Continuous Sub Q Morphine

i've given sev'l hundred mgs/hr.

there is no ceiling.

your mom will likely require even more than what she is currently getting.

whatever it takes to get and keep her comfortable...

blessings to you both.

leslie

Oh, I'm quite aware there is no ceiling. At the hospice house where she is staying they haven't seen anyone above 28/hour continuous, which I found strange, because I have heard second-hand of people up in the 100's.

I was just curious as what other people have seen.

The past few days, I took care of a 60 y/o man with tongue CA and a long history of spinal cord injury from a military service-related accident. He came to our inpatient unit on an IV (picc line) continuous Dilaudid infusion, which was running at 8 mg/hr with a demand dose (PRN) of 6 mg with q 15 min lockout. In the 24 hours prior to his admission, he had received over 700 mg of Dilaudid with no adverse side effects of the narc. Our MD increased his cont. rate to 25 mg/hr and his demand dose to 25 mg with q 30 min lockout. Yes, we were all a little nervous about this, and he was closely monitored for improvement in pain as well as unintended SEs. He did remarkably well, requiring an increase to 30 mg/hr continuously with sporadic demand dose usage. I think his highest daily dose of Dilaudid was nearly 1 gram. He died peacefully yesterday.

Thank goodness for no ceilings on opioids!!!

Scribbler: I wish peace and comfort for your mom, you, and your family during this difficult time.

Mark

Thanks for your reply!

Now she is up to 35mg/ cont per hour with 15mg bolus q15 min. I imagine the bolus will increase over the weekend, as one or the other goes up about every 2-3 days.

The proper dose of morphine is the dose that controls the symptoms. The only limitations on the SQ morphine is the amount of fluid you are infusing into the SQ tissue, which should not exceed 3cc/hour (I try to stay below 2.5cc's before asking the pharmacist to change the concentration). Another tip is with the higher the dose of morphine, consider rotating the SQ site more frequently to ensure absorption over adipose tissue (I have seen more irritation at the site with larger doses). I once had a 28 year ovarian CA patient that was on 100 (or 90?--my memory fades with age) mg's of Dilaudid an HOUR IV with breakthrough of 90 (or 100) mg's of bolus dosage an hour (and she was regularly using the total bolus). She was up and walking to the local grocery store, with minor pain indicaations only with activity) with her family on a daily basis on this dosage. During the week before her death, we also titrated her up to the total Dilaudid dosage hourly ALONG with Versed IV that was titrated to 14mg /hour. She was peaceful at her death. I remember calling her physician to conference with him at one point, because I had never seen such high doses to control pain. He reminded me of "the proper dose is the dose that controls the pain" as he chuckled and said "that's my girl"(about his patient), even as he remarked tha she was on enough medication to sedate a football team!. To this day, she has been one of my favorite patients (although we are not supposed to have them)--I think she made as much of an impact on my life as I did on hers. :redbeathe

The proper dose of morphine is the dose that controls the symptoms. The only limitations on the SQ morphine is the amount of fluid you are infusing into the SQ tissue, which should not exceed 3cc/hour (I try to stay below 2.5cc's before asking the pharmacist to change the concentration). Another tip is with the higher the dose of morphine, consider rotating the SQ site more frequently to ensure absorption over adipose tissue (I have seen more irritation at the site with larger doses). I once had a 28 year ovarian CA patient that was on 100 (or 90?--my memory fades with age) mg's of Dilaudid an HOUR IV with breakthrough of 90 (or 100) mg's of bolus dosage an hour (and she was regularly using the total bolus). She was up and walking to the local grocery store, with minor pain indicaations only with activity) with her family on a daily basis on this dosage. During the week before her death, we also titrated her up to the total Dilaudid dosage hourly ALONG with Versed IV that was titrated to 14mg /hour. She was peaceful at her death. I remember calling her physician to conference with him at one point, because I had never seen such high doses to control pain. He reminded me of "the proper dose is the dose that controls the pain" as he chuckled and said "that's my girl"(about his patient), even as he remarked tha she was on enough medication to sedate a football team!. To this day, she has been one of my favorite patients (although we are not supposed to have them)--I think she made as much of an impact on my life as I did on hers. :redbeathe

A comment about SQ rates. Our policy was up to 5 ml/hr, and I never saw any problems with this. If we were in a bind, and needed to go up before we had a new concentration mixed, I've gone higher for a short people of time.

