N212: Hydromorphone (Dilaudid)

What are adverse reactions/side effects of hydromorphone?

*CNS*: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. *EENT*: blurred vision, diplopia, miosis. *Resp*: respiratory depression. *CV*: hypotension, bradycardia. *GI*: constipation, dry mouth, nausea, vomiting. *GU*: urinary retention. *Derm*: flushing, sweating. *Misc*: physical dependence, psychological dependence, tolerance.

What is the maximum dose of hydromorphone for child and adults under 50 kg?

5 mg

A health-care provider's (HCPs) progress notes state a plan to initiate an oral NSAID for a child's pain. Based on this information, a nurse should consult with the HCP when noting that which medication was prescribed? 1. Acetaminophen (Tylenol®) 2. Tolmetin (Tolectin®) 3. Hydromorphone (Dilaudid®) 4. Naproxen (Naprosyn®)

ANSWER: 3 Hydromorphone is an opioid analgesic, not an NSAID. Acetaminophen, tolmetin, and naproxen are all NSAIDs. ➧ Test-taking Tip: This is a false-response item; select the medication that is not an NSAID.

A 76-year-old client, hospitalized for cancer treatment, has an emergency bowel resection for a bowel obstruction. Four hours postoperatively, the client is experiencing pain. A nurse has the choice of standing postoperative pain orders or standing orders for cancer clients (protocol orders) of which all medications are listed on the client's medication administration record. Which medication should the nurse initially select to treat the client's postoperative pain? 1. Meperidine (Demerol®) 75 mg IM 2. Fentanyl (Duragesic®) transdermal patch 50 mcg/hr 3. Morphine sulfate (Duramorph®) 4 mg IVP q3-4h prn 4. Hydromorphone (Dilaudid®) continuous infusion 15 to 30 mg/hr

ANSWER: 3 Morphine sulfate is recommended for severe, acute pain. It alters the client's perception and response to painful stimuli while producing generalized CNS depression. Meperidine has been reported to cause delirium in the elderly; older adults are at increased risk for meperidine toxicity. Fentanyl is recommended for moderate to severe chronic pain requiring continuous opioid analgesic therapy. Hydromorphone will take additional time to prepare; although it is a good option to obtain the medication for later dosing. Starting at the lowest dose (15 mg/hr) is recommended for older adult clients. ➧ Test-taking Tip: Knowledge of analgesics for older adults is necessary to answer this question. If unsure, use the process of elimination, eliminating options 2 and 4 because of the longer time of onset and the client is in acute pain.

A nurse is caring for a group of clients all in need of pain medication. The nurse has determined the most appropriate pain medication for each client based on the client's level of pain. Prioritize the order in which the nurse should plan to administer the pain medications beginning with the analgesic for the client with the most severe pain. ______ Ketorolac (Toradol®) 10 mg oral ______ Fentanyl (Sublimaze®) intravenously (IV) per patient-controlled analgesia (PCA) with a bolus dose ______ Hydromorphone (Dilaudid®) 5 mg oral ______ Morphine sulfate 4 mg IV ______ Propoxyphene (Darvon®) 65 mg oral

ANSWER: 4, 1, 3, 2, 5 The most potent of the medications is fentanyl (Sublimaze®), an opioid narcotic analgesic that binds to opiate receptors in the central nervous system (CNS), altering the response to and perception of pain. A dose of 0.1 to 0.2 mg is equivalent to 10 mg of morphine sulfate. Morphine sulfate is also an opioid analgesic. Hydromorphone, another opioid analgesic, would be third in priority. The oral dosing of this medication would indicate that the client's pain is less severe than the client receiving fentanyl or morphine sulfate. Hydromorphone 7.5 mg oral is an equianalgesic dose to 30 mg of oral morphine or 10 mg parenteral morphine. Ketorolac is a NSAID and nonopioid analgesic that inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Propoxyphene is last in priority. It also binds to opiate receptors in the CNS but is used in treating mild to moderate pain. It has analgesic effects similar to acetaminophen. ➧ Test-taking Tip: Focus on ordering the medications starting with the most potent opioid analgesics and ending with the nonopioid analgesic.

What is the rate of IV administration of hydromorphone?

Administer slowly, at a rate not to exceed 2 mg over 3-5 min.

What should be assessed before and periodically during administration of hydromorphone?

Assess BP, pulse, and respirations before and periodically during administration.

What does the nurse need to keep in mind in regards to GI symptoms of the patient taking hydromorphone? How can this side effect be prevented?

