Dilaudid Max Dose

[laurainaz]

My facility has just implemented a "2 mg Dilaudid max dose" policy d/t several pts that have coded after receiving 4 mg doses. Are there other facilities that have made changes to the dosing of Dilauded d/t respiratory depression and codes? RNs are also being educated to not push the drug faster than 1mg/min; I think most of us do this anyway but I guess sometimes people get in a hurry and don't actually go that slow. I'm just a little curious as to whether this is an issue at other facilities as well as mine. Thanks.

[memphispanda, RN]

Not at my facility. We have several chronic pain type patients who receive 6mg when they come in. Of course the "normal" patients get 1 or 2.

[sharann, BSN, RN]

As panda said above, there are too many exceptions to make a certain dosage policy. That being said, for the opioid naive patient, 4mg would be too high a dose, while 2 to 3mg might work fine. It should be based on weight and renal function as well as history of narcotic use. I have given 25mg of Demerol to one person and kncked them out, while another required 200mg! I think that we must use judgement here.

[jannecdote]

We had a retired RN, frequent flyer, diabetic, non-healing foot wounds. She received lots of pain meds but her favorite was Dilaudid. She was on Dilaudid 4mg IVP q 3 hours until her last admission.

The doc changed her dose to 8mg po every six hours. I remember thinking that I had never given anybody that much Dilaudid at one time. She scared us because she would be talking like a drunk woman and asking for more pain meds. When the doc would try to wean her dosages down, all hell would break loose in dealing with this woman and invariably, her dosage would remain the same.

She was given the same script upon discharge. Within a week, she was found unresponsive at home and died. I think she Dilaudided(??) herself to death.

I know this is wandering off the threaded path here, but I thought about this lady when reading the posts.

[chinny7150]

I work in a rural hospital in the ER. Dilaudid is the number one choice of pain med for one doctor. Last night I gave a young man of 46-6 mg IV Dilaudid over 1 hrs time. When we finally caught up and relieved his pain he was max-sedated, respirations at 14. O2 at 6L per NC kept his sats above 90 but you had to be at bedside and constantly monitor him for respirations and adjust the oxygen as needed.

From 2130 to 0500 he received a total of 11mg of Dilaudid. I was not comfortable with giving that much Dilaudid nor the condition of my patient.

[RoyalPrince]

I work in a rural hospital in the ER. Dilaudid is the number one choice of pain med for one doctor. Last night I gave a young man of 46-6 mg IV Dilaudid over 1 hrs time. When we finally caught up and relieved his pain he was max-sedated, respirations at 14. O2 at 6L per NC kept his sats above 90 but you had to be at bedside and constantly monitor him for respirations and adjust the oxygen as needed.

From 2130 to 0500 he received a total of 11mg of Dilaudid. I was not comfortable with giving that much Dilaudid nor the condition of my patient.

no wonder malpractice insurance prems are getting higher and higher!!!

[Turd Ferguson]

From 2130 to 0500 he received a total of 11mg of Dilaudid. I was not comfortable with giving that much Dilaudid nor the condition of my patient.

Good gosh! What's the ratio of Dilaudid to Morphine... isn't it around 1mg Dilaudid = 8mg Morphine?

[LouisVRN, RN]

Ours has a policy that initial dose may not be higher than 2mg IV unless there has been a pain management/pharmacy/palliative care consult.

[nurseprnRN, BSN, RN]

what you need to know is that dilaudid (hydromorphone, a synthetic opioid), like any other opioid, has different effects on people depending on whether they are opioid-naive (meaning, they aren't used to taking it) or have developed tolerance to it (note, this is not the same as being addicted. look up addiction, tolerance, and habituation before you discuss this with anyone, so you don't look ignorant).

as one poster above notes, you can give someone who's habituated and tolerant a dose that would put the rest of us under the table (if not in the box). the highest dose of morphine i ever gave was 500mg per hour, which works out to something like 50+mg of dilaudid (look up "equianalgesic dose").

so: your facility's policy was written by someone who doesn't know much about pain medication, your staff don't know much about monitoring for pain or opioid side effects, and some of your patients will be in pain unnecessarily because of it. ufema and mccaffery are the people you want to read on pain management. also ask your local hospice nurse to come in and give a staff inservice on this-- they know it better than anyone and are usually thrilled to be asked.

[MunoRN, RN]

I don't think an absolute max dose makes much sense given the variations in opioid response. Although a limit on the initial dose makes sense. ISMP suggests limited the initial dose to 0.5mg (equivalent to 3.5mg morphine). It's fast acting so if it's not sufficient you can give more fairly quickly.

In the past 5 years my facility has had two sentinel events, both were due to dilaudid, so it's worth being careful.

[MomRN0913]

How is that going to work?

I had a chronic pain patient, 4 mg IVP Q4, I believe and on a Fentanyl gtt at 150mcgs/hr.... on NC. Talking up a storm and all over the call bell. This was in the ICU of course.

i had another CA patient, end-stage..... recieved him from the ER. 3 mg dilaudid IVP. Asked to just "push it fast". MD was at bedside and when I looked at him, he said "go ahead"

I believe many times it is not prescribed right. No, the 90 year old patient with no history of chronic pain doesn't need to be getting Dilaudid. Many factors need to be in place when prescribing such a potent drug. I've seen patients code from it.

There was a young CA patient on end of life/comfort care, on trach collar and 60 mg of morphine/hr and ativan Q4. 2 weeks until she stopped breathing.