question about dilaudid

[Majorpain]

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Just a question about Dilaudid. What's the maximum dose that a patient can get in a 24 hr period? I know that it depends on the pt's tolerance, if pt has received it before, etc.? My pt is currently on 3 mg IV q2 hrs straight (36 mg in 24 hrs). Is it too much? Thanks.

 

[gutonc]

Just a question about Dilaudid. What's the maximum dose that a patient can get in a 24 hr period? I know that it depends on the pt's tolerance, if pt has received it before, etc.? My pt is currently on 3 mg IV q2 hrs straight (36 mg in 24 hrs). Is it too much? Thanks.

Is s/he breathing? If so, then it's not too much. Also, what kind of pain is the dilaudid for? If this is a chronic LBP then yes, it's too much. If this is malignant bone pain, you give what you need to.

Good luck trying to titrate down and transition to orals though.

 

[Majorpain]

yes the pt is breathing. Pt is a sickle cell pt, but has history of drug abuse before (from the opioids she's getting coz of her disease). Tricky situation.

 

[gutonc]

yes the pt is breathing. Pt is a sickle cell pt, but has history of drug abuse before (from the opioids she's getting coz of her disease). Tricky situation.

Clearly tricky w/ the abuse history. Sicklers are a bear to take care of and that's just one of the reasons. If it makes you feel better, I've had plenty of patients (onc folks mind you) on dilaudid PCAs @ 2mg/h basal w/ another 4-6mg/h available as PCA dosing so 36mg/24h, while definitely a truckload, is not unprecedented by any means.

 

[muscles]

I think you have to put it in context of the patient - if you have a patient in a great deal of pain (such as a sickle cell crisis), who has required and tolerated large doses in the past, then dilaudid 3mg q12hrs may be reasonable. On the other hand, if you give this to someone who has never had narcotics before, you'll probably be calling the critical care fellow soon...

Agree with gutonc; I have had patients on higher doses of dilaudid pca's and they tolerated it without any major unwanted side effects.

 

[CambieMD]

yes the pt is breathing. Pt is a sickle cell pt, but has history of drug abuse before (from the opioids she's getting coz of her disease). Tricky situation.

Is the pt a drug abuser or does the pt have increased tolerance. Have you thought of working something long acting like methadone. You may want to add another drug that hits a different receptor like your NMDA receptor.

The pt pain must be treated appropriately. A malingering pt is a different story. Titrate your pain medication to effect.

What drug did the pt abuse. Was the pt treating her pain with street drugs.

Good luck.

Cambie

 

[bigpharmD]

this max dose is what they can handle...you would be shocked

 

[teri78]

The first thing is to decide if you believe the pt is truly in pain or is malingering. If you believe the pt is in pain then use whatever dose is necessary to control their pain, and doesn't cause respritory depression. It might be a good idea to ask the nurses to specifically check his RR more frequently if you are concerned the dose might be to high.

Although a long-acting med might be very appropriate, I probably would try to stay away from methadone for acute pain unless you are very familiar using it. It does give the added benefit of NMDA receptor antagonism, but it is extremely tricky to titrate. Also, it may cause qt prolongation.

 

[dragonfly99]

Sickle cell patients can be hard to treat. They do have real pain, but they also become tolerant to pain meds and require high doses. When you add in past and possible current drug dependence and/or abuse to this, it makes it complex to treat. The patient really needs a great outpatient hematologist to treat him/her...on our teaching service they finally created a situation where these guys would consult on their patients whenever admitted...otherwise you get multiple people giving the patient mixed messages about what pain meds will be given, etc. Tough situation. These patients really benefit from specialist care.

 

[critcare]

cant we put holding parameters like "hold if somnolent or if respi. rate less than 12/pulse ox < 94 etc", also vital signs( tachy etc) and labs( high retic, bili, falling Hb) may help single out the "seekrs", atleast in sicklers

 

[gutonc]

cant we put holding parameters like "hold if somnolent or if respi. rate less than 12/pulse ox < 94 etc", also vital signs( tachy etc) and labs( high retic, bili, falling Hb) may help single out the "seekrs", atleast in sicklers

Not only can you, but you really should. Our EMR automatically includes holding orders for all IV narcs including PCAs and the PCA orders also include a narcan protocol. You can delete them if you want but you have to go out of your way to get rid of them. Personally, my parameters are RR <8, O2 sat <92 and GCS <10 but the GCS thing is kind of a joke...I'm pretty sure I'd get paged to figure out what that meant.

 

[Adcadet]

My pt is currently on 3 mg IV q2 hrs straight (36 mg in 24 hrs). Is it too much? Thanks.

Please tell me you're not using SDN for medical advice for somebody you're currently taking care of. Whether "currently" means that you've signed out and have gone home for the day or you're currently in the hospital talking to the patient and writing the next Dilaudid order, it's not a good idea.

 

[dragonfly99]

Another thing to consider w/Dilaudid is a risk of seizures (at least theoretically).

 

[obiwan]

i had a tangent question for this thread... in patients who are allergic to opioids, what are some good alternatives? i know that i've seen dilaudid being used in that situation but isn't it also an opiod type?

 

[gutonc]

i had a tangent question for this thread... in patients who are allergic to opioids, what are some good alternatives? i know that i've seen dilaudid being used in that situation but isn't it also an opiod type?

Most (not ALL) people who claim an opioid allergy are just intolerant to the side effects of a particular drug. Morphine in particular can cause a histamine release leading to hives, pruritis, nausea, and a variety of other unpleasant side effects, most of which can be managed and are not actual allergies. As long as the allergy isn't anaphylaxis, it's not unreasonable to attempt to use other opioids. Dilaudid and fentanyl both have fewer side effects than morphine but at the same time also may not have the same positive effect because their receptor binding is more restricted.

This is why it's important to ask people what they mean by "allergic" to any medication. I've heard "constipation," "tiredness" and a variety of other bogus "allergies" to narcotics. Just like the person who tells you they're allergic to clindamycin or vanco b/c they got diarrhea and and c diff from them. Side effect != allergy.

 

[muscles]

Agree with gutonc - in addition to "allergies" of narcotics including constipation and tiredness, I very frequently hear "nausea"...

 

[dragonfly99]

agree w/guton
true narcotic allergy is unusual, though it does exist.
It's very unusual.
Some people don't tolerate morphine, as mentioned above.
Also, some people lack the ability to convert codeine to morphine (genetic deficiency fairly common in white population) and so will have a lot of codeine side effects but not the beneficial morphine effect of pain relief.

 

[subtle1epiphany]

Also, some people lack the ability to convert codeine to morphine (genetic deficiency fairly common in white population) and so will have a lot of codeine side effects but not the beneficial morphine effect of pain relief.

We learned about that in pharm, but I was still surprised when I took a dose of Tylenol #3 after opening my hand trying to cut through those tough plastic packages. After getting a couple sutures they discharged me with a couple and once it started to throb I took two. No effect (completely opioid naive). So I took some normal Tylenol later and went to sleep. Aleve was my best bet.
Of course, we're comparing a few sutures with sickle cell and true pain...there's no real comparison.
Very cool to learn about that first "hand."
Pharmacology and path/physiology are awesome!

 

[dragonfly99]

Yeah, I think that genetic deficiency/inability to convert codeine is found in 13% of the white population, or something like that.