Assess bowel function routinely. Institute prevention of constipation with increased intake of fluids and bulk, and laxatives to minimize constipating effects. Administer stimulant laxatives routinely if opioid use exceeds 2-3 days, unless contraindicated.

When should pain level be assessed in the client taking hydromorphone

Assess type, location, and intensity of pain prior to and 1 hr following IM or PO and 5 min (peak) following IV administration. When titrating opioid doses, increases of 25-50% should be administered until there is either a 50% reduction in the patient's pain rating on a numerical or visual analogue scale or the patient reports satisfactory pain relief. When titrating doses of short-acting hydromorphone, a repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal.

What is the action and therapeutic effect of hydromorphone?

Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression. Suppresses the cough reflex via a direct central action. Therapeutic Effects: Decrease in moderate to severe pain. Suppression of cough.

What drug natural products can cause CNS depression in patients taking hydromorphone?

Concomitant use of kava-kava, valerian, chamomile, or hops can increase CNS depression.

When is hydromorphone contraindicated?

Contraindicated in: Hypersensitivity; Some products contain bisulfites and should be avoided in patients with known hypersensitivity; Severe respiratory depression (in absence of resuscitative equipment) (extended-release only); Acute or severe bronchial asthma (extended-release only); Paralytic ileus (extended- release only); Acute, mild, intermittent, or postoperative pain (extended-release only); Prior GI surgery or narrowing of GI tract (extended-release only); Opioid non-tolerant patients (extended-release only); *OB, Lactation*: Avoid chronic use during pregnancy or lactation.

What solution is hydromorphone compatible in?

D5W, D5/0.45% NaCl, D5/0.9% NaCl, D5/LR, D5/Ringer's solution, 0.45% NaCl, 0.9% NaCl, Ringer's , LR.

How should naloxone be diluted?

Dilute the 0.4-mg ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by direct IV push every 2 min. For children and patients weighing < 40 kg, dilute 0.1 mg of naloxone in 10 mL of 0.9% NaCl for a concentration of 10 mcg/mL and administer 0.5 mcg every 2 min. Titrate dose to avoid withdrawal, seizures, and severe pain.

What are drug-drug interactions of hydromorphone?

Drug-Drug: Exercise extreme caution with MAO inhibitors (may produce severe, unpredictable reactions— reduce initial dose of hydromorphone to 25% of usual dose, discontinue MAO inhibitors 2 wk prior to hydromorphone). Increase risk of CNS depression with alcohol, antidepressants, antihistamines, and sedative/ hypnotics including benzodiazepines and phenothiazines. Administration of partial antagonists (buprenorphine, butorphanol, nalbuphine, or pentazocine) may precipitate opioid withdrawal in physically dependent patients. Nalbuphine or pentazocine may decrease analgesia.

True or False Most patient develop a psychological dependence of hydromorphone.

FALSE Though prolonged use may lead to physical and psychological dependence and tolerance, this should not prevent patient from receiving adequate analgesia. Most patients who receive hydromorphone for pain do not develop psychological dependence. Progressively higher doses may be required to relieve pain with long-term therapy.

What should the nurse keep in mind when administering hydromorphone to geriatric and pediatric clients?

Geri, Pedi: Assess geriatric and pediatric patients frequently; more sensitive to the effects of opioid analgesics and may experience side effects and respiratory complications more frequently.

What is the generic name for Dilaudid?

Hydromorphone

How many mg/hr can be given in an continuous infusion of hydromorphone? Can a bolus of hydromorphone be given, and if so, how much?

IV (Adults): Continuous infusion (unlabeled)— 0.2-30 mg/hr depending on previous opioid use. An initial bolus of twice the hourly rate in mg may be given with subsequent breakthrough boluses of 50-100% of the hourly rate in mg.

What is the safe dose range for giving hydromorphone IV, IM, or Subcut??

IV, IM, Subcut (Adults > 50 kg): 1.5 mg q 3-4 hr as needed initially; may be increased. IV, IM, Subcut (Adults and Children < 50 kg): 0.015 mg/kg mg q 3-4 hr as needed initially; may be increased.

What drug reverses respiratory depression in the patient taking an opioid agonist?

If an opioid antagonist is required to reverse respiratory depression or coma, naloxone (Narcan) is the antidote.

What should the nurse do if the respiratory rate falls below 10/min in the patient taking hydromorphone?

