Randomized clinical trial of the 2 mg hydromorphone bolus protocol versus the
"1+1" hydromorphone titration protocol in treatment of acute, severe pain in the
first hour of emergency department presentation.
Author(s): Chang AK(1), Bijur PE, Lupow JB, Gallagher EJ.
Affiliation(s): Author information:
(1)Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore
Medical Center, Bronx, NY. Electronic address: achang@montefiore.org.
Publication date & source: 2013, Ann Emerg Med. , 62(4):304-10
STUDY OBJECTIVE: We compare a high initial dose of 2 mg intravenous hydromorphone
against titration of 1 mg intravenous hydromorphone followed by an optional
second dose.
METHODS: Patients aged 21 to 64 years with severe pain were randomly allocated to
2 mg intravenous hydromorphone in a single bolus or the "1+1" hydromorphone
titration protocol. 1+1 Patients received 1 mg intravenous hydromorphone followed
by a second 1 mg dose 15 minutes later if they answered yes when asked, Do you
want more pain medication? The primary outcome was the between-group difference
in proportion of patients who declined additional analgesia at 60 minutes.
RESULTS: Of the 350 enrolled patients, 334 had sufficient data for analysis. The
proportion who declined additional analgesics was 67.5% in the 2 mg bolus arm and
67.3% in the 1+1 titration arm (difference 0.2%; 95% confidence interval -9.7% to
10.2%). The between-group difference in numeric rating scale pain scores was 0.4
numeric rating scale units (95% confidence interval -0.3 to 1.1). The incidence
of adverse effects was similar; 42.3% of 1+1 patients achieved satisfactory
analgesia at 1 hour with only 1 mg hydromorphone.
CONCLUSION: A hydromorphone 1+1 titration protocol provides similar pain relief
to an initial 2 mg bolus dose, with no apparent clinical advantage to the latter.
The 1+1 titration protocol had an opioid-sparing effect because 50% less opioid
was needed to achieve satisfactory analgesia for 42.3% of patients allocated to
this protocol.
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