Know the risks of Demerol
The synthetic opioid Demerol (meperidine) is not suitable for chronic pain patients, but the practice continues in many EDs, says Paula Tanabe, RN, PhD, CEN, CCRN, clinical nurse specialist and trauma coordinator for the ED at Northwest Community Hospital in Arlington Heights, IL.
"Current guidelines stipulate that, after 48 hours, patients should not be getting Demerol, and elderly patients should not be getting it at all," she stresses.1"The information is out there, but people are so used to using it, they are still giving Demerol when they shouldn't be."
There is a trend toward discontinuing the use of Demerol, Tanabe reports. "There are hospitals who are taking it off the formulary, including Northwestern Memorial in Chicago, and hopefully we will see more of that," she says.
The drug is especially harmful when given in repeated doses. "In the ED, one dose of Demerol isn't the worst thing in the world, but it's a cumulative effect," says Tanabe. The drug is transformed into a neurotoxic metabolite, normeperidine, which can accumulate after repeated doses.
Adverse effects can be severe, including anxiety, hallucinations, tremors, myoclonus, and seizures. "When you give repetitive doses, people can seize, or act bizarrely," says Tanabe. "Also, of all the opioids, Demerol causes the most hypotension."
It's important to realize that other alternatives are available. "If we didn't have other options, we might have to resort to using Demerol, but we do have other choices," says Tanabe. "We need to become comfortable with fentanyl, morphine, and dilaudid."
Elderly patients are especially at risk for severe side effects. "They are at much higher risk for CNS toxicity with Demerol," says Tanabe. The drug is also contraindicated for patients with decreased renal or hepatic function, atrical flutter, or other supraventricular tachycardias.
At the University of Wisconsin, the hospital pharmacy looked at the use of Demerol and found it was commonly used in ED. "We took a specific look at migraine patients and Demerol, to find out why we were using it so much," says Debra Gordon, RN, MS, the hospital's clinical nurse specialist for pain management. One reason was that patients asked for the drug, so an effort was made to educate those patients, she notes.
After a retrospective review was conducted, hospital guidelines were established to restrict the use of Demerol. "In one year, we reduced the use of it by 65%," reports Gordon.
1. Acute Pain Management Guidelines. Agency for Health Care Policy and Research, 1992.