c-06-13-60334 injectable opioid agonist...

INJECTABLE OPIOID AGONIST THERAPY (iOAT)

DOCUMENT TYPE: PROTOCOL

Site ApplicabilityBC Women’s Hospital Maternal-Newborn Program – FIR In-patient Unit and High Acuity Unit only (Perinatal Additions Service).

Practice Level/CompetenciesAdvanced Skill: RN, RPN – perinatal addictions experience or high acuity skills

The assessments and interventions required to enact this practice are within the scope of practice for registered nurses and registered psychiatric nurses with perinatal addictions experience or high acuity skills. Nurses unfamiliar with administering injectable opioid agonist treatment (iOAT) must first familiarize themselves with this protocol and the prescriber’s orders on the pre-printed order set or powerplan– Perinatal Addictions Service – Injectable Opioid Agonist Treatment (iOAT) – HYDROmorphone Titration or Maintenance (Adult). Just-in-time education and skill validation may be provided by a Clinical Resource Nurse, Nurse Educator, or another appropriately skilled clinical support person.

Physician iOAT Clinical Privileging HYDROmorphone for iOAT, ordered in doses that are significantly higher than what is commonly prescribed, can only be prescribed by Perinatal Addictions Service (PAS) Physicians who have iOAT Clinical Privileges. This requires the completion of the BC Center for Substance Use iOAT training program with clinical preceptorship (Provincial Health Services Authority [PHSA], 2018). Physicians without iOAT privileging must consult one with privileges for iOAT management. Note: It is the expectation that all physicians who are members of the PAS will obtain iOAT privileges. In addition, members of the Department of Anesthesia are encouraged to complete the training. PAS Coverage: 24/7 on-call.

BackgroundiOAT is an evidence-based high intensity treatment option on the continuum of care for Opioid Use Disorder (OUD). Hydromorphone is one of the medications used for iOAT (the other being diacetylmorphine, the active ingredient in heroin). It is the highest intensity treatment option available for people with severe OUD who have been unsuccessful at reducing or ceasing illicit non-medical opioid use with the assistance of adequately dosed lower-intensity treatment options (i.e., oral Opioid Agonist Therapy (OAT) (British Columbia Centre on Substance Use [BCCSU], 2018). In the community setting it is primarily self-injected under supervision at a designated iOAT Program. In hospital it may be administered by nursing or medical staff via the IV direct, IM, and subcutaneous routes, or orally. There are currently no published studies or practice guidelines on iOAT in pregnancy. There is one case report in the literature on the initiation of high dose hydromorphone and two on the continuation of treatment with diacetylmorphine. All report positive pregnancy outcomes (Hartwig et al, 2008; Groh, Urlichs, Hillemacher, Bleich & Heberlein, 2014; Griffiths et al, 2020).

ProtocolA. Eligibility

Patients are eligible for iOAT therapy at BC Women’s Hospital if they have already been initiated on iOAT in the community or if they are an inpatient and have failed to stabilize on oral OAT despite an optimal dosing history.

General criteria for patient selection includes:

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▪ Capacity to consent and fully understand goals of treatment (level of intensity, risks, etc.)

▪ 18 years of age minimum

▪ Well established history of injection drug use and severe OUD (DSM-V)

▪ Confirmation of current opioid injection use

▪ Past experience with appropriately dosed OAT with evidence of regular and ongoing

injection drug use while trialed on these therapies

▪ Significant risk of medical consequences of injection drug use or existing medical and/or

psychiatric comorbidities

▪ No co-prescribed sedatives

▪ No active severe alcohol use disorder (relative contraindication

(Refer to the BCCSU (2018) iOAT Guideline for details) Eligibility must be confirmed by a second physician with iOAT privileges who reviews the case and

is in agreement that iOAT is required. Prior to initiating iOAT, the physician must confirm that there is a prescriber or clinic in the

community who will accept the patient and continue iOAT treatment after discharge. A shared decision making process on risks and benefits must take place between the patient,

physician and interdisciplinary team. Refer to Injectable Opioid Agonist Treatment: Informed Consent Discussion Guide.

B. iOAT Orders during Titration and Stabilization There are no fixed doses for optimal stabilization. Single doses up to 200 mg IV

Direct/IM/Subcutaneous and daily total doses of up to 500 mg or higher have been used. Dose is determined based on previous use, and titrated according to tolerance and clinical effect (i.e. cessation of illicit opioid use and cravings, and avoidance of side effects). No maximum dose has been established. Refer to the Adult Parenteral Drug Therapy Manual (British Columbia Women’s Hospital and Health Center, Providence Health Care & Vancouver Coastal Health, 2019). Refer to Appendix B for monograph.