If respiratory rate is 10/min, assess level of sedation. Dose may need to be decreased by 25-50%. Initial drowsiness will diminish with continued use.

What drugs can increase the risk of CNS depression in the patient taking hydromorphone?

Increase risk of CNS depression with alcohol, antidepressants, antihistamines, and sedative/ hypnotics including benzodiazepines and phenothiazines.

Is it safe for pregnant women to use hydromorphone?

It is Pregnancy Category C. This means: Risk not ruled out: Animal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women, or no animal studies have been conducted and there are no adequate and well-controlled studies in pregnant women.

Should the PO medication of hydromorphone be given on an empty stomach?

It may be administered with food or milk to minimize GI irritation.

What are lab considerations of hydromorphone?

May increase plasma amylase and lipase concentrations.

Why should hydromorphone be discontinued gradually after long-term use?

Medication should be discontinued gradually after long-term use to prevent withdrawal symptoms.

What is the indication for hydromorphone?

Moderate to severe pain (alone and in combination with non-opioid analgesics); extended release product for opioid-tolerant patients requiring around-the-clock management of persistent moderate-to-severe pain. Antitussive (lower doses).

Where is hydromorphone metabolized?

Mostly metabolized the liver.

Is hydromorphone and morphine the same medication?

No. Do not confuse with morphine; fatalities have occurred.

What is the onset, peak, and duration of IV hydromorphone?

Onset: 10-15 min Peak: 15-30 min Duration: 2-3 hr

What is the onset, peak, and duration of PO-IR (immediate release) hydromorphone?

Onset: 30 min Peak: 30-90 min Duration: 4-5 hr

What is the half-life of hydromorphone?

Oral (immediate-release), or injection— 2-4 hr; Oral (extended-release)—8-15 hr.

What is the PO dose range of hydromorphone?

PO (Adults > 50 kg): Immediate-release— 4-8 mg q 3-4 hr initially (some patients may respond to doses as small as 2 mg initially); or once 24-hr opioid requirement is determined, convert to extended-release by administering total daily oral dose once daily.

How much hydromorphone should be given to children?

PO (Adults and Children < 50 kg): 0.06 mg/kg q 3-4 hr initially, younger children may require smaller initial doses of 0.03 mg/kg.

In order to have an antitussive effect, how much hydromorphone should b given?

PO (Adults and Children > 12 yr): 1 mg q 3-4 hr. PO (Children 6-12 yr): 0.5 mg q 3-4 hr.

How often should a client on a continuous infusion of hydromorphone have boluses?

Patients on a continuous infusion should have additional bolus doses provided every 15-30 min, as needed, for breakthrough pain. The bolus dose is usually set to the amount of drug infused each hour by continuous infusion.

What drug schedule is hydromorphone? What does that schedule mean?

Schedule II High potential for abuse and extreme liability for physical and psychological dependence (amphetamines, opioid analgesics, dronabinol, certain barbiturates). Outpatient prescriptions must be in writing. In emergencies, telephone orders may be acceptable if a written prescription is provided within 72 hr. No refills are allowed.

When teaching parents of a pediatric patient how to administer hydromorphone, what should the nurse teach about the measuring device?

Teach parents or caregivers how to accurately measure liquid medication and to use only the measuring device dispensed with the medication.

What are the classifications for hydromorphone?

Therapeutic: allergy, cold, and cough remedies (antitussives), opioid analgesics Pharmacologic: opioid agonists

When should hydromorphone be used cautiously?

Use Cautiously in: Head trauma; increased intracranial pressure; Severe renal, hepatic, or pulmonary disease; Hypothyroidism; Seizure disorder; Adrenal insufficiency; Alcoholism; Undiagnosed abdominal pain; Prostatic hypertrophy; Biliary tract disease (including pancreatitis); *Geri*: Geriatric and debilitated patients may be more susceptible side effects; dose decrease recommended.

Can hydromorphone cause orthostatic hypotension?

Yes

Is hydromorphone and morphine Y site compatible?

Yes

Is hydromorphone and nitroglycerin Y site compatible?

Yes

Does hydromorphone cross the placenta or enters breast milk?

Yes, it does

Is hydromorphone a high-alert medication?

Yes-It is an opioid analgesic.

Should hydromorphone be diluted? If not, why? If so, how much and with what diluent?

Yes. Dilute with at least 5 mL of sterile water or 0.9% NaCl for injection.

Coadministration of hydromorphone with nonopioid analgesics may have ________ analgesic effects and permit _____ opioid doses.

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