/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/medications/,

/clinical/cckm-tools/content/cpg/medications/name-97578-en.cckm

201706158

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Medications

Meperidine – Adult/Pediatric/Neonatal – Inpatient

Meperidine – Adult/Pediatric/Neonatal – Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Medications


1
Meperidine - Adult/Pediatric/Neonatal -
Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ..................................................................................................................... 3
SCOPE ................................................................................................................................................ 4
METHODOLOGY ................................................................................................................................ 5
INTRODUCTION ................................................................................................................................. 5
RECOMMENDATIONS ....................................................................................................................... 6
UW HEALTH IMPLEMENTATION ...................................................................................................... 7
REFERENCES .................................................................................................................................... 8
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

2
CPG Contact for Content:
Name: Cindy Gaston, PharmD, BCPS - Pharmacy Department
Phone Number: (608) 265-8161
Email Address: cgaston@uwhealth.org
CPG Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS – Pharmacy Manager, Drug Policy Program
Phone Number: (608) 263-1328
Email Address: PTrapskin@uwhealth.org
Guideline Update Author(s):
C. Gaston, PharmD, BCPS
Coordinating Team Members:
C. Gaston, PharmD, BCPS
Review Individuals/Bodies:
N. Rudin, MD - Department of Orthopedics/Rehab
J. Limjoco, MD – Department of Pediatrics, Neonates
B. Anderson, MSN, RN – Adult Pain CNS
J. Kunz, MS, RN – Adult Pain CNS
P. Riley, RN, MN, MPH – Pediatric Pain CNS
Committee Approvals/Dates:
Pharmacy & Therapeutics Committee (08/20/2015)
Release Date: August 2015 | Next Review Date: August 2018
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
This clinical practice guideline guides clinicians in the appropriate use of meperidine in adult and
pediatric patients. Graded recommendations for indications, dosing, administration, and precautions
for use are included.
Key Practice Recommendations
1. Alternative such as morphine, hydromorphone, fentanyl, oxycodone, hydrocodone, codeine
(for adult patients) and tramadol should be used in preference to meperidine for analgesia.
(Class I, Level C)
2. Meperidine should be avoided in elderly patients and patients with renal dysfunction. (Class I,
Level C)
3. Appropriate indications for use of meperidine
3.1. Prevention or treatment of drug-induced or blood product-induced rigors (e.g.,
amphotericin B, platelets) and treatment of post-anesthesia shivering. (Class IIa, Level B).
3.2. Reduction of the shivering threshold during therapeutic hypothermia (Class IIa, Level
B)
3.2 Procedural sedation used as a single injection prior to adult procedures requiring pre-
procedure analgesia, where rapid onset and short duration may improve patient care and
fentanyl is not indicated. (Class I, Level C)
3.3 Management of acute episodes of moderate to severe pain only if the patient has a
history one or more of the following concerns(Class I, Level C):
3.3.1 Unmanageable adverse reactions to other available opioids
3.3.2 Treatment failure with first-line other available opioids given in adequate doses
3.4 Research protocols specifying the use of meperidine. (Class I, Level C)
4. Meperidine is inappropriate therapy for migraine headache, although it has been commonly
used. Meperidine is not recommended for this use because of its very short duration, its toxic
metabolite, and because it is painful to inject. While IM meperidine has a slightly faster onset
than morphine, its disadvantages outweigh this very small advantage. (Class III, Level B)
5. Adult Dose, Route, and Duration of Therapy
5.1. Do not use meperidine for more than 48 hours or at doses greater than 600 mg IV per 24
hours. (Avoid use in renal dysfunction.) (Class III, Level A)
5.2. The oral dosage form SHOULD NOT BE USED due to high first-pass metabolism and
increased concentration of normeperidine. Oral tablets are non-formulary at UWHC (Class III,
Level C)
5.3. Adult parenteral doses may range from 50 to 150 mg subcutaneously every 3 hours as
needed. (Class I, Level A)
5.4. Intravenous (IV) push route may also be used, at a starting dose of 25 mg, increasing in 25
mg increments to a maximum of 100 mg, every 2 to 3 hours as needed, within the limitations
noted. (Class I, Level A)
5.5. Intramuscular (IM) absorption is erratic and IM injections are painful; therefore, this route
should not routinely be used. (Class III, Level C)
5.6. For the prevention of rigors and reduction of the shivering threshold, 12.5 to 50 mg should be
administered via slow IV push over 4 minutes. (Class IIa, Level C)
5.7. For treatment of rigors or post-anesthesia shivering, 12.5 to 50 mg should be given once by
slow IV push over 4 minutes.(Class IIa, Level B)
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