For patients initiating iOAT in hospital a rapid titration up is appropriate, usually a BID or TID frequency, plus PRN doses while titrating to clinical effect.

Dosing frequency during the induction phase may be individualized. If more frequent doses are required, as stabilization occurs the doses are consolidated to BID/TID if possible in order to facilitate continuation in the community.

iOAT also includes oral doses of HYDROmorphone, as well as methadone or oral long acting morphine (Kadian) to manage cravings and withdrawal symptoms between injections.

When a patient is admitted on OAT or iOAT the prescribing physician will contact the community prescriber to confirm the last dose.

Review the Pre-Printed Orders (or Powerplan): Perinatal Addictions Service Injectable Opioid Agonist Treatment (iOAT) – HYDROmorphone Titration or Maintenance (Adult). These orders include guidance on titration and maintenance.





C. Pre-Administration Assessment: Pre-administration assessments ensure that the patient is not sedated, nor has any other acute

condition that would increase the risk of an adverse event with the use of injectable HYDROmorphone.

Review the iOAT Pre- and Post-Administration Assessment Form to ensure that the patient did not experience excessive sedation following their last dose, or if there have been missed doses.

Assess sedation using the Pasero Opioid-Induced Sedation Scale (POSS, Table 1), respiratory rate (RR), and O2 saturation (Sp02).

Note: While RR is an important vital sign, a patient may have a low rate while still maintaining good oxygenation, therefore the SpO2 is the more relevant parameter to guide actions.

Hold the HYDROmorphone if:o the patient is drowsy and not easily rousable (Pasero 3 and above), or there are additional

signs of sedation (slurred speech, confusion)o SpO2 is less than 95%

Contact the PAS Physician if HYDROmorphone is held or missed for any reason. If pregnant 22+0 weeks EGA and above, auscultate prior to each scheduled dose until a stable

dose is achieved (refer to section J).

Table 1. Pasero Opioid Induced Sedation Scale (POSS) Score Meaning of Score Action (provided that the SpO2 > 95%)

S Sleep, easy to arouse Acceptable Give ordered dose of HYDROmorphone

1 Awake and alert Acceptable Give ordered dose of HYDROmorphone

2 Slightly drowsy, easily roused Acceptable Give ordered dose of HYDROmorphone

3

Frequently drowsy, rousable, drifts off to sleep during conversation

UnacceptableWithhold HYDROmorphone Contact PAS PhysicianMonitor sedation level, respiratory status, and SpO2 until sedation less than 3 and SpO2 95% or higher on room air

4

Somnolent, minimal or no response to verbal and physical stimulation (use trapezius muscle squeeze for physical stimulation - do not use sternal rub)

UnacceptableWithhold HYDROmorphoneO2 by mask 10L/min (if not COPD) and monitor vital signsProvide airway and breathing supportCall a Code Blue if indicatedAdminister naloxone as per orderSTAT Call to PAS Physician On-Call

D. Dispensing High Concentration HYDROmorphone:

CAUTION: For iOAT HYDROmorphone comes in two concentrations 10 mg/mL and 50 mg/mL (note: there are other lower concentrations available for other uses)

Pharmacy, Omnicell, and Independent Double Check process for high-concentration HYDROmorphone to ensure patient safety:





Alert pharmacist to iOAT orders (after hours page pharmacist in NICU 2400-0700). Pharmacy will supply patient specific vials of high concentration HYDROmorphone (10mg/mL 1 mL vials

OR 50 mg/mL 1 mL vials) depending on the dose ordered. Caution: both the 10 mg/mL and 50 mg/mL concentrations may be dispensed for the same patient (for when the regular dose is >25 mg and the prn dose is <25 mg).

High concentration HYDROmorphone will only be loaded into the specific Omnicell where the patient is located (Fir Unit, High Acuity Unit - T2 633). When patient is transferred alert pharmacy to stock omnicell in new location.

For profiled Omnicell cabinets (FIR Unit) the high concentration HYDROmorphone can only be accessed under that specific patient’s name.

For non-profiled Omnicell cabinets (HAU) the pharmacy will place the vials in a patient labeled zip-lock bag.

