Case #2 Answers:

 

 

 

 

 

 

 

 

 

 

 

 

 

Answer 1

Avinza = 180 mg
Hydromorphone  20 mg x 6 doses = 120 mg hydromorphone po

Based on various equianalgesia charts, when switching between opioids, you need to know:   
30 mg po morphine = 7.5 mg po hydromorphone. 

Now if we set up cross multiplication, solve for X: 

120 mg hydromorphone         =            X  mg morphine 
 7.5 mg hydromorphone                    30 mg morphine     

 X = (120 x 30) = 3600  = 480 mg morphine 
             7.5            7.5

480 mg + 180 mg = 660 mg po morphine in 24 hours.

 

 

 

 

 

 

 

 

Answer 2

660 mg po morphine divided by 3 = 220 mg IV morphine.
This is roughly equivalent to 10 mg/hr morphine for her basal infusion.

 

 

 

 

 

 

 

 

 

Answer 3

5 mg every 10 mins

 

 

 

 

 

 

 

 

 

Answer 4

300 mg IV morphine X 3 =  900 mg po morphine.  Divide by 2 to equal 450 mg po q 12 hours.  In the hospital you just put that order in, but if you were to write  prescriptions for discharge then you need to know how the tabs come.

 

 

 

 

 

 

 

 

 

Answer 5

A bowel program was started and included:  a stool softener (colace 100 mg twice a day), milk of magnesia,  a laxative (senekot), and a suppository (dulcolax) if no response occurred in two days.

 

 

 

 

 

 

 

Answer 6

Continue to provide symptom relief:  compazine 10 IM or 25 mg suppository  

Tigan 400 mg suppository
Zofran 4-8 mg IV, po, or ODT(oral dissolvable tablet)
Reglan 10 mg IV or po
Hydroxyzine 25-50 mg IM

 Consider changing to different opioid:  dilaudid, fentanyl

 Make sure the patient is not constipated 

Unrelenting nausea with dry heaves:  consider nalaxone.  But would titrate in:  dilute 1 amp narcan (o.4 mg/ml) into 10 ml normal saline.  Final concentration = 40 mcg/ml;  give 1 ml IVP at a time til symptoms abate/reduce.  Give 2-5 minutes between doses so as not to reverse analgesia. If you give 1 amp all at once you will reverse analgesia and have sympathetic surge that may include N/V.

Narcan is short acting, may need to be repeated or start narcan infusion titrated to relieve N/V while maintaining  analgesia.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Answer 7

Switch to a different sustained release opioid: 

Fentanyl patch.   Take total 24 hour ORAL morphine dose, divide by 2 and round off to closest patch.  900 mg po morphine divided by 2 = 450  mcg/hour fentanyl. This is accomplished by placing 4 - 100 mcg/hr patches and 1 – 50 mcg/hr patch on her trunk. 

Oxycontin:  2/3 of 900 mg oral morphine = 600 mg oxycontin po/day or 180 mg po q 8 hours.