Medication Conservation Guidelines

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