HydromorphoneNursing considerations

Side effects by what to assess

Sources: [1][2][3][4][5][6][7][8][9][10]

Blood pressure

Why

Severe hypotension and orthostatic hypotension

When

After starting or titrating the dose

Act on

Avoid in circulatory shock

Normal

Below 120/80 mm Hg.

Sources: [1][2]

Oxygen saturation and level of consciousness

Why

Sedation and hypoventilation, especially with COPD, older age, or CNS depressants

When

Closely during initiation and titration

Sources: [1][2]

Respiratory rate

Why

Opioid respiratory depression

When

Closely at initiation and after each dose increase

Act on

Give naloxone for clinically significant respiratory depression

Normal

12 to 18 breaths per minute in adults.

Sources: [1][2][3]

High-alert status

High-alert medication. Opioids, including IV and oral forms, are on the ISMP acute care high-alert list.

Sources: [1]

Narrow therapeutic index

The labels do not describe a narrow therapeutic index or direct dosing by measured blood levels of the drug.

Sources: [1][2]

Boxed warning

Serious and life-threatening risks: addiction, abuse, and misuse that can lead to overdose and death; life-threatening respiratory depression, highest at the start and after dose increases; profound sedation, respiratory depression, coma, and death with benzodiazepines, alcohol, or other CNS depressants; neonatal opioid withdrawal syndrome after prolonged use in pregnancy; fatal overdose from accidental ingestion, especially by children; and oral solution dosing errors from mg and mL confusion.

Sources: [1][2]

Antidote or reversal

Naloxone (or nalmefene) for clinically significant respiratory or circulatory depression, after securing the airway and ventilation. Reversal wears off before hydromorphone does, so keep monitoring until spontaneous breathing is reliable and redose as needed. In opioid-dependent patients, the usual dose can precipitate acute withdrawal.

Sources: [1]

Patient teaching

• It can cause addiction even at prescribed doses; store it locked away, never share it, and dispose of leftovers
• One accidental dose can kill a child
• Keep naloxone or nalmefene available and make sure family knows where it is
• Do not combine with alcohol, benzodiazepines, or other sedatives unless your provider directs
• Do not drive or operate machinery until you know how it affects you
• Do not stop suddenly after regular use; your provider will taper the dose

Sources: [1][2][3][4][5]

Sound-alike and look-alike names

• HYDROmorphone and morphine
• Dilaudid and Dilaudid-5

Sources: [1]

Adult dose

IV, first opioid

0.2 to 1 mg every 2 to 3 hours, given slowly over at least 2 to 3 minutes; lower in older or debilitated patients.

Subcutaneous or IM, first opioid

1 to 2 mg every 2 to 3 hours as needed; may start lower in opioid-naive patients.

Oral tablets

2 to 4 mg every 4 to 6 hours as needed.

Oral solution (1 mg/mL)

2.5 to 10 mg (2.5 to 10 mL) every 3 to 6 hours as needed.

Sources: [1][2]

Renal adjustment

Begin with 25% to 50% of the normal starting dose, scaled to how impaired the kidneys are, and monitor closely during titration.

Sources: [1]

Hepatic adjustment

Moderate impairment raises exposure about 4-fold: start at one-fourth to one-half the usual starting dose and monitor closely. Severe impairment has not been studied, and exposure is expected to be higher still.

Sources: [1][2][3]

Mechanism

A full opioid agonist, relatively selective for mu receptors, with no ceiling for analgesia; dosing is limited by respiratory and CNS depression. It depresses brainstem respiratory centers, causes miosis, slows GI motility, and causes vasodilation from histamine release. It is extensively glucuronidated in the liver to hydromorphone-3-glucuronide; the IV half-life is about 2.3 hours. Moderate hepatic impairment raises exposure about 4-fold.

Sources: [1][2][3]