The pharmacy will ensure there is a MINIMUM 24 hour supply for the patient at all times and will ensure refilling before the weekend.

Two-Finger Identification is required to remove the HYDROmorphone from the Omnicell. Two nurses will perform an Independent Double Check for High Alert Medications with a second

RN (refer to C&W Policy # PTN.01.013 Independent Double Check for Medication Administration), paying specific attention to:

○ Most recent iOAT prescriber orders (*Attention: Due to frequent adjustments the dose on the vial may not be the same as the latest order).

○ Pre-administration assessment meets criteria for administration○ Right dose, concentration, and volume

● Refer to: Administration of iOAT Checklist.

E. Administration: Refer to the BC Women’s Hospital Pre-Printed Order Set/Powerplan – Perinatal Addictions Service -

Injectable Opioid Agonist Treatment (iOAT) Hydromorphone Titration or Maintenance (Adult). For all routes (IV direct, IM, subcutaneous, oral):

○ For doses less than 25 mg, use 10 mg/mL vial○ For doses of 25 mg or more, use 50 mg/mL vial

Preparation and administration as per Table 2. Intramuscular and subcutaneous sites should be rotated regularly.

Table 2. HYDROmorphone Preparation and Administration Route HYDROmorphone Preparation and Administration Instructions

IV Direct Administer undiluted; flush slowly over 2 to 3 minutes with a 10 mL NS flush (for PIV) or 20 mL NS flush (for PICC/CVC). Do not infuse via IV mini-bag.*

IM Inject undiluted*

SC Inject undiluted*

Oral Draw measured amount from ampule via syringe with filter needle, transfer to medicine cup or simply remove needle from the syringe, and administer a witnessed ingestion.

*As per Adult Parenteral Drug Therapy Manual; refer to Elsevier Nursing Procedures for administration of medication via a saline lock. Note: The primary mode will be IV Direct via a saline lock.





F. Post-Administration Assessment: Sedation is a very sensitive indicator of impending opioid-induced respiratory depression and

precedes clinically significant episodes (Pasero, 2009). Side effects of parenteral administration also include respiratory and circulatory depression, and

orthostatic hypotension, which may be increased with rapid IV injection. Post-administration assessments of sedation, respirations and O2 saturation are performed to

inform dosing (e.g. lowering dose if sedation occurs) and ensure safety (e.g., respond to respiratory depression).

Assess sedation using the Pasero Opioid-Induced Sedation Scale (POSS). Respiratory status is assessed using breaths per minute, for a full minute. During the initiation and titration phase when the HYDROmorphone dose is being adjusted

assessments are more frequent. As the dose is being increased, an initial dose is given, followed by a 15 minute pause to assess for effect and sedation before administering the remaining dose.

Once stable dosing is achieved (3 doses), assessments may be scaled back. Complete post-administration assessments as per frequency in Table 3.

Table 3. HYDROmorphone Post-Administration Assessment

Route Assessment Frequency

During initiation and titration phase assess POSS, RR and SpO2:

IV Direct 5, 10, and 15 minutes after each dose

IM or SC 10, 20, and 30 minutes after each dose

Oral 30, 45, and 60 minutes after each dose

Once dose is stable for 3 doses with no excess sedation assess POSS, RR and SpO2:

All routes Once, 30 to 60 minutes after each dose

If post-assessment indicates signs of increased sedation i.e. POSS 3 or 4, or SpO2 less than 95%, increase surveillance and initiate interventions by following the Decision Support Tool for Monitoring and Interventions Post iOAT Administration (Appendix A).

Hypoxemia develops more rapidly in the pregnant patient compared with the non-pregnant patient; therefore, rapid, high-quality, and effective airway and breathing interventions are essential (American Heart Association, 2015).

G. Administration of Naloxone in the context of iOAT: If patient has a decreased level of consciousness AND is difficult to rouse AND has a respiratory

rate below 8 breaths per minute, follow pre-printed orders/power plan ‘Perinatal Addictions Service - injectable Opioid Agonist Treatment (iOAT) and administer naloxone 0.1 mg IV/IM/Subcutaneous STAT and repeat every 2 to 3 minutes PRN.

Note: if at any time a nurse encounters a patient in significant respiratory depression due to a suspected opioid overdose, independent of whether the patient is receiving iOAT, the calling of a code blue, initiation of cardiorespiratory support, and administration of the standard dose of naloxone 0.4 mg (1 ml ampule) IM is appropriate.

