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High Alert
meperidine (me-per-i-deen)
Demerol
Classification
Therapeutic: opioid analgesics
Pharmacologic: opioid agonists
Schedule II
Pregnancy Category C
Indications
Moderate or severe pain (alone or with nonopioid agents). Anesthesia adjunct. Analgesic during labor. Preoperative sedation. Unlabeled Use: Rigors.
Action
Binds to opiate receptors in the CNS. Alters the perception of and response to painful
stimuli, while producing generalized CNS depression. Therapeutic Effects: Decrease in severity of pain.
Pharmacokinetics
Absorption: 50% from the GI tract; well absorbed from IM sites. Oral doses are
Plate # 0-Composite
pg 1 # 1
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Hypersensitivity to bisulfites (some injectable products); Recent (within 14 days) MAO inhibitor therapy; Severe respiratory insufficiency; OB: Chronic use may pose risk to the fetus including possible addiction;
Lactation: Excreted in breast milk and can cause respiratory depression in the infant.
Use Cautiously in: Head trauma;qintracranial pressure; Severe renal or hepatic
impairment; Acute asthma attack, COPD, hypoxia, or hypercapnea; Hypothyroidism;
Adrenal insufficiency; Alcoholism; Debilitated patients (dosepsuggested); Undiagnosed abdominal pain or prostatic hyperplasia; Patients with renal impairment, or
extensive burns; High-dose or prolonged therapy (⬎600 mg/day or ⬎2 days;qrisk of
CNS stimulation and seizures due to accumulation of normeperidine); Sickle cell
anemia (may requirepinitial doses); OB: Use during labor and delivery can cause
respiratory depression in the newborn; Pedi: Syrup contains benzyl alcohol, which
can cause “gasping syndrome” in neonates. Children haveqrisk of seizures due to
accumulation of normeperidine; Geri: Appears on Beers list; morphine recommended.
Adverse Reactions/Side Effects
CNS: SEIZURES, confusion, sedation, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp:
respiratory depression. CV: hypotension, bradycardia. GI: constipation, nausea,
vomiting. GU: urinary retention. Derm: flushing, sweating. Misc: allergic reactions
about half as effective as parenteral doses.
including ANAPHYLAXIS, physical dependence, psychological dependence, tolerance.
Distribution: Widely distributed. Crosses the placenta; enters breast milk.
Protein Binding: Neonates: 52%; Infants 3– 18 mo: 85%; Adults: 60– 80%.
Metabolism and Excretion: Mostly metabolized by the liver; some converted to
Interactions
Drug-Drug: Do not use in patients receiving MAO inhibitors or procarba-
normeperidine, which may accumulate and cause seizures. 5% excreted unchanged
by the kidneys.
Half-life: Neonates: 12– 39 hr; Infants 3– 18 mo: 2.3 hr; Children 5– 8 yr: 3 hr;
Adults: 2.5– 4 hr (qin impaired renal or hepatic function [7– 11 hr]).
TIME/ACTION PROFILE (analgesia)
ROUTE
ONSET
PEAK
DURATION
PO
IM
Subcut
IV
15 min
10–15 min
10–15 min
immediate
60 min
30–50 min
40–60 min
5–7 min
2–4 hr
2–4 hr
2–4 hr
2–3 hr
⫽ Canadian drug name.
⫽ Genetic Implication.
zine (may cause fatal reaction— contraindicated within 14 days of MAO inhibitor
therapy).qCNS depression with alcohol, antihistamines, and sedative/hypnotics. Administration of agonist/antagonist opioid analgesics may precipitate
opioid withdrawal in physically dependent patients. Nalbuphine or pentazocine
maypanalgesia. Protease inhibitors mayqeffects and adverse reactions (concurrent use should be avoided). Phenytoinqmetabolism and maypeffects. Chlorpromazine and thioridazine mayqthe risk of adverse reactions (concurrent use
should be avoided). May aggravate side effects of isoniazid. Acyclovir may q
plasma concentrations of meperidine and normeperidine.
Drug-Natural Products: Concomitant use of kava-kava, valerian, or chamomile canpCNS depression. St. John’s wort mayqserious side effects, concurrent
use is not recommended.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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Name /bks_53161_deglins_md_disk/meperidine
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Route/Dosage
PO, IM, Subcut (Adults): Analgesia— 50 mg q 3-4 hr; may beqas needed (not to
exceed 600 mg/24 hr). Analgesia during labor— 50– 100 mg IM or subcut when
contractions become regular; may repeat q 1– 3 hr. Preoperative sedation— 50–
100 mg IM or subcut 30– 90 min before anesthesia.
