Hydromorphone epidural

When epidural morphine (Duramorph 10 micrograms/ kg/hour) was compared with epidural fentanyl (1 micro-gram/kg/hour) and epidural hydromorphone (1 micro-gram/kg/hour) in 90 children undergoing orthopedic procedures, hydromorphone was considered to be safe and efficacious (4). The combined incidences of pruritus, nausea, and vomiting were 25, 20, and 10% respectively and for pruritus alone 35,15, and 8% respectively. 

Hydromorphone. Early respiratory depression has been reported when droperidol was given 10 minutes before epidural hydromorphone 1.25 mg the patient beeame apnoeic 15 minutes after the epidural was given. Naloxone did not reverse the respiratory depression, but spontaneous ventilation resumed within 3 minutes of a 1-mg intravenous dose of physostigmine. ... 

Off-label use has been reported for treatment of refractory erythromelalgia, and good pain relief is achieved with a combination of epidural hydromorphone and clonidine. 

Reported epidural therapeutic doses for treatment of acute pain in adults are 0.5-1.5 mg diluted in normal saline to a total volume of 5-15 mL. This can be supplemented with a continuous infusion of 0.2 mg/h. The epidural hydromorphone needs to be preservative free, and the standard 2 and 4 mg/mL single dose vials fulfill this requirement. The spread of analgesia can be increased by increasing the diluent to 15 mL, and if epinephrine is added to the solution at 1 200 000 concentration, the onset of action is hastened and the duration of action is prolonged [5,6]. 

Brodsky JB, Chaplan SR, Brose WG, Mark JBD. Continuous epidural hydromorphone for postthoracotomy pain relief. Ann Ihorac Surg 1990 50 888-893. 

Epidural hydromorphone s primary site of action is at endogenous opioid receptors located on neurons in lamina 1-11 (substantia gelatinosa) and lamina V of the spinal dorsal horn. Following epidural administration, hydromorphone enters the spinal cord and activates pre- and postsynaptic mu receptors and suppresses pain transmission. Systemic absorption and activation of central opioid receptors may provide additional analgesia. Hydromorphone is not particularly hydrophilic, and rostral migration in CSF is of lower magnitude than that observed with morphine. Rostral spread of hydromorphone may result in undesirable side effects such as pruritus, nausea and vomiting, and sedation. Epidural hydromorphone is associated with dose-dependent reductions in respiratory rate and minute ventilation however, unlike morphine, delayed-onset respiratory depression is less likely to occur [3,4]. 

Surgical acute pain epidural hydromorphone alone or in combination with dilute local anesthetics can effectively relieve moderate to severe surgical pain. 

Chronic pain infusions of intrathecal and epidural hydromorphone maybe employed for control of chronic benign and malignancy-related pain. 

Common adverse events sedation, respiratory depression, pruritus, nausea/vomiting, constipation, and urinary retention, which are treated with a naloxone 40-80 pg IV bolus followed by an infusion of 50-100 pg/h. However, these adverse events are relatively less commonly observed with epidural hydromorphone than with neuraxial morphine regimens. Pruritus is treated with a naloxone infusion of 50-100 pg/h, diphenhydramine 12.5-50 mg or propofol infusion of 10 mg/h. Nausea and vomiting is best treated with either ondansetron (4-8 mg IV), low-dose droperidol (0.625-1.25 mg IV), metoclopramide (10 mg IV every 4-6 h), or transdermal scopolamine patch during the first 10 hours following administration. 

Opioids maybe administered in a variety of routes including oral (tablet and liquid), sublingual, rectal, transdermal, transmucosal, intravenous, subcutaneous, and intraspinal. While the oral and transdermal routes are most common, the method of administration is based on patient needs (severity of pain) and characteristics (swallowing difficulty and preference). Oral opioids have an onset of effect of 45 minutes, so intravenous or subcutaneous administration maybe preferred if more rapid relief is desired. Intramuscular injections are not recommended because of pain at the injection site and wide fluctuations in drug absorption and peak plasma concentrations achieved. More invasive routes of administration such as PCA and intraspinal (epidural and intrathecal) are primarily used postoperatively, but may also be used in refractory chronic pain situations. PCA delivers a self-administered dose via an infusion pump with a preprogrammed dose, minimum dosing interval, and maximum hourly dose. Morphine, fentanyl, and hydromorphone are commonly administered via PCA pumps by the intravenous route, but less frequently by the subcutaneous or epidural route. 

