My opioid of choice in the perioperative and ICU settings is hydromorphone (Dilaudid). This medication is roughly 5-10 times more potent than morphine and comes in intravenous (IV) and oral formulations.
Similar to other narcotics, hydromorphone is a very selective μ-opioid receptor agonist; however, compared to morphine, it induces less histamine release and has a more favorable metabolic profile since it does NOT form an active 6-glucoronide compound like morphine (M6G). These metabolites are poorly excreted in renal failure and may accumulate leading to prolonged sedation and respiratory depression.
Although pooled studies often show no significant difference in the side effect profiles of morphine versus hydromorphone, I preferentially use the latter due to its better efficacy as an analgesic, in my opinion (and that of many visitors to emergency centers).
Although hydromorphone may not hit as hard or fast as fentanyl, sometimes I choose a longer acting narcotic to minimize the “peaks and troughs” patients experience with regards to pain management once their acute needs are met.
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