What nursing‑administered hydromorphone bolus dose should be given for an opioid‑naïve adult with breakthrough pain ≥4/10 on patient‑controlled analgesia, and how should the dose and interval be adjusted for patients ≥70 years or with moderate renal impairment (creatinine clearance < 60 mL/min) or hepatic impairment?

Nursing-Administered Hydromorphone Bolus Dosing for Breakthrough Pain on PCA

For an opioid-naïve adult with breakthrough pain ≥4/10 on PCA, administer a nursing bolus of 0.4–0.8 mg IV hydromorphone (2–4 times the PCA demand dose), repeated every 15 minutes as needed until pain is ≤3/10. 1

Standard Nursing Bolus Protocol

For patients on continuous hydromorphone infusion:

• Give a bolus equal to 2× the hourly infusion rate every 15 minutes as needed for breakthrough pain or respiratory distress 2
• If the patient receives 2 bolus doses within 1 hour, double the infusion rate 2
• Reassess pain intensity and sedation every 15 minutes during active titration 1

For opioid-naïve patients not yet on continuous infusion:

• Start with 0.4–0.8 mg IV (equivalent to 2–4× a typical 0.2 mg PCA demand dose) 1
• Repeat every 15 minutes if pain remains ≥4/10 2, 1
• If pain is unchanged after the initial bolus, increase the next dose by 50–100% 3
• Continue until numeric rating scale (NRS) is ≤3 in two consecutive 15-minute intervals 4

Dose Adjustments for Special Populations

Elderly Patients (≥70 Years)

Reduce all bolus doses by 50%:

• Initial nursing bolus: 0.2–0.4 mg IV (instead of 0.4–0.8 mg) 1
• Lockout interval: extend to 10 minutes (instead of 6–8 minutes) 1
• Maximum hourly dose: limit to 1–1.5 mg (instead of 2–3 mg) 1
• The FDA label recommends starting elderly or debilitated patients at the lower end of the dosing range, as low as 0.2 mg IV 5

Moderate Renal Impairment (CrCl < 60 mL/min)

Reduce bolus doses by 50% and extend intervals:

• Initial nursing bolus: 0.2–0.4 mg IV 1
• Extend lockout to 10–15 minutes 1
• Hydromorphone is preferred over morphine in renal impairment because it lacks active metabolites that accumulate 2, 6
• For CrCl < 30 mL/min, the FDA label recommends starting at one-fourth to one-half the usual dose 5
• Fentanyl remains the safest option in severe renal failure (CrCl < 30 mL/min), but reduced-dose hydromorphone is acceptable 6, 7

Hepatic Impairment (Moderate)

Reduce bolus doses by 50%:

• Initial nursing bolus: 0.2–0.4 mg IV 1
• Set lockout to 10 minutes 1
• The FDA label specifies starting at one-fourth to one-half the usual dose depending on severity of impairment 5
• Hydromorphone undergoes glucuronidation, which may be impaired in hepatorenal syndrome 3

Titration Algorithm for Breakthrough Pain

Step 1: Assess pain severity

• If NRS ≥4 after 2–3 PCA attempts, administer nursing bolus 1

Step 2: Initial bolus administration

• Opioid-naïve: 0.4–0.8 mg IV (reduce by 50% for elderly/renal/hepatic impairment) 1, 5
• Opioid-tolerant on infusion: 2× hourly infusion rate 2
• Administer slowly over 2–3 minutes 5

Step 3: Reassess at 15 minutes

• If NRS remains ≥4 and unchanged: increase next bolus by 50–100% 3
• If NRS decreased but still 4–6: repeat the same dose 3
• If NRS ≤3: hold further boluses and reassess hourly 1

Step 4: Adjust baseline therapy

• If >10 PCA demands per hour or patient requires >3–4 nursing boluses per day, increase the PCA demand dose by 25–50% 1, 3
• For patients on basal infusion requiring 2 boluses in 1 hour, double the infusion rate 2

Critical Safety Monitoring

Continuous monitoring requirements:

• Oxygen saturation, respiratory rate, and sedation level must be monitored throughout bolus administration 1
• Use a validated sedation scale (e.g., Pasero Opioid-Induced Sedation Scale) and intervene before respiratory depression develops 1
• Naloxone 0.4 mg IV must be immediately available; if needed, administer 0.04–0.08 mg IV every 30–60 seconds until respiratory rate improves 1

Respiratory depression risk:

• Respiratory depression can occur at any time, especially during initiation and after dose increases 5
• The 15-minute interval matches hydromorphone's IV onset (5–15 min) and peak effect (≈15 min) 2, 1
• Never set intervals <6 minutes; shorter intervals allow dose stacking before peak effect 1

Common Pitfalls and Avoidance Strategies

Do not simply increase the hourly PCA limit when pain remains uncontrolled:

• Instead, give a clinician-administered bolus and reassess the PCA settings 1
• Increasing only the hourly maximum without adjusting demand dose or giving a bolus leaves the patient undertreated 1

Do not use basal infusions in opioid-naïve patients:

• Demand-only dosing minimizes oversedation risk 1
• Reserve basal infusions only for opioid-tolerant patients with stable requirements 1

Do not forget incomplete cross-tolerance:

• When converting from other opioids, reduce the calculated hydromorphone dose by 25–50% 2, 8
• IV morphine to IV hydromorphone uses a 5:1 ratio (10 mg IV morphine ≈ 2 mg IV hydromorphone) 2, 8

Do not neglect supportive care:

• Implement a stimulant laxative regimen for all patients receiving sustained hydromorphone 1
• Provide prophylactic antiemetics (e.g., ondansetron 4 mg IV q8h) for patients with history of opioid-related nausea 1

Opioid-Tolerant Patients

Calculate equianalgesic requirements:

• Use the 5:1 morphine-to-hydromorphone ratio for IV conversions 2, 8
• Set nursing bolus at 2× the hourly infusion rate for breakthrough pain 2
• Consider a basal infusion at 50% of calculated hourly requirement with demand doses for breakthrough 1
• Reduce calculated dose by 25–50% when converting between opioids to account for incomplete cross-tolerance 2, 8