Demerol® (Meperidine) Protocol Evaluation
Data Collection Sheet
Creighton University Medical Center, March 2007
Patient Name
Room #
MR #
Age Sex
Prescribing MD / Service
Primary Care Doctor
Length of Stay
Serum Creatinine (mg/dL) CrCl (mL/min) Weight (kg) Height (in)
Rationale for Demerol
Meperidine Order Sheet or PCA Order Sheet:
Rigors due to blood products or meds; uncontrolled by APAP or Diphenhydramine
Post- operative shivering
Pre-procedure sedation
Confirmed allergy to morphine/derivatives:________________________________
Failure of 2 1st line opioids to achieve pain relief:___________________________
Intolerable side effects from opioid not manageable with PRN meds:___________
Other:_______________________________________________________________
Demerol Protocol Indicators Yes/No/Comments
Dose Prescribed
(PCA: 10mg/ml)
(IM: naïve pt 50-75 mg q 3-4 hrs)
Loading Dose
(Usual 25 mg)
Dose Administered in 24 hr __/__ __/__ __/__ __/__
(Max dose 600 mg/24 hr)
Length of Therapy
(Max length of therapy 48 hr)
Was an order set completed?
Was order set filled out correctly?
If no what was missing?
Additional Comments/Charting Issues:
Data Collected by: Initials______________________ Date Completed_____________