Medication Conservation Guidelines

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Recommendations for Conservation of Critical Medications - Pain and Sedation

Last update: April 6, 2020

Refer to the tables below for alternative agents for both COVID +/PUI as well as for all critically ill patients.

For conservation of continuous IV sedatives

If patient is receiving continuous IV sedation for > 48 hours, not on vasopressor support, NPO or paralyzed, and use is expected to continue consider scheduling one of the below agents.

Scheduled

Chlordiazepoxide

  • PO/NGT: 25-100 mg q6hr
    (Increase each dose by 25 mg every 24 hrs to a max daily dose of 400 mg)
  • NPO: None

Clonidine

  • PO/NGT: 0.2-0.3 mg q6hr
    (Titrate up every 24 hrs to a max daily dose of 2.4 mg)
  • NPO: consider SL administration
  • ADE: hypotension

Hold if SBP < 90

Wean over 3-5 days to avoid rebound sympathetic hyperactivity

SL = PO bioavailability

Ideal agent for alcohol or opioid withdrawal symptoms/agiation

Gabapentin

  • PO/NGT: Load 800 mg x 1, followed by 300-900 mg q8hr
    (Titrate up every 24 hrs to a max daily dose of 3200 mg)
  • NPO: None

Utilize liquid only for patients receiving medications via feeding tube

Adjust frequency to q12h or q24h for patients with an AKI or CKD

No weaning required

Ideal agent for alcohol or opioid withdrawal symptoms/agitation. If using for withdrawal, minimum starting dose 600 mg q8H

Olanzapine

  • PO/NGT: 5-10 mg q12-24hr
  • NPO: 5-10 mg IM q12-24hr
  • (Titrate up every 24 hrs to a max daily dose of 20 mg combined PO/IM)
  • Black Box warning: IM olanzapine + IM lorazepam

Start with 2.5 mg PO/IM in patients with history of dementia

ODT tablets need to be dissolved and swallowed for optimal effect

Phenobarbital

  • *Load all patients with 5-10 mg/kg IBW IVPB over 30 mins*
    (May repeat 30 minutes after completion of previous infusion up to two times)
  • PO/NGT: 64.8-97.2 mg PO/NGT q8h (max daily dose 20mg/kg IBW*)
  • NPO: No recommendation for scheduled, utilize PRN’s: 130 mg IV over 3 mins or 260 mg IV over 5 mins q4hr (max daily dose 20mg/kg IBW*)
  • ADE: respiratory depression with rapid administration, dermatologic reactions, hypotension
  • Drug-drug interactions: CYP 3A4 inducer

Contains propylene glycol

May check serum trough levels if needed (goal < 20). *Max dose may be higher as directed by TDM

Ideal agent for agitation or symptoms related to alcohol withdrawal

Quetiapine

  • PO/NGT: 25-100 mg q8-12hr
    (Titrate up every 12-24 hrs to a max daily dose of 300 mg)
  • NPO: None

Ideal agent for agitation and to promote sleep 

Valproate/divalproex

  • PO/NGT: 500-1000 mg q8hr
    (Titrate up to a max daily dose of 3000 mg*)
  • NPO: 500-1000 mg IV q8hr
    (Titrate up to a max daily dose of 3000 mg*)
  • ADE: hyperammonemia, thrombocytopenia, hepatotoxicity
  • Drug-drug interactions: (Meropenem decreases VPA concentration, phenobarbital increases VPA concentration)

Not recommended in liver insufficiency

No weaning necessary

Contraindicated in pregnancy

May check serum levels if needed (goal < 100) *Max dose may be higher as directed by TDM or ADE

PO/NGT formulation should be divalproex sprinkle capsules

Ideal agent for agitation related to traumatic brain injury

PRN

Chlorpromazine

25-50 mg IV/IM q6-8H PRN

(If IV min infusion rate 1 mg/min due to hypotension)

