General

High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error.

Pronunciation
me-PER-i-deen

Trade Name(s)

• Demerol

• pethidine

Controlled Substance Schedule
II

Pregnancy Category
Category C

Ther. class.
opioid analgesics

Pharm. class.
opioid agonists

Indications

• Moderate or severe pain (alone or with nonopioid agents)

• Anesthesia adjunct

• Analgesic during labor

• Preoperative sedation

Unlabelled Use(s):
Rigors

Action

Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli, while producing generalized CNS depression.

Therapeutic Effect(s):
Decrease in severity of pain

Pharmacokinetics

Absorption: 50% from the GI tract; well absorbed from IM sites. Oral doses are about half as effective as parenteral doses

Distribution: Widely distributed. Crosses the placenta; enters breast milk.

Protein Binding: Neonates: 52%; Infants 3–18 months: 85%; Adults: 60–80%

Metabolism and Excretion: Mostly metabolized by the liver; some converted to normeperidine, which may accumulate and cause seizures. 5% excreted unchanged by the kidneys

Half-life: Neonates: 12–39 hr; Infants 3–18 months: 2.3 hr; Children 5–8 yr: 3 hr; Adults: 2.5–4 hr (prolonged in impaired renal or hepatic function [7–11 hr]).

TIME/ACTION PROFILE (analgesia)

ROUTE	ONSET	PEAK	DURATION
PO	15 min	60 min	2–4 hr
IM	10–15 min	30–50 min	2–4 hr
Subcut	10–15 min	40–60 min	2–4 hr
IV	immediate	5–7 min	2–3 hr

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity

• Hypersensitivity to bisulfites (some injectable products)

• Pregnancy or lactation (chronic use)

• Recent (14–21 days) MAO inhibitor therapy

Use Cautiously in:

• Head trauma

• Increased intracranial pressure

• Severe renal, hepatic, or pulmonary disease

• Hypothyroidism

• Adrenal insufficiency

• Alcoholism

• Geri: Appears on Beers list. Geriatric patients (morphine recommended)

• Debilitated patients (dose reduction suggested)

• Undiagnosed abdominal pain or prostatic hyperplasia

• Labor (respiratory depression may occur in the newborn)

• Patients with renal impairment, or extensive burns

• High dose or prolonged therapy (>600 mg/day or >2 days; increased risk of CNS stimulation and seizures due to accumulation of normeperidine)

• Sickle cell anemia (may require reduced initial doses)

• Pedi: Neonates (syrup contains benzyl alcohol)

• Pedi: Children (increased risk of seizures due to accumulation of normeperidine)

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: physical dependence, psychological dependence, tolerance.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Interactions

Drug-Drug

• Do not use in patients receiving MAO inhibitors or procarbazine (may cause fatal reaction—contraindicated within 14–21 days of MAO inhibitor therapy)

• CNS depression with alcohol, antihistamines, and sedative/hypnotics

• Administration of agonist/antagonist opioid analgesics may precipitate opioid withdrawal in physically dependent patients

• Nalbuphine or pentazocine may analgesia

• Protease inhibitor antiretrovirals may effects and adverse reactions (concurrent use should be avoided)

• Phenytoin metabolism and may effects

• Chlorpromazine and thioridazine may the risk of adverse reactions (concurrent use should be avoided)

• May aggravate side effects of isoniazid

• Acyclovir may increase plasma concentrations of meperidine and normeperidine

Drug-Natural Products

• Concomitant use of kava, valerian or chamomile can CNS depression

• St. John's wort may increase serious side effects, concurrent use is not recommended

Route/Dosage

• PO, IM, SC, IV (Adults):
Analgesia—50–150 mg q 3–4 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, SC, IV (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 0f 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.

Availability

• Tablets: 50 mg, 100 mg

» Cost: 50 mg $99.04/100, 100 mg $188.37/100.

