Duramorph/Bupiv Spinals

I give everyone 15 mcg fentanyl, 0.2 mg morphine, and 1.6 mL 0.75% hyperbaric bupivacaine for scheduled c-sections.

You don't get much more than extra side effects once you get past about 0.25 mg of morphine. Onset of the morphine lags for quite a while and the fentanyl does a nice job intraop.

DreamLover said:

Any opinions on people's favorite dose of duramorph to use with bupivacaine for SAB for c-sections?

Honestly, during residency, we mainly used fentanyl for our CSXN spinals, but the new practice I'm with uses duramorph for about every section. Opinions on adequate doses (0.2-0.4mg duramorph?) Vs side effects (Itching, resp depression)?

Opinions welcome....any good recipes are always appreciated!!

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We use 0.1-0.2mg IT morphine, along with 20-25mcg fentanyl.

As regards the morphine, it seems like they all get itching at least mild itching, some severe, and I can't tell if analgesia vs. side effects is different at 0.1mg vs. 0.2mg. 0.4mg seems like a lot though.

pgg said:

I give everyone 15 mcg fentanyl, 0.2 mg morphine, and 1.6 mL 0.75% hyperbaric bupivacaine for scheduled c-sections.

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Exactly what I have been doing as well. I think the literature supports 0.15-0.2mg of duramorph as the dose that will maximize analgesia while limiting side effects. More than that and the returns don't outweigh the downside.

0.1-0.2mg Duramorph here as well. But I don't usually add any fentanyl, they just seem to itch too much early on. I haven't seen the benefits unless there was an epidural running prior to the c/s and I want to cut down on the bupiv in the spinal to avoid a higher spinal then i care for after I pull the epidural and place a spinal.

Your partner is "old school".

Trust me, your OB nurses have no idea what's going on in the spinal. Do what you think is best.

DreamLover said:

The more pages about pain, nausea, and itching that I can avoid, the better for me AND my patients

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Your group should have standing orders to deal with these issues. You should not be bothered with pages for this unless the standing orders have been in acted and there is no relief.

DreamLover said:

I just don't want the L&D nurses to flip out on me because I've deviated from their "norm"

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Doesn't matter what you do, the L&D nurses are going to flip out on you. My theme song for L&D is "Feels Like The First Time." (My personal theme song and nickname is Dr. Feelgood) Their metric for intrathecal morphine is simply +/-, not 0.1 vs 0.4 mg. Personally I use 0.1 along with 0.1 epi and 1.6 bupi for almost all comers.

I never saw the point of using both fent and morphine in the spinal. It makes no pharmacologic sense and I haven't seen a clinical difference.

- pod

periopdoc said:

I never saw the point of using both fent and morphine in the spinal. It makes no pharmacologic sense and I haven't seen a clinical difference.

- pod

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Hey Dr. Feelgood, can you explain why it doesn't make pharm sense to add Fent and morphine? I explained why I don't do it but it isn't because I don't think it can add something pharmacologically. Fent has a shorter onset than MS and has a synergistic effect with bupivicaine. MS won't be effective until after the c/s is complete. I'm not following your train of thought here.

From a pharmacologic sense, morphine will be working before the bupi wears off so the fent isn't adding anything there.

A subarachnoid bupi injection provides complete block and IT fent adds little but additional side effects.

It makes synergistic sense in a epidural infusion because you are not providing complete blockade so targeting additional receptors leads to a better block.

IMHO

- pod

I use 0.2-0.3mg Duramorph, and I get plenty of nausea and itching. I heard from someone recently that the analgesic effect peaks at 0.1mg Duramorph and higher doses just give you more side effects. I'm planning to reduce my doses to 0.15-0.2mg. I've never every used more than 0.3mg.

I used 10mcg fentanyl + duramorph 0.3mg + 0.75% bupiv 1.6cc in residency, but I find that the SAB is a dense enough anesthetic that I don't need the fentanyl, and if you're surgeons are fast, you can use 1.2-1.4cc, even for repeat C-S.