PO, IM, Subcut (Children): Analgesia— 1– 1.5 mg/kg q 3– 4 hr (should not exceed 100 mg/dose). Preoperative sedation— 1– 2 mg/kg 30– 90 min before anesthesia (not to exceed adult dose).
IV (Adults): 15– 35 mg/hr as a continuous infusion; PCA— 10 mg initially; with a
range of 1– 5 mg/incremental dose, recommended lockout interval is 6– 10 min
(minimum 5 min).
IV (Children): Continuous infusion— 0.5– 1 mg/kg loading dose followed by 0.3
mg/kg/hr, titrate to effect up to 0.5– 0.7 mg/kg/hr.
NURSING IMPLICATIONS
Assessment
● Assess type, location, and intensity of pain prior to and 1 hr following PO, subcut,
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pg 2 # 2
● Monitor patients on chronic or high-dose therapy for CNS stimulation
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and IM doses and 5 min (peak) following IV administration. When titrating opioid
doses, increases of 25– 50% should be administered until there is either a 50%
reduction in the patient’s pain rating on a numerical or visual analogue scale or
the patient reports satisfactory pain relief. A repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal.
An equianalgesic chart (see Appendix B) should be used when changing routes or
when changing from one opioid to another.
Assess BP, pulse, and respirations before and periodically during administration.
If respiratory rate is ⬍10/min, assess level of sedation. Dose may need to be decreased by 25– 50%. Initial drowsiness will diminish with continued use.
Assess bowel function routinely. Prevention of constipation should be instituted
with increased intake of fluids and bulk and with laxatives to minimize constipating effects. Stimulant laxatives should be administered routinely if opioid use exceeds 2– 3 days, unless contraindicated.
Prolonged use may lead to physical and psychological dependence and tolerance.
This should not prevent patient from receiving adequate analgesia. Most patients
who receive meperidine for pain do not develop psychological dependence. Progressively higher doses may be required to relieve pain with long-term therapy.
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(restlessness, irritability, seizures) due to accumulation of normeperidine metabolite. Risk of toxicity increases with doses ⬎600 m g/24 hr,
chronic administration (⬎2 days), and renal impairment.
Geri: Meperidine has been reported to cause delirium in the elderly; older adults
are at increased risk for normeperidine toxicity. Monitor frequently.
Pedi: Assess pediatric patient frequently; neonates, infants, and children are
more sensitive to the effects of opioid analgesics and may experience respiratory
complications, excitability and restlessness more frequently.
Lab Test Considerations: Mayqplasma amylase and lipase concentrations.
Toxicity and Overdose: If an opioid antagonist is required to reverse respiratory depression or coma, naloxone (Narcan) is the antidote. Dilute the 0.4-mg
ampule of naloxone in 10 mL of 0.9% NaCl and administer 0.5 mL (0.02 mg) by
direct IV push every 2 min. For children and patients weighing ⬍40 kg, dilute 0.1
mg of naloxone in 10 mL of 0.9% NaCl for a concentration of 10 mcg/mL and administer 0.5 mcg/kg every 2 min. Titrate dose to avoid withdrawal, seizures, and
severe pain. In patients receiving meperidine chronically, naloxone may
precipitate seizures by eliminating the CNS depressant effects of meperidine, allowing the convulsant activity of normeperidine to predominate. Monitor patient closely.
Potential Nursing Diagnoses
Acute pain (Indications)
Disturbed sensory perception (visual, auditory) (Side Effects)
Risk for injury (Side Effects)
Implementation
● High Alert: Accidental overdose of opioid analgesics has resulted in fatalities.
Before administering, clarify all ambiguous orders; have second practitioner independently check original order, dose calculations, and infusion pump settings.
Pedi: Medication errors with opioid analgesics are common in the pediatric population and include misinterpretation or miscalculation of doses and use of inappropriate measuring devices.
● Explain therapeutic value of medication prior to administration to enhance the analgesic effect.
● Regularly administered doses may be more effective than prn administration. Analgesic is more effective if given before pain becomes severe.
● Coadministration with nonopioid analgesics may have additive analgesic effects
and permit lower doses.
