In this episode, I’ll discuss whether hydromorphone can be used as a continuous infusion in place of fentanyl for ICU patients on a ventilator.
Some hospitals are being faced with supply shortages of critical medications such as fentanyl, and are faced with using less ideal alternatives for continuous sedation and analgesia in ventilated ICU patients. Shout out to “Pharmacy Alex” for highlighting this.
One proposed alternative to fentanyl is hydromorphone. Hydromorphone is less ideal as an ICU analgesic because of its longer half-life and greater potential to accumulate in the setting of renal failure. However, unlike morphine, hydromorphone does not have metabolites that may cause unwanted side effects such as seizure with accumulation.
There is a small amount of data available that describes using continuous infusions of hydromorphone in place of fentanyl for ICU sedation and analgesia. The most detailed account is a 2013 single-center, prospective, observational analysis of transitioning patients from fentanyl to hydromorphone infusion.
Forty-six patients were included in the analysis. The reasons for transitioning to hydromorphone were ventilator compliance (28.3%), tachyphylaxis or better pain control (19.6%), and reduction in sedatives (13.0%).
The median fentanyl infusion rate of 100 mcg/hr was transitioned to 1 mg/hr of hydromorphone.
The transition appeared to be well tolerated as there was no difference in positive pain scores or the total amount of analgesics required in the 24 hours surrounding the transition period.
The depth of sedation was significantly deeper than contemporary guidelines recommend with the median RASS scores being -4 during the 24 hours prior to and after transition.
Many of the patients in the study had ARDS, and the transition appeared to be well tolerated whether or not the patient had ARDS.
Proprofol and midazolam requirements did drop after the transition to hydromorphone.
The study is limited by small size and its lack of any type of control group.
An abstract published in 2018 in Critical Care Medicine that analyzed 59 patients does seem to confirm the feasibility of switching from fentanyl to hydromorphone. In this study the median hydromorphone infusion rate was 1 mg/hr with a max of 2mg/hr.
The Hospital Quality Institute has published on their website a sedation guideline that does include hydromorphone infusion as an option for ICU patients. The suggested starting rate of 0.4 to 0.8 mg/hr hydromorphone is compared to fentanyl 25 to 50 mcg/hr in these guidelines. A bolus of hydromorphone IV 0.2 to 0.8 mg is considered every 10 minutes if pain control is inadequate, and the infusion is titrated by 0.2 to 0.4mg/hr each time the patient requires more than 2 bolus doses in a 1 hour period. The maximum rate is listed as 3mg/hr.
While the use of hydromorphone as a continuous infusion is less than ideal, this protocol is presented in a logical manner and is one I would consider if I had no better alternatives available.
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Hydromorphone gtt might also be clinically advantageous to Fent gtt for ECMO patients. I think you had some knucklehead you did a podcast interview with a few years back that eluded to the same thing.
Landolf_et_al-2020- Pharmacotherapy__The_Journal_of_Human_Pharmacology_and_Drug_Therapy
Great point Ash! Here is that podcast episode: https://pharmacyjoe.com/starting-extracorporeal-membrane-oxygenation-ed-ecmo-pharmacotherapy-interview-joe-bellezzo-md-ashkan-khabazian-pharmd/