Safety and Efficacy of Rapid Titration Using 1mg Doses of Intravenous Hydromorphone in Emergency Department Patients With Acute Severe Pain: The “1+1” Protocol
Received 5 August 2008; received in revised form 8 September 2008 and 11 September 2008; accepted 18 September 2008. published online 11 November 2008.
Study objective
We evaluate the safety and efficacy of a pain protocol using 1 mg intravenous (IV) hydromorphone followed by an optional dose of 1 mg IV hydromorphone 15 minutes later.
Methods
Prospective interventional study at an urban academic emergency department (ED). One milligram of IV hydromorphone was administered to adults 21 to 64 years of age who had acute severe pain. Fifteen minutes later, patients were asked whether they wanted more pain medication. If they answered yes, they received another 1 mg of IV hydromorphone and were again asked 15 minutes later whether they wanted more pain medication. The primary efficacy outcome was the proportion of patients who had adequate analgesia, defined as declining additional hydromorphone within 1 hour of entering the protocol. The primary safety outcome was incidence of oxygen desaturation less than 95%. Secondary outcomes included numeric rating scale pain scores and adverse events.
Results
Of the 223 patients with complete data, 1 mg IV hydromorphone provided adequate analgesia for 77% (95% confidence interval 71% to 82%) within 15 minutes and 96% (95% confidence interval 92% to 98%) within 1 hour of entering the protocol. Eighty-six percent of patients reported pain scores that decreased by 2 or more numeric rating scale units. Five percent experienced transient oxygen desaturation below 95%, which was corrected promptly with oxygen.
Conclusion
A rapid titration protocol using IV hydromorphone (1 mg hydromorphone followed by an optional 1 mg 15 minutes later) is efficacious in nonelderly ED patients with acute severe pain. There were no serious adverse events.
Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY
Address for correspondence: Andrew Chang, MD, MS, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467; 718-920-7464, fax 718-798-0730
Supervising editor: Steven M. Green, MD
Author contributions: AKC, PEB, MKM, and EJG conceived the study and designed the trial. AKC and CMC managed the data, including quality control. PEB analyzed the data and provided all figures and tables. AKC drafted the article, and all authors contributed substantially to its multiple revisions. AKC takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Dr. Chang was supported by a Society for Academic Emergency Medicine Research Training Grant.
Publication date: Available online November 8, 2008.
ABSTRACT