4
5.8. For procedural sedation in patients unable to tolerate other opioids, single incremental doses
of 12.5 to 50 mg IV may be given, 5 to 10 minutes prior to procedures. Note: Intravenous
administration or administration of IV doses greater than 50 mg require heightened sedation
monitoring (Class I, Level A)
6. Pediatric Dose, Route, and Duration of Therapy
6.1. Meperidine is not indicated for analgesia in children unless they are unable to tolerate all
other opioids.(Class I, Level C)
6.2. The analgesic dose is 1 to 1.5 mg/kg subcutaneously or slow IV push over 4 minutes every 3
hours as needed (Class I, Level A).
6.3. For the prevention or treatment of rigors, a single dose of 0.5 mg/kg may be administered via
slow IV push over 4 minutes (Class IIa, Level C).
7. Neonate Population – Avoid the use of meperidine in neonatal patients to avoid harmful side
effects.1-3 (Class III, Level C)
Companion Documents
1. UWHC Guidelines for Renal Function-Based Dose Adjustments in Adult Inpatients
2. Intravenous Administration of Formulary Medications – Adult – Inpatient/Ambulatory Clinical
Practice Guideline
3. Intravenous Administration of Formulary Medications – Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Pertinent UW Health Policies & Procedures
Patient Resources - NA
Scope
Disease/Condition(s): Appropriate use in meperidine for adult and pediatric patients
Intended Users: Prescribers, nurses and pharmacists
Objective(s): Guidance for appropriate use of meperidine for treatment of rigors and
avoidance of adverse drug reactions associated with meperidine.
Target Population: Inpatients requiring analgesia for severe pain or treatment of rigors.
Guideline Metrics: Adverse events submitted through the Patient Safety Network (PSN)
will be monitored.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

5
Methodology
A modified Grading of Recommendations Assessment, Development and Evaluation (GRADE)
developed by the American Heart Association and American College of Cardiology (Figure 1) was
used to assess the Quality and Strength of the Evidence in this Clinical Practice Guideline.4 PubMed,
CINHAL plus, and Cochrane databases and were searched using the terms “meperidine”, “pain”,
“rigors”.
Introduction
Meperidine is a synthetic opioid, an analog of fentanyl, sufentanil and alfentanil with analgesic
properties similar to morphine. It is not as potent an analgesic as morphine and has a short
duration of action, so that frequent large doses are needed to control moderate to severe pain5 In
addition meperidine is transformed into a neurotoxic metabolite, normeperidine, which can
accumulate after repeated administration even in mild renal insufficiency.6 Adverse effects of
normeperidine include tremor, myoclonus and seizures. Problems associated with meperidine
use have historically resulted in inadequate pain control and adverse effects for many patients.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

