Introduction This Fast Fact will discuss appropriate ways to write opioid infusion titration orders. See Fast Fact # 34 for further information on the appropriate symptom management during a ventilator withdrawal.
A bad example: ‘Morphine 2-10mg/hour, titrate to pain relief.’ This order is commonly written for terminally ill patients and in the context of terminal ventilator withdrawals.
What is wrong with this order?
- It places full responsibility for dose titration upon the nurse.
- It provides no guidance regarding how fast to titrate (e.g. every hour, every shift?) or dose titration intervals (e.g. for poorly treated pain, should the dose be raised from 2 to 3 mg, 2 to 10 mg, other?).
- It poses the potential for overdosage by too zealous dose escalation and provides only one option for poorly controlled pain – increasing the continuous infusion rate.
- Given that it takes at least 8 hours to achieve steady-state blood levels after a basal dose change, it makes no pharmacological sense to dose escalate the basal dose more frequently than q 8 hours.
A better way to write this order: ‘Morphine 2 mg/hour and morphine 2 mg q 15 minutes for breakthrough pain (or 2 mg via PCA dose). RN may dose escalate the PRN dose to a maximum of 4 mg within 30 minutes for poorly controlled pain.’
Why is this better?
- This order is preferred as it provides a basal rate and a breakthrough dose. The breakthrough dose has a peak effect within 5-10 minutes. Thus, if the breakthrough dose is inadequate it can be safely increased, as often as every 15-30 minutes, to achieve analgesia – without a need for rapid upward titration of the basal rate.
- Reassess the need for a change in the basal rate no more frequently than every 8 hours; use the number of administered bolus doses as a rough guide when calculating a new basal rate. However, never increase the basal rate by more than 100% at any one time. When increasing the basal rate, always administer a loading dose so as to more rapidly achieve steady-state blood levels.
- Principles of Analgesic Use in the Treatment of Acute and Cancer Pain. 5th Ed. Glenview, IL: American Pain Society; 2003. Available at: http://www.ampainsoc.org/pub/principles.htm.
- Acute Pain Management Guideline Panel. Acute pain management: Operative or Medical Procedures and Trauma Clinical Practice Guideline. AHCPR Publication No. 92-0032. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.32241.
- Management of Cancer Pain. Clinical Practice Guideline No. 9; AHCPR Publication No. 94-0592.Rockville, MD. Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service; 1992, 1994. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.18803.
Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2006; 3rd Edition May 2015. Current version re-copy-edited April 2009; then again May 2015.
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