• Syrup (banana flavor): 50 mg/5 ml

• Injection: 10 mg/ml [canada], 25 mg/ml, 50 mg/ml, 75 mg/ml, 100 mg/ml

• In combination with: promethazine (Mepergan) and atropine. See combination drugs

Assessment

• Assess type, location, and intensity of pain prior to and 1 hr following PO, subcut, 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 Equianalgesic Dosing Guidelines) should be used when changing routes or when changing from one opioid to another

• Assess blood pressure, 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. Pedi: Neonates and infants are more susceptible to respiratory depression. Assess respiratory rate frequently

• 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

• Monitor patients on chronic or high-dose therapy for CNS stimulation (restlessness, irritability, seizures) due to accumulation of normeperidine metabolite. Risk of toxicity increases with doses >600 mg/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; children are more sensitive to the effects of opioid analgesics and may experience respiratory complications, excitability and restlessness more frequently

Lab Test Considerations

• May plasma 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. Do not confuse with morphine or hydromorphone; fatalities have occurred. 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

» Oral dose is <50% as effective as parenteral. When changing to oral administration, dose may need to be increased (see Equianalgesic Dosing Guidelines)

» Medication should be discontinued gradually after long-term use to prevent withdrawal 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 Adminstration:

• Direct IV:
Diluent: Dilute with sterile water or 0.9% NaCl for injection
Concentration: <=10 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.

• Syringe Compatibility:

» atropine

» chlorpromazine

» cimetidine

» dimenhydrinate

» diphenhydramine

» droperidol

» glycopyrrolate

» hydroxyzine

» ketamine

» metoclopramide

» midazolam

» ondansetron

» perphenazine

» prochlorperazine

» promazine

» promethazine

» ranitidine

» scopolamine

• Syringe Incompatibility:

» heparin

» morphine

» pantoprazole

» pentobarbital

• Y-Site Compatibility:

» amifostine

» amikacin

» ampicillin

» ampicillin/sulbactam

» atenolol

» aztreonam

bivalirudin

» bumetanide

» cefazolin

» cefotaxime

» cefoxitin

» ceftazidime

» ceftizoxime

» ceftriaxone

» cefuroxime

» chloramphenicol

» cisatracurium

» cladribine

» clindamycin

» dexamethasone

» dexmedetomidine

» digoxin

» diltiazem

» diphenhydramine

» dobutamine

» docetaxel

» dopamine

» doxycycline

» droperidol

» erythromycin lactobionate

» etoposide phosphate

» famotidine

» fenoldopam

» filgrastim

» fluconazole

» fludarabine

» gemcitabine

» gentamicin

» granisetron

» heparin

» hydrocortisone sodium succinate

» insulin

» kanamycin

» labetalol

» lidocaine

» linezolid

» magnesium sulfate

» melphalan

» methyldopate

» methylprednisolone

» metoclopramide

» metoprolol

» metronidazole

» ondansetron

» oxacillin

» oxaliplatin

» oxytocin

» paclitaxel

» pemetrexed

» penicillin G potassium

» piperacillin/tazobactam

» potassium chloride

» propofol

» propranolol

» ranitidine

» remifentanil

» sargramostim

» teniposide

» thiotepa

» ticarcillin/clavulanate

» tobramycin

» trimethoprim/sulfamethoxazole

» vancomycin

» verapamil

» vinorelbine

• Y-Site Incompatibility:

» allopurinol

» amphotericin B cholesteryl sulfate

» cefepime

» cefoperazone

» doxorubicin liposome

» idarubicin

» imipenem/cilastatin

» lansoprazole

Patient/Family Teaching

• Instruct patient on how and when to ask for pain medication.

• Instruct patient to take meperidine as directed. If dose is less effective after a few 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

• Encourage patient to turn, cough, and breathe deeply every 2 hr to prevent atelectasis

Evaluation/Desired Outcomes

Decrease in severity of pain without a significant alteration in level of consciousness or respiratory status

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