6
Recommendations
1. Alternative opioids such as morphine, hydromorphone, fentanyl, oxycodone, hydrocodone,
codeine (in adults) and tramadol should be used in preference to meperidine for analgesia.7-10
(Class I, Level C)
2. Meperidine should be avoided in elderly patients and patients with renal dysfunction.9,11,12
(Class I, Level C)
2.1. An increased risk of delirium is associated with meperidine in elderly post-surgical
patients, whereas the same correlation has not been identified with alternative opioids.12
3. Appropriate indications for use of meperidine
3.1. Prevention or treatment of drug-induced or blood product-induced rigors (e.g.,
amphotericin B, platelets) and treatment of post-anesthesia shivering.13-18 (Class IIa,
Level B).
3.1.1. For the prevention and treatment of rigors and reduction of the shivering threshold,
12.5 to 50 mg should be administered via slow IV push over 4 minutes
3.1.2. Shivering related to neuraxial analgesia may respond to fentanyl, nalbuphine,
dexmedetomidine, ketamine, propofol or ondansetron.13 (Class IIb, Level B)
3.1.3. Dexmedetomidine, nalbuphine may be an alternative agent for post-operative
shivering.16,19 (Class IIb, Level B)
3.2. Reduction of the shivering threshold during therapeutic hypothermia20 (Class IIa, Level B)
3.2.1. Dexmedetomidine, fentanyl, midazolam, neuromuscular blocking agents and
magnesium sulfate infusion may be reasonable as alternative agents.21-23 (Class IIb,
Level C)
3.3. Procedural analgesia used as a single injection prior to adult procedures requiring pre-
procedure analgesia, where rapid onset and short duration may improve patient care and
fentanyl is not indicated.5 (Class I, Level A)
3.4. Management of acute episodes of moderate to severe pain only if the patient has a
history one or more of the following problems7-9 (Class I, Level C):
3.4.1. Unmanageable adverse reactions to other available opioids.
3.4.2. Treatment failure with other available opioids given in adequate doses
3.5. Research protocols specifying the use of meperidine. (Class I, Level C).
4. Meperidine is inappropriate therapy for migraine headache, although it has been commonly
used. Meperidine is not recommended for this use because of its very short duration, its toxic
metabolite, and because it is painful to inject. While IM meperidine has a slightly faster onset
than morphine, its disadvantages outweigh this very small advantage.24 (Class III, Level B).
5. Adult Dose, Route, and Duration of Therapy
5.1. Meperidine should not be used for longer than 48 hours or parenteral doses greater than
600 mg per 24 hours in patients with normal renal function.8 (Class III, Level A)
5.2. The oral dosage form SHOULD NOT BE USED due to high first-pass metabolism and
increased concentration of normeperidine.25 (Class III, Level C)
5.3. Adult parenteral doses may range from 50 to 150 mg subcutaneously every 3 hours as
needed.5 (Class I, Level A)
5.4. Intravenous (IV) push route may also be used, at a starting dose of 25 mg, increasing in
25 mg increments to a maximum of 100 mg, every 2 to 3 hours as needed, within the
limitations noted.5 (Class I, Level A)
5.5. Intramuscular (IM) absorption is erratic and IM injections are painful; therefore, this route
should be avoided whenever possible.6,7 (Class III, Level C).
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

7
5.6. For the prevention of rigors and reduction of the shivering threshold, 12.5 to 50 mg
should be administered via slow IV push over 4 minutes (Class IIa, Level C).
5.7. For treatment of rigors or post-anesthesia shivering, 12.5 to 50 mg should be given once
by slow IV push over 4 minutes.(Class IIa, Level B).
5.8. For procedural analgesia in patients unable to tolerate other opioids, single doses of 12.5
to 50 mg IV may be given, preferably incrementally, 5 to 10 minutes prior to procedures.
Note: Intravenous administration or administration of IV doses greater than 50 mg require
heightened sedation monitoring (Class I, Level A)
6. Pediatric Dose, Route, and Duration of Therapy
6.1. Meperidine is not indicated for analgesia in children unless they are unable to tolerate all
other opioids.26,27 (Class I. Level C)
6.1.1. The analgesic dose is 1 to 1.5 mg/kg subcutaneously or slow IV push over 4
minutes every 3 hours as needed (Class I, Level A).
6.2. For the prevention or treatment of rigors, a single dose of 0.5 mg/kg may be administered
via slow IV push over 4 minutes (Class IIa, Level C).
7. Neonate Population – Avoid the use of meperidine in neonatal patients to avoid harmful side
effects.1-3 (Class III, Level C)
UW Health Implementation
Potential Benefits and Harms:
Use of this guideline should encourage use of low doses meperidine only for the treatment of
rigors and thereby minimize adverse events. No harm is anticipated as the result of using this
guideline.
Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Links to this guideline will be updated and/or added in appropriate Health Link or
equivalent tools, including the meperidine ERX.
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach for
most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for
all patients. It is understood that some patients will not fit the clinical condition contemplated
by a guideline and that a guideline will rarely establish the only appropriate approach to a
problem.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org