For epidural C-S, I use 2%lido w/epi w/HCO3 1:10 15cc (12-20cc), fentanyl 100mcg, then Duramorph 3mg. Epidural anesthesia can be less dense, so I feel that the fentanyl helps. I use lido with epi because we don't have big bottles of lido plain.

Try the 0.1. Your patients will prefer it.

When I worked in a place that had c-sections that were scheduled to start every hour on the hour (and equally importantly the surgeons did not exteriorize the uterus) I dropped my bupi dose to 1.2-1.4. My current OB's are not fast enough and they all exteriorize the uterus. Thus I went back to 1.6 or more and added epi to try to get a high enough block that lasts until the end of the section.

- pod

If that were the case then why are so many people adding Fent to there spinals? And I'm sure you have noticed that you can cut your bupiv dose down when Fent is added to the mix however, this is not the case with MS. So I argue that there is a benefit to adding Fent to the spinal but it is unnecessary and will result in more and earlier pruritis. But to say that it doesn't make pharmacological sense is a bit off base IMHO.

Mostly because (like most things in anesthesiology) we practice in the manner in which we were trained and we never bothered to reason it out and/ or test it out.

The addition of fentanyl to a morphine-bupivacaine spinal adds little but side effects and does not make pharmacologic sense when you consider the time of onset and duration of action of the three drugs. Bupi from t=0 to t=120 min (give or take.) Fent from t=5 to t=90 min. Morphine from t=30min to t=24 h or so.

So, unless you are dosing your bupi so low that you are already relying on opiates for adequate blockade before 30 minutes has elapsed, the fentanyl really hasn't given you anything extra. I would recommend that one not try to cut the dosing that close, and if one does then he should be prepared for a lot of IV supplementation for failed blocks.

The addition of fentanyl to a plain bupivacaine spinal makes pharmacologic and practical sense as there is no morphine there at the 30 min mark and the fentanyl may improve the late block over bupi alone. We aren't really improving that early block with the addition of the opiates, it is the late block that we are improving (from t=45- 60min out), and the bupi should have plenty of coverage to get us to that point.

-pod

im not trying to improve the block with fentanyl, im giving it for the modest systemic effects (decreased shivering and mild relaxation/euphoria), which i appreciate to be significant. i consider this to be a risk-free addition to a spinal. itching is probably a ilttle more pronounced, but we give zofran pre-spinal and nubain post-spinal, both should help the itching.

also, 100mcg of duramorph is the optimal dose.

my cocktail: 12.5 bupiv/25 mcg clonidine/25 mcg fentanyl/100 mcg duramorph

Chestnut 4th edition said:

We recommend the combined administration of a lipid-soluble opioid (with a short latency) and a water-soluble opioid (with a long duration of action) when spinal anesthesia is used for cesarean section.

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Figure 26-5

Chestnut 4th edition said:

Schematic illustration of the pharmacokinetic and pharmacodynamic activities resulting from the neuraxial administration of a lipid-soluble opioid (e.g., fentanyl) and a water-soluble opioid (e.g., morphine) for analgesia. The transition point varies according to the opioid drugs and doses administered. For most commonly used opioids, this transition point occurs in the postoperative period.

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Bold is mine.


I will give the 0.1 mg morphine dose a try, though.

Just curious - given a labor epidural, what are you all using for sections?

For routine sections, I give 100 mcg fentanyl and 3 mg morphine up front with lidocaine 2% : bicarb in a 10:1 ratio.

If fetal well being is in question, I use chloroprocaine and hold the opiates until cord clamping.

Topping off epidurals for sections: 15-20ccs of 2% lido.

For spinals 12-13 mg of .75% bupi with 15-20 mcgs of fentanyl. + T-burg for a couple of minutes.

PCA post op.

When I use duramorph in my spinals (rarely): 150 mcgs.

Ketafol20 said:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1159169/

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They were not adding fentanyl to a bupivacaine/ morphine spinal, they were adding it to a bupivacaine spinal. As I have already stated, that makes pharmacologic sense.

This line from the paper makes me wonder about the depth of their experience with IT fent.