Be aware that following naloxone administration, acute withdrawal may occur. Signs and symptoms of opioid withdrawal include but are not limited to:





o Tachycardiao Hypertensiono Anxiety, irritability, aggressive behaviouro Dilated (mydriatic) pupilso Sweating, chills, goosebumps (cutis anserine)o Nausea and vomitingo Diarrheao Abdominal crampso Tremulousnesso Muscle and joint pain

Though the use of naloxone in pregnancy can potentially precipitate withdrawal, causing fetal distress or premature labour, the advantages of its administration outweigh the potential risks (BCCDC, 2018).

Naloxone has a relatively short duration of action of 30-90 minutes compared to HYDROmorphone. Continue to monitor respiratory rate Q 15 minutes until no naloxone given for 1 hour; then Q1H for 4 hours (Adult Parenteral Drug Manual).

H. PRN Oral Opioid Medications Ongoing illicit use is not a contraindication to administering PRN’s. Patients may experience cravings and withdrawal symptoms between doses, in which case PRN

medications should be offered. Assess cravings by the patient's reported symptoms. The Subjective Opioid Withdrawal Scale may

be used (BCCSU, 2017). PRN medications should be given until the cravings or withdrawal symptoms are relieved or until

the respirations or POSS score drops enough to hold the medications.

I. Pain Management Consult anesthesia antenatally in order to develop a pain management strategy in collaboration

with the patient and clinical care team. Consider that any opioid tolerant patient may be hyperalgesic, but especially those requiring high

doses, therefore patients on iOAT will require an individualized multimodal approach to acute pain management involving additional pain strategies and titration of medications.

iOAT, as with any opioid agonist therapy, should be continued through labour and considered separate from any pain management strategies employed during labour and delivery.

If opioid analgesics are used, much higher doses may be required to compensate for increased tolerance.

Postpartum stabilization (cesarean or vaginal births) may require short term higher acuity care, with pain co-managed by anesthesia, iOAT privileged physicians, and pharmacy.

J. Fetal and Neonatal Considerations If initiation and stabilization occurs during pregnancy, perform antepartum fetal surveillance as per

the parameters below:o 22+0 weeks EGA and above: Auscultate prior to each scheduled dose until stable, then daily

according to condition.o 24+0 weeks and above: NST weekly, or according to other indications.





Note that HYDROmorphone may cause diminished variability, loss of reactivity and a pseudo-sinusoidal FHR pattern (Keikah, Vahdani, & Latifa, 2014; Perinatal Services British Columbia, 2007).

Anticipate possible respiratory depression at delivery - an antenatal pediatric consult and presence at birth is recommended.

If the newborn is vigorous, it may stay together with the mother and be admitted to Fir. No continuous cardiorespiratory monitoring is necessary.

Breastfeeding is not recommended. Hydromorphone is excreted in breastmilk and large maternal dosages may cause neonatal central nervous system depression.

If, following an informed discussion with the mother on the risks and benefits, her decision is to breastfeed, the newborn would require transfer to NICU (Rabbit Pod) for increased surveillance. An Advanced Collaborative Care Plan should be in place. Observe infant closely for excessive drowsiness, poor feeding, respiratory depression, bradycardia, limpness (LactMed Database, 2019).

Documentation iOAT Pre- and Post-Injection Assessment Form Medication Administration Record Document all variances in the Interprofessional Notes

Patient & Family Engagement/Education Encourage patient to tell you if they are experiencing cravings or withdrawal symptoms. Alert to increased risk for an overdose when mixed with other central nervous system depressants

such as benzodiazepines or alcohol. Provide patient with harm reduction education (Take Home Naloxone Kit, safe injection supplies) if

needed. Refer to patient education pamphlets:

o Overdose Survival (BCCDC) https://towardtheheart.com/assets/uploads/1543604433tReOlxWvoSAEoDxmJdg9UcjdWcStybE9EqJPj55.pdf

o Safer Injecting (VCH) https://vch.eduhealth.ca/PDFs/DB/DB.500.S34.pdf

ReferencesAmerican Heart Association (2015). Cardiac Arrest in Pregnancy. 132:18, 1747–1773.BC Center for Disease Control (Dec 2018). Overdose Survival. Retrieved July 23, 2019 from:

https://towardtheheart.com/assets/uploads/1543604433tReOlxWvoSAEoDxmJdg9UcjdWcStybE9EqJPj55.pdf BC Center on Substance Use (2017). The Subjective Opioid Withdrawal Scale. Retrieved July 23, 2019 from:

http://www.bccsu.ca/wp-content/uploads/2017/08/SOWS.pdf BC Centre on Substance Use. (2018). Guidance for Injectable Opioid Agonist Treatment for Opioid Use