  • ADE: QTc prolongation, EPS
  • Hypotension: IV >> IM
Haloperidol

5-10 mg IV q4hr PRN

  • ADE: QTc prolongation, EPS

Ketamine

4-5 mg/kg IM

  • ADE: emergence reaction, hypersalavation, tachycardia

If emergence reactions develop treat with lorazepam 2 mg IV

Olanzapine

5-10 mg IM PRN q8hr

Phenobarbital

130 mg IV over 3 mins or 260 mg IV over 5 mins q4hr max daily dose 20mg/kg IBW)

Preferred agent for agitation related to alcohol withdrawal

Ziprasidone

10-20 mg IV PRN q4hr

  • ADE: QTc prolongation
  • EPS = extrapyramidal symptoms
  • If HR < 60 bpm use QT and not QTc for medication monitoring
  • *all PO meds are 90-100% bioavailable

For conservation of continuous IV opioids

If patient is receiving continuous IV opioids for > 48 hours, not on vasopressor support, NPO or paralyzed, and use is expected to continue add scheduled oxycodone and consider alternative agents as outlined below:

  • Fentanyl < 100 mcg/hr: initiate oxycodone 15-30 mg q4H + IV fentanyl q1h prn
  • Fentanyl 100-150 mcg/hr: initiate oxycodone 30-45 mg q4
  • Fentanyl 150-200 mcg/hr: initiate oxycodone 45-60 mg q4
  • Fentanyl > 200 mcg/hr: initiate oxycodone 60-90 mg q4H

Alternatively:

  • Fentanyl patch 100 mcg/hr + IV fentanyl q1h PRN
  • Adjust fentanyl patch dose every 72h based on how much PRN fentanyl pt is requiring

Scheduled

Acetaminophen

  • PO/NGT: 500-1000 mg q8-6hr (Max 4000 mg/day, in patients with liver dysfunction 2000 mg/day)
  • NPO: None

Gabapentin

  • PO/NGT: 300-900 mg q8hr (Titrate up every 24 hrs to a max daily dose of 3200 mg)
  • NPO: None

Utilize liquid only for patients receiving medications via feeding tube

Not recommended in patients with AKI or CKD

No weaning required

Ideal agent for neuropathic pain

Ketorolac

  • PO/NGT: 10 mg q4-6h prn
  • NPO: 15 mg IV q6h x 72 hr

Maximum 5 days total duration of therapy combined IV/PO

Avoid in patients with CHF or cirrhosis

Lidocaine

  • Patch: 5% patch on for 12 hours and off for 12 hours before reapplying (max of 3 patches/day)
  • IV: 1-2 mg/kg bolus followed by 0.5-2 mg/kg/hr
  • ADE: blurred vision, numbness, dizziness, N/V, hearing alterations, tremors

CI in patients with allergies to amide local anesthetics

Use lower doses in patients with renal, cardiac and hepatic dysfunction

Consider IBW in patients with BMI > 40 kg/m2

Level: >5 - CNS toxicities. Consider if using for >36 hours

Methadone

*Start if patient has been on continuous IV opioids for at least 72 hrs*

  • PO/NGT: 5-20 mg q8hr
  • NPO: 5-15 mg IV q8hr
    (Titrate up to a max daily dose of 45 mg IV)
QTc prolongation
  • IV > PO · Continuous telemetry monitoring required for patients on multiple QTc prolonging medications
  • Careful consideration of IV methadone in patients receiving hydroxychloroquine +/- azithromycin

Drug-drug interactions: CYP 3A4 substrate

1:2 IV:PO

Consult with clinical pharmacist for dosing recommendations and opioid infusion titrations1

Methocarbamol

PO/NGT: 500-1000 mg q6-8hr

NPO: 500-1000 mg IV q6-8hr

Ideal agent for musculoskeletal pain or spasms
1. Convert IV+PO opioid requirements to morphine equivalents. Utilize Lexicomp methadone dosing recommendations based on morphine equivalents for initial starting dose. After second dose of methadone attempt to wean opioid infusion via PAD bundle down titration. May need additional methadone up titration based on response and CPOT/SAS scores