Epidural analgesia is frequently used for lower extremity procedures and pain (e.g., knee surgery, labor pain, and some abdominal procedures). Intermittent bolus or continuous infusion of preservative-free opioids (morphine, hydromorphone, or fentanyl) and local anesthetics (bupivacaine) may be used for epidural analgesia. Opiates given by this route may cause pruritus that is relieved by naloxone. Adverse effects including respiratory depression, hypotension, and urinary retention may occur. When epidural routes are used in narcotic-dependent patients, systemic analgesics must also be used to prevent withdrawal since the opioid is not absorbed and remains in the epidural space. Doses of opioids used in epidural analgesia are 10 times less than intravenous doses, and intrathecal doses are 10 times less than epidural doses (i.e., 10 mg of IV morphine is equivalent to 1 mg epidural morphine and 0.1 mg of intrathecally administered morphine).45... 

A hypertensive crisis and myocardial infarction occurred in a 62-year-old woman after a combined injection of hydromorphone 48 mg and clonidine 12 mg subcutaneously in an attempt to refill an implanted epidural infusion pump (42). She was immediately treated with naloxone, but she subsequently had accelerated hypertension, a brief tonic-clonic seizure, and an anteroseptal myocardial infarction. Cardiac catheterization showed no coronary narrowing or blockage, but an anterior infarct was confirmed. 

Goodarzi M. Comparison of epidural morphine, hydromorphone and fentanyl for postoperative pain control in children undergoing orthopaedic surgery. Paediatr Anaesth 1999 9(5) 419-22. 

Myoclonic seizures after epidural morphine 25 mg/hour and after intrathecal hydromorphone have been reported (149). 

Effective in the management of severe postoperative, chronic, or cancer pain. Spinal opioids can be administered by a single bolus injection into the epidural or subarachnoid space or by continuous infusion via an indwelling catheter. Dosage requirement by these routes is significantly less than with IV administration (epidural opioid doses 10-fold lower than IV doses intrathecal opioid doses 100-fold lower than IV doses). Morphine, hydromorphone, fentanyl, and sufentanil are effective when administered intrathecally. The most commonly used local anesthetic in continuous epidural infusions is bupivacaine. Fentanyl, morphine, or hydromorphone is usually combined with bupivacaine for epidural infusions. 

Drug administration route Patient-controlled epidural analgesia with bupivacaine 0.06% and hydromorphone 10 micrograms/ml in postoperative 3736 orthopedic patients was associated with nausea (30%), pruritus (15%), hypotension (10%), and sedation (0.08%) [105. Respiratory depression was not reported, and Acre were no epidural hematomas or abscesses. 

Liu SS, Bieltz M, Wukovits B, John RS. Prospective survey of patient-controlled epidural analgesia with bupivacaine and hydromorphone in 3736 postoperative orthopedic patients. Reg Anesth Pain Med 2010 35(4) 351. ... 

Hydromorphone is a semisynthetic opioid agonist prescribed for control of moderate to severe pain. It was first synthesized in 1924 and introduced by Knoll pharmaceuticals under the brand name Dilaudid . Intravenous hydromorphone is about 5-6 times more potent than morphine however, when administered epidurally, morphine provides greater spinal selectivity and 2-3 times greater analgesic potency than hydromorphone. Hydromophone is available as a... 

At Yale New Haven Hospital, epidural solutions are prepared by hospital pharmacy services by adding 5 mg (0.5 mL) preservative-free hydromorphone (taken from a mutidose vial of Dilaudid-HP 10 pg/mL) to a 500 mL normal saline solution. Calculated volumes of... 

Brose WG, Tanelian DL, et al. CSF blood pharmacokinetics of hydromorphone and morphine following lumbar epidural administration. Pain 1991 45 11-15. 

If you have relief over only part of the incisional site, consider infusing larger volumes of solution (14-16 mL/h). As above, consider giving an additional loading dose of 0.5 mg hydromorphone epidurally, or up to 2 mg hydromorphone if the patient is opioid-dependent. Also consider a more concentrated epidural infusion. 

If the patient is highly opioid-dependent, consider administering a more concentrated epidural infusion (hydromorphone 20-30 pg/mL plus bupivacaine 1/16 %). In addition, opioid-dependent patients will almost always require oral or IV opioid supplementation. They may benefit from combined IV-PCA hydromorphone (0.4-1 mg q 6 min) plus a continuous epidural infusion of more concentrated solution. Alternatively, parenteral doses of morphine... 

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