Disorder. Retrieved July 23, 2019 from: http://www.bccsu.ca/wp-content/uploads/2017/10/BC-iOAT-Guidelines-10.2017.pdf

BC Women’s Hospital + Health Center, Providence Health Care, and Vancouver Coastal Health (2019). Adult Parenteral Drug Therapy Manual - HYDROmorphone. Retrieved from: http://pdtm.vch.ca/Documents/HYDROmorphone%20NEW.pdf



http://www.bccsu.ca/wp-content/uploads/2017/08/SOWS.pdf

https://towardtheheart.com/assets/uploads/1543604433tReOlxWvoSAEoDxmJdg9UcjdWcStybE9EqJPj55.pdf



Canadian Research Initiative in Substance Misuse (2019). National Clinical Guideline: Injectable Opioid Agonist Treatment – iOAT for Opioid Use Disorder.

Canadian Research Initiative in Substance Misuse (2018). National Guideline: Clinical Management of Opioid Use Disorder.

C&W Policy # PTN.01.013 Independent Double Check for Medication Administration. Retrieved from: http://policyandorders.cw.bc.ca/resource-gallery/Documents/Pharmacy,%20Therapeutics%20and%20Nutrition/C-0506-11-60285%20Independent%20Double%20Check%20for%20Medication%20Administration.pdf

Fraser Health (2019). Clinical Protocol: Continuation of Injectable Opioid Agonist Therapy (CPO #03-2948).Fraser Health Authority (2019). Injectable Opioid Agonist Therapy Pre-Printed Orders. Griffiths, S., Campbell, D.,Caudarella, A., Guimond, T., Lamba, W., Lurie, E., Nader, M., Sgro, M., and Turner,

S. (2020). Use of Injectable Opioid Agonist Therapy in a In-Patient Setting for a Pregnant Patient With Opioid Use Disorder: A Case Report. Journal of Addiction Medicine. DOI: 10.1097/ADM.0000000000000776.

Groh, A., Urlichs, F., Hillemacher, T., Bleich, S., and Heberlein, A. (2014). Case report: Pregnancy and birth under heroin-assisted treatment (HAT) Heroin Addiction and Related Clinical Problems. 16(2): 47-52.Hartwig, C., Haasen, C., Reimer, J., Garbe, W., Lichtermann, D., Wuellenweber, L., and Dilg, C. Pregnancy

and birth under maintenance treatment with diacetylmorphine (heroin): a case report. European addiction research. 2008;14(2):113- 114. 57.

Keikah, F; Vahdani, F.; and Latifa, S. (2016). The Effects of Maternal Opium Abuse on Fetal Heart Rate using Non-Stress Test. Iran J Med Sci. 41(6): 479-485.

Perinatal Services BC (2007). Pain Management Options During Labour. Retrieved July 23, 2019 from http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/PainManagementGuideline.pdf

Providence Health Care (2015). B-00-12-10126 - Nursing Practice Standard - High Dose HYDROmorphone for Opioid Use Disorder.

Providence Health Care (2018). Prescriber Orders - HYDROmorphone High-Dose Orders.Providence Health Care (2015) Subcutaneous Butterfly Cannula: Insertion, Maintenance, and Medication

Administration - PH policy B-00-12-10060Provincial Health Services Authority (2018). BC Medical Quality Initiative iOAT Privileging Dictionary. Vancouver Coastal Health (2018). Safer Injecting. Retrieved July 23, 2019 from

https://vch.eduhealth.ca/PDFs/DB/DB.500.S34.pdf

DefinitionsInjectable Opioid Agonist Therapy (iOAT): Injectable Opioid Agonist Therapy is the branch of OAT that uses diacetylmorphine (the active ingredient in Heroin) or HYDROmorphone to treat long term severe and treatment resistant Opioid Use Disorder (BC Centre on Substance Use, 2017).Opioid Use Disorder (OUD): a problematic pattern of opioid use leading to clinically significant impairment or distress that meets the Diagnostic Statistical Manual-5 criteria for Opioid Use Disorder (American Psychiatric Association, 2013).Precipitated Withdrawal: A withdrawal syndrome that can occur when an opioid antagonist, or partial agonist, is administered to a patient who is physically dependent and has recently used a full opioid agonist. The agonist displaces opioids from the mu (μ) receptors, without activating the receptor to an equivalent degree, resulting in a net decrease in effect. Precipitated withdrawal is more intense and has a much faster onset than typical withdrawal from opioids (Canadian Research Initiative in Substance Misuse).



