Hydromorphone Hydrochloride (Dilaudid)

Anesthesia Implications

Classification: Opioid, Narcotic
Therapeutic Effects: Analgesia
Time to Onset: IV: immediate
IM: 15-30 minutes
Epidural: 5 minutes
Time to Peak: IV: 5-20 min
IM: 30-60 min
Epidural: 30 min
Duration: IV: 2-4 hrs
IM: 4-6 hrs
Epidural: 10-16 hrs

Primary Considerations

Side effects – hypotension, bradycardia, respiratory depression, urinary retention, sedation, drowsiness, euphoria, arterial/venous dilation, histamine release (pruritus, urticaria, bronchospasm), Meiosis, CTZ activation (nausea and vomiting), cough reflex supression. At high doses, there may be chest wall rigidity and the adrenocortical system will have blunted affects to stress.

Pruritus – can be treated with diphenhydramine (12.5 – 25 mg IV or IM every 6 hours PRN)

Nausea and Vomiting – can be treated with metoclopramide (10 mg IV every 6 hours PRN)

OB – Hydromorphone crosses the placenta and could produce respiratory depression in the neonate.

Urinary Retention – Naloxone (0.2 – 0.4 mg) is the typical treatment, but straight catheterization may be used as well where naloxone is not working or contraindicated.

Dose Reduction – reduce in the hypovolemic and elderly.

Drug interactions – central nervous system affects of hydromorphone will be potentiated by other CNS depressants. Analgesic affects can be potentiated/amplified/prolonged by alpha-agonists (dexmedetomidine). Diuretic affects can be reduced by using hydromorphone. Adding epinephrine to neuraxial doses will result in increased side effects and a prolonged motor blockade.

IV push dose

0.5 – 2.0 mg (0.01-0.04 mg/kg) PRN every 4-6 hours

IV infusion dose

0.1-0.5 mg/hr (2-10 mcg/kg/hr)
Typical dilution: 5mg in 100 ml crystalloid to make 50 mcg/ml

IM dose

2-4 mg PRN every 4-6 hours

Epidural bolus dose

1-2 mg (20-40 mcg/kg)
Typically 1-2 mg is diluted in 10 ml of PRESERVATIVE FREE normal saline

Epidural maintenance rate

0.15 – 0.30 mg/hr (2.0-3.5 mcg/kg/hr)
Typically 5 mg is diluted in 100 ml of local anesthetic/normal saline PRESERVATIVE FREE solution to make 50 mcg/ml

Spinal bolus dose

0.1 – 0.2 mg (2-4 mcg/kg)

Reversal

Naloxone 0.2-0.4 mg. See the Naloxone drug post. Always consider the possibilities of withdrawal in the narcotic dependent and pain that was previously covered by opioids.

Method of Action

Opioid agonist. Seven times more potent than morphine.

Metabolism

Hepatic