8
References
1. Pokela ML. Pain relief can reduce hypoxemia in distressed neonates during routine treatment procedures.
Pediatrics. 1994;93(3):379-383.
2. Pokela ML. Overdoses of pethidine given to two preterm neonates. Acta Paediatr. 1997;86(3):323-325.
3. Pokela ML, Olkkola KT, Koivisto M, Ryhanen P. Pharmacokinetics and pharmacodynamics of intravenous
meperidine in neonates and infants. Clin Pharmacol Ther. 1992;52(4):342-349.
4. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline methodology summit
report: a report of the American College of Cardiology Foundation/American Heart Association Task Force
on Practice Guidelines. J Am Coll Cardiol. 2013;61(2):213-265.
5. Meperidine hydrochloride injection [Package Insert]. Deerfield, IL: Baxter Healthcare; 2013.
6. Latta KS, Ginsberg B, Barkin RL. Meperidine: a critical review. Am J Ther. 2002;9(1):53-68.
7. Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis, MO: Mosby, Inc;
2011.
8. Miaskowski C, Bair M, Chou R, et al. Principles of Analgesics Use in the Treatment of Acute Pian and
Cancer Pain. 8th ed. Glenview, IL: American Pain Society; 2008.
9. Institute for Safe Medical Practices (ISMP). Reducing Patient Harm from Opioids. Available at:
https://www.ismp.org/newsletters/acutecare/articles/20070222.asp. Accessed July 14, 2015.
10. National Comprehensive Cancer Network. Adult Cancer Pain (version 2.2015)
http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf. Accessed July 17, 2015.
11. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older
adults. J Am Geriatr Soc. 2012;60(4):616-631.
12. Fong HK, Sands LP, Leung JM. The role of postoperative analgesia in delirium and cognitive decline in
elderly patients: a systematic review. Anesth Analg. 2006;102(4):1255-1266.
13. Crowley LJ, Buggy DJ. Shivering and neuraxial anesthesia. Reg Anesth Pain Med. 2008;33(3):241-252.
14. Kranke P, Eberhart LH, Roewer N, Tramer MR. Pharmacological treatment of postoperative shivering: a
quantitative systematic review of randomized controlled trials. Anesth Analg. 2002;94(2):453-460, table of
contents.
15. Schwarzkopf KR, Hoff H, Hartmann M, Fritz HG. A comparison between meperidine, clonidine and urapidil
in the treatment of postanesthetic shivering. Anesth Analg. 2001;92(1):257-260.
16. Wang JJ, Ho ST, Lee SC, Liu YC. A comparison among nalbuphine, meperidine, and placebo for treating
postanesthetic shivering. Anesth Analg. 1999;88(3):686-689.
17. Apfelbaum JL, Silverstein JH, Chung FF, et al. Practice guidelines for postanesthetic care: an updated
report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology.
2013;118(2):291-307.
18. Kranke P, Eberhart LH, Roewer N, Tramer MR. Single-dose parenteral pharmacological interventions for
the prevention of postoperative shivering: a quantitative systematic review of randomized controlled trials.
Anesth Analg. 2004;99(3):718-727, table of contents.
19. Elvan EG, Oc B, Uzun S, Karabulut E, Coskun F, Aypar U. Dexmedetomidine and postoperative shivering in
patients undergoing elective abdominal hysterectomy. Eur J Anaesthesiol. 2008;25(5):357-364.
20. Mokhtarani M, Mahgoub AN, Morioka N, et al. Buspirone and meperidine synergistically reduce the
shivering threshold. Anesth Analg. 2001;93(5):1233-1239.
21. Zweifler RM, Voorhees ME, Mahmood MA, Parnell M. Magnesium sulfate increases the rate of hypothermia
via surface cooling and improves comfort. Stroke. 2004;35(10):2331-2334.
22. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med.
2002;346(8):549-556.
23. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest
with induced hypothermia. N Engl J Med. 2002;346(8):557-563.
24. Friedman BW, Kapoor A, Friedman MS, Hochberg ML, Rowe BH. The relative efficacy of meperidine for the
treatment of acute migraine: a meta-analysis of randomized controlled trials. Ann Emerg Med.
2008;52(6):705-713.
25. Meperidine (Demerol Issues in Medication Safety. ISMP Canada Safety Bulletin. http://www.ismp-
canada.org/download/safetyBulletins/ISMPCSB2004-08.pdf. Updated August 2004. Accessed July 29, 2015
26. Kraemer FW. Treatment of acute pediatric pain. Semin Pediatr Neurol. 2010;17(4):268-274.
27. Tobias JD. Acute pain management in infants and children-Part 2: Intravenous opioids, intravenous
nonsteroidal anti-inflammatory drugs, and managing adverse effects. Pediatr Ann. 2014;43(7):e169-175.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2015CCKM@uwhealth.org