRider]

I remember asking this question in residency and essentially the answer I got was to avoid medication errors. I do healthy peds in my practice and I will admit that the reason I use morphine is because it comes out of the Pyxis in 1mg doses and I won’t have to find someone to waste medications with like I would with Dilaudid.

 

[kb1900]

we never use morphine for our kids here. Or adults for that matter. in fact I don’t know if we stock it in our OR pharmacy (no Pyxis)

 

[Airway]

Double dilution or triple on babies... annoying

 

[Justice4all]

Will agree the preference for morphine is for ease, less error-prone in infants. And NICU does not use hydromorphone unless they already have exhausted morphine and doing an opioid rotation. Usually my preference for long-acting agent in infants in the OR .