Vomiting hydromorphone

Hydromorphone is more potent than morphine by weight and is believed to produce analgesic effects four to eight times greater than morphine. Side effects are comparable to morphine with the exception of vomiting, which tends to be less frequent with hydromorphone use. 

Hydromorphone has comparable side effects to those produced by morphine use. This is true for sedation, respiratory depression, and constipation, but hydromorphone is associated with less vomiting than morphine. Nausea caused by hydromorphone and other opioids can be minimized by administering the drug along with food and having the patient lie down following administration. 

In a retrospective review of 37 patients with chronic non-malignant pain (mostly from failed lumbosacral spine surgery) treated with intrathecal hydromorphone there was an analgesic response in six of the 16 patients who were switched from morphine to hydromorphone because of poor pain relief (1). Opioid-related adverse effects, such as nausea, vomiting, pruritus, and sedation, were also reduced by hydromorphone in the 21 patients who were switched to hydromorphone because of morphine-related adverse effects, especially 1 month after use. These results should be treated cautiously, because of the limitations of a retrospective study that lacks strict inclusion criteria, with obvious population bias and under-reporting, and without standardized procedures for rotation to hydromorphone. 

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. 

PE On physical examination, her vital signs are T 37.6°C, BP 128/82 mm Hg, HR 84 beats/min, and RR 18 breaths/min. The pain is described as a chronic 9/10. Her current pain regimen includes oxycodone 10-20 mg every 4 to 6 hours as needed (prn) for pain (about 100 mg/day) and hydromorphone 0.8-1.2 mg IV every 1 to 2 hours prn for breakthrough pain (about 8 mg/day). Allergies (ALL) Morphine (itching, flushing), codeine (nausea, vomiting), meperidine (involuntary leg movements, and facial tics). 

Hydromorphone has the potential for abuse. Chronic users may develop tolerance, thus necessitating larger doses for the desired effect. Abrupt cessation can cause withdrawal, yielding restlessness, insomnia, hypertension, tachycardia, tachypnea, vomiting, and diarrhea. 

Hydromorphone hydrochloride is an opioid analgesic that relieves pain by stimulating opiate receptors in CNS it also causes respiratory depression, inhibition of cough reflex, peripheral vasodilation, inhibition of intestinal peristalsis, sphincter of Oddi spasm, stimulation of chemoreceptors that cause vomiting, and increased bladder tone. It is indicated for the relief of moderate to severe pain and control of persistent nonproductive cough. 

Hydromorphone binds to mu and delta opiod receptors in the central nervous system. It has no effect at the kappa, sigma, or epsilon opioid receptors. Activity at the mu receptors causes analgesia, but also miosis, urinary retention, constipation, hyperthermia, and euphoria. Other side effects such as respiratory depression, pruritus, nausea, vomiting, and development of tolerance are due to binding at both mu and delta receptors. Hydromorphone, unlike other opioids, also has a direct depressant effect on the respiratory brainstem center and the cough center in the medulla. 

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]. 

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. 

The adverse effects of extended-release hydromorphone are similar to other opioid medications with constipation, nausea, vomiting, pruritus, and urticaria being common. Other possible side effects include confusion, somnolence, euphoria, and respiratory depression. Respiratory depression is the most dangerous side effect of hydromorphone as it may result in hypoxia, coma, and death. Hydromophone should be used with caution in patients taking other CNS depressant medications. High doses of hydromorphone can result in the accumulation of neuroexcita-tory metabolites which may cause seizures and myoclonus. One advantage over morphine is that hepatic metabolites of hydromorphone have minimal analgesic or respiratory depressant activity. 

Common/serious adverse events for hydromorphone respiratory depression, dependence, tolerance, nau-sea/vomiting, constipation, sedation, primitus. 

Observational studies In 223 patients who were given intravenous hydromorphone 1 mg followed by an optional 1 mg 15 minutes later, there was oxygen desaturation in 5%, bradycardia in 10%, nausea in 13%, vomiting in 7%, and pruritus in 5% no serious adverse events were reported [Sl ]. 

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