How do you order Dilaudid (hydromorphone) Patient-Controlled Analgesia (PCA) for a hospice patient in the Intensive Care Unit (ICU)?

Ordering Dilaudid PCA for a Hospice Patient in the ICU

For a hospice patient in the ICU requiring Dilaudid (hydromorphone) PCA, initiate with a continuous basal infusion plus demand dosing: start with 0.2-0.4 mg/hour continuous infusion, demand dose of 0.2-0.4 mg every 10-15 minutes (lockout interval), no 1-hour or 4-hour limits given the palliative goals, and always prescribe a bowel regimen with stimulant or osmotic laxatives unless contraindicated. 1, 2, 3

Initial PCA Programming Parameters

For Opioid-Naïve Patients

• Continuous basal infusion: 0.2-0.4 mg/hour 2, 3
• Demand (bolus) dose: 0.2-0.4 mg (equal to hourly infusion rate) 2
• Lockout interval: 10-15 minutes 2
• No hourly or 4-hour limits in hospice patients, as there is no maximum dose ceiling when titrating for comfort 2

For Opioid-Tolerant Patients

• Calculate equianalgesic dose from current regimen using a 5:1 conversion ratio if converting from IV morphine (10 mg IV morphine = 2 mg IV hydromorphone) 2, 4
• Reduce calculated dose by 25-50% to account for incomplete cross-tolerance 2, 4
• Continuous infusion: Start with the calculated hourly equivalent 2
• Demand dose: 10-20% of total 24-hour opioid dose, or equal to/double the hourly infusion rate 2
• Lockout interval: 10-15 minutes 2

Titration Protocol

Breakthrough Pain Management

• If patient requires breakthrough dosing: Give a bolus equal to or double the hourly infusion rate 2
• If two bolus doses are needed within one hour: Double the continuous infusion rate 2
• Reassess pain control every 15 minutes after each demand dose to determine if further titration is needed 2, 3

Dose Escalation Strategy

• The correct dose is that which adequately relieves pain without unacceptable adverse effects—there is no ceiling dose for hydromorphone in palliative care 2
• Titrate using small incremental IV doses with rapid titration as the preferred approach 1, 2
• If pain control remains inadequate after 2-3 cycles of breakthrough dosing, increase the basal infusion rate rather than shortening intervals 2

Special Population Adjustments

Renal Impairment

• Start with one-fourth to one-half the usual dose 1, 2, 3
• Hydromorphone is safer than morphine in renal failure, but active metabolites can still accumulate between dialysis treatments 1, 2
• Use cautiously and monitor for myoclonus, which may indicate metabolite accumulation 1

Hepatic Impairment

• Start with one-fourth to one-half the usual dose 2, 3
• Reduce dose rather than extending intervals 2

Essential Concurrent Orders

Bowel Regimen (Critical)

• Prescribe a stimulant laxative (e.g., senna) or osmotic laxative (e.g., lactulose) at PCA initiation 1, 2
• This is mandatory unless contraindications exist (bowel obstruction, diarrhea) 1
• Constipation is the most persistent opioid side effect and does not abate with continued treatment 1

Monitoring Parameters

• Track bowel function as a basic component of ICU monitoring 1
• Monitor for myoclonus, especially with chronic use, renal failure, or electrolyte disturbances 1, 2
• Assess for hypotension, sedation, and respiratory depression, though in hospice patients comfort takes priority over these concerns 1

Sample Order Set

Hydromorphone PCA Order:

• Concentration: 0.2 mg/mL or 1 mg/mL (depending on institutional protocol)
• Continuous infusion: 0.2-0.4 mg/hour (adjust based on opioid tolerance)
• Demand dose: 0.2-0.4 mg
• Lockout interval: 10-15 minutes
• 1-hour limit: None (hospice patient)
• 4-hour limit: None (hospice patient)

Concurrent Orders:

• Senna 2 tablets PO twice daily OR docusate/senna combination
• Lactulose 15-30 mL PO twice daily if senna ineffective
• Antiemetic PRN (ondansetron 4 mg IV q8h PRN or scheduled if nausea develops)

Common Pitfalls to Avoid

Do Not Use Background Infusions Inappropriately

• While continuous background infusions are contraindicated in postoperative PCA for elderly patients 5, they are appropriate and recommended for hospice patients where the goal is continuous comfort rather than recovery 6, 7

Do Not Underdose

• Hydromorphone is 5-7 times more potent than morphine, meaning physicians may be more comfortable prescribing adequate analgesia with smaller milligram amounts 2
• The quicker onset of action (compared to morphine) supports more frequent dosing intervals for optimal pain control 2

Do Not Forget Bowel Prophylaxis

• Failure to prescribe laxatives at PCA initiation is a critical error that will lead to preventable suffering 1, 2

Do Not Set Arbitrary Dose Limits

• In hospice patients, there is no maximum dose—titrate to comfort 2
• Removing 1-hour and 4-hour limits allows appropriate symptom management in the palliative setting 2

Rationale for Hydromorphone in This Setting

• All IV opioids are equally effective when titrated to similar pain endpoints 1
• Hydromorphone has a quicker onset of action than morphine, making it particularly suitable for breakthrough pain 2
• Smaller volume administration due to higher potency may be beneficial in fluid-restricted ICU patients 2
• Hydromorphone is safer than morphine in renal failure (though still requires dose adjustment) 1, 2