http://policyandorders.cw.bc.ca/resource-gallery/Documents/Pharmacy,%20Therapeutics%20and%20Nutrition/C-0506-11-60285%20Independent%20Double%20Check%20for%20Medication%20Administration.pdf

http://policyandorders.cw.bc.ca/resource-gallery/Documents/Pharmacy,%20Therapeutics%20and%20Nutrition/C-0506-11-60285%20Independent%20Double%20Check%20for%20Medication%20Administration.pdf



Related Documents (Find on ePOPS)1. Injectable Opioid Agonist Therapy: Informed Consent Discussion Guide2. iOAT Pre- and Post-Administration Assessment Form3. Administration of iOAT Checklist4. Pre-printed orders/power plan for Perinatal Addictions Service – Injectable Opioid Agonist Treatment

(iOAT) HYDROmorphone Administration for Opioid Use Disorder (Adult)

Appendix Appendix A: Decision Support Tool for Monitoring and Interventions Appendix B: Adult Parenteral Drug Manual: HYDROmorphone Monograph

Developed ByBCW Family Practice – Physician

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN23-Jul-2019 C-06-13-60334 High Dose Hydromorphone For Opioid

Use DisorderApproved at: Perinatal Best Practice Committee

08-Oct2019 “ Approved at: Pharmacy, Therapeutics & Nutrition Committee

11-May-2021

C-06-13-60334 Injectable Opioid Agonist Therapy Approved at: Pharmacy, Therapeutics & Nutrition Committee

DisclaimerThis document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.



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Appendix A. Decision Support Tool for Monitoring and Interventions Post iOAT Administration

Stage 1 Stage 2 Stage 3 Stage 4Assessment

POSS S or 1 or 2:AND,• SpO2 95% or higher on

room air

POSS 2: AND • SpO2 90-94% on

room air

POSS 3:AND• SpO2 81% - 89% on room air OR• RR less than 10/min

POSS 4:AND• SpO2 80% or lower on room

airOR • Apneic or gasping

Interventions• Continue to monitor

POSS, RR and SpO2

per routine post-administration assessment (table 3)

• Continue to monitor POSS, RR and Sp02 Q 15 min until SpO2 95%or higher

• If pregnant > 22 weeks perform intermittent auscultation Q 15 min until stable

• If no improvement alert FPMS2 Physician On-Call

• If respiratory or mental status worsens, proceed to stage 3

• Call for assistance• Initiate STAT call to OB On-Site and

Anesthesia L&D; Alert PAS Physician On-Call

• Stimulate and ensure airway is secure• If pregnant >20 weeks place in a full

left lateral decubitus position to relieve aortocaval compression

• Apply O2 by mask 10 L/min to a target O2 of >95%

• Apply continuous SpO2 monitor.• Monitor RR and sedation level Q 5 min

until stable • Call a Code Blue if patient does not

respond to stimulation and O2• IF RR below 8 administer naloxone

STAT as prescribed on PPO• Repeat dose as needed every 2-3

minutes up to maximum of 5 mg and until RR more than 10-12 per minute

• If pregnant >22 weeks perform intermittent auscultation Q 15 min until stable

• If SpO2 decreases to less than 80%, patient appears cyanotic or if respiratory or mental status worsens, proceed to stage 4

• Call a Code Blue• If pregnant >20 weeks, also

call a Code Pink (and consider calling Code Neo-Resus)

• Initiate cardio respiratory support according to Adult Basic Life Support algorithm, including modifications if pregnant

• Use bag-valve mask ventilation with 100% O2 at > 15 L/min to support respirations

• Administer naloxone as per PPO. Repeat dose every 2 minutes up to a maximum of 5 mg and until RR more than 10-12/minute.

• Alert PAS Physician On-Call• Transfer to HAU for

continuous monitoring until stable





APPENDIX B: Adult Parenteral Drug Therapy Manual HYDROmorphone Monograph