Never thought about rotating more often w/higher doses -- we general kept to a 3 day schedule.

I have not seen them used in hospice but does anyone use Hyaluronidase (brand name Hylenex) for fast sub q flow rates?

Also, I'll get on one of my hobby horses here -- it seems like an awful lot of institutions still use a straight amount increase rather than making it a ratio, which is considered best practice.

A quote from Fast Fact #20:

Opioids should be done on the basis of a percentage increase. In fact, this is reflexively done when opioid-non-opioid fixed combination products are prescribed; going from one to two tablets of codeine/acetaminophen represents a 100% dose increase. The problem arises when oral single agents (e.g. oral morphine) or parenteral infusions are prescribed.

Increasing a morphine infusion from 1 to 2 mg/hr is a 100% does increase; while going from 5 to 6 mg/hr is only a 20% increase, and yet many orders are written, "increase drip by 1 mg/hr, titrate to comfort." Note: some hospitals and nursing units have this as a standing pre-printed order or nursing policy.

In general, patients do not notice a change in analgesia when dose increases are less than 25% above baseline.

There is a paucity of clinical trial data on this subject. A common formula used by many practitioners includes:

• moderate to severe pain increase by 50-100%, irrespective of starting dose
  
• mild-moderate pain increase by 25-50%, irrespective of starting dose.

When dose escalating long-acting opioids or opioid infusions, do not increase the long-acting drug or infusion basal rate more than 100% at any one time, irrespective of how many bolus/breakthrough doses have been used.

These guidelines apply to patients with normal renal and hepatic function. For elderly patients, or those with renal/liver disease, dose escalation percentages should be reduced.

The recommended frequency of dose escalation depends on the half-life of the drug. Short-acting oral single-agent opioids (e.g. morphine, oxycodone, hydromorphone), can be safely dose escalated every 2 hours. Sustained release oral opioids can be escalated every 24 hours, and for Duragesic â (Fentanyl transdermal), methadone or levorphanol, no less than every 72 hours is recommended.

My mouth actually fell open when I read that! It is so true and I never even thought of it. Having only been in the acute care setting through my nursing career, I can't tell you how much I've already learned in this first week of sitting through a hospice orientation and also reading through the hospice threads.

Hospice nurses ROCK :bowingpur

PH

A quote from Fast Fact #20:

Opioids should be done on the basis of a percentage increase. In fact, this is reflexively done when opioid-non-opioid fixed combination products are prescribed; going from one to two tablets of codeine/acetaminophen represents a 100% dose increase. The problem arises when oral single agents (e.g. oral morphine) or parenteral infusions are prescribed.

Increasing a morphine infusion from 1 to 2 mg/hr is a 100% does increase; while going from 5 to 6 mg/hr is only a 20% increase, and yet many orders are written, "increase drip by 1 mg/hr, titrate to comfort." Note: some hospitals and nursing units have this as a standing pre-printed order or nursing policy.

In general, patients do not notice a change in analgesia when dose increases are less than 25% above baseline.

There is a paucity of clinical trial data on this subject. A common formula used by many practitioners includes:

• moderate to severe pain increase by 50-100%, irrespective of starting dose
  
• mild-moderate pain increase by 25-50%, irrespective of starting dose.

When dose escalating long-acting opioids or opioid infusions, do not increase the long-acting drug or infusion basal rate more than 100% at any one time, irrespective of how many bolus/breakthrough doses have been used.

These guidelines apply to patients with normal renal and hepatic function. For elderly patients, or those with renal/liver disease, dose escalation percentages should be reduced.

The recommended frequency of dose escalation depends on the half-life of the drug. Short-acting oral single-agent opioids (e.g. morphine, oxycodone, hydromorphone), can be safely dose escalated every 2 hours. Sustained release oral opioids can be escalated every 24 hours, and for Duragesic â (Fentanyl transdermal), methadone or levorphanol, no less than every 72 hours is recommended.

Thanks for the great information! I really appreciate it.

Now she is on cont of 40 with q15 bolus of 20. Conc is 50/ml.

The percent increase was an interesting read. The hospice where my mom is is not following that but increasing usually by 2 mg at a time. Truthfully this seems to be working well for her, so I have that to be thankful of!