䉷 2015 F.A. Davis Company
CONTINUED
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CONTINUED
meperidine
● Oral dose is ⬍50% as effective as parenteral. When changing to oral administra-
tion, dose may need to be increased (see Appendix B).
● Medication should be discontinued gradually after long-term use to prevent with-
drawal symptoms.
● May be administered via PCA pump.
● PO: Doses may be administered with food or milk to minimize GI irritation. Syrup
should be diluted in half-full glass of water.
● IM: Administration of repeated subcut doses may cause local irritation.
IV Administration
● pH: 3.5– 6.0.
● Direct IV: Diluent: Dilute with sterile water or 0.9% NaCl for injection. Con-
centration: ⱕ10 mg/mL. Rate: High Alert: Administer slowly over at least 5
min. Rapid administration may lead to increased respiratory depression, hypotension, and circulatory collapse.
● Intermittent Infusion: Diluent: Dilute with D5W, D10W, dextrose/saline combinations, dextrose/Ringer’s or lactated Ringer’s injection combinations, 0.45%
NaCl, 0.9% NaCl, or Ringer’s or LR. Administer via infusion pump. Concentration: 1 mg/mL. Rate: Administer over 15– 30 min.
● Y-Site Compatibility: alemtuzumab, alfentanil, amifostine, amikacin, aminocaproic acid, aminophylline, amiodarone, anidulafungin, argatroban, ascorbic acid,
atracurium, atropine, azithromycin, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, busulfan, calcium chloride, calcium gluconate, carboplatin,
carmustine, caspofungin, cefazolin, cefotaxime, cefoxitin, ceftaroline, ceftazidime, ceftriaxone, cefuroxime, chlorpromazine, ciprofloxacin, cisatracurium,
cisplatin, cladribine, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, daunorubicin, daunorubicin liposome, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine,
dobutamine, docetaxel, dolasetron, dopamine, doripenem, doxacurium, doxorubicin hydrochloride, doxycycline, droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, filgrastim,
⫽ Canadian drug name.
⫽ Genetic Implication.
Plate # 0-Composite
pg 3 # 3
floxuridine, fluconazole, fludarabine, fluorouracil, folic acid, fosphenytoin, gemcitabine, gentamicin, glycopyrrolate, granisetron, hetastarch, hydrocortisone sodium phosphate, ifosfamide, insulin, irinotecan, isoproterenol, ketamine, ketorolac, labetalol, leucovorin calcium, levofloxacin, lidocaine, linezolid, mannitol,
mechlorethamine, melphalan, mesna, metaraminol, methotrexate, methyldopate,
metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitomycin,
mitoxantrone, morphine, multivitamins, mycophenolate, naloxone, nitroglycerin,
nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin,
oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, papaverine, pemetrexed, penicillin G, pentamidine, phentolamine, phenylephrine, phytonadione, piperacillin/tazobactam, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, propofol, propranolol, protamine,
pyridoxime, quinupristin/dalfopristin, ranitidine, remifentanil, rituximab, rocuronium, sargramostim, sodium acetate, streptokinase, streoptzocin, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, topotecan,
trastuzumab, trimetaphan, vancomycin, vasopressin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine, zoledronic acid.
● Y-Site Incompatibility: allopurinol, amphotericin B cholesteryl, amphotericin
B colloidal, amphotericin B liposome, azathioprine, cefepime, cefoperazone,
dantrolene, diazepam, diazoxide, ganciclovir, idarubicin, indomethacin, lorazepam, micafungin, nafcillin, pantoprazole, pentobarbital, phenobarbital, phenytoin, sodium bicarbonate, thiopental.
Patient/Family Teaching
● Instruct patient on how and when to ask for and take pain medication.
● Instruct patient to take meperidine as directed. If dose is less effective after a few
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weeks, do not increase dose without consulting health care professional. Pedi:
Teach parents or caregivers how to accurately measure liquid medication and to
use only the measuring device dispensed with the medication.
May cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving or other activities requiring
alertness until response to medication is known.
Advise patient to change positions slowly to minimize orthostatic hypotension.
Instruct patient to avoid concurrent use of alcohol or other CNS depressants.
Advise ambulatory patients that nausea and vomiting may be decreased by lying
down.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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Plate # 0-Composite
pg 4 # 4
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● Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelec-
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tasis.
Evaluation/Desired Outcomes
● Decrease in severity of pain without a significant alteration in level of conscious-
ness or respiratory status.
Why was this drug prescribed for your patient?
䉷 2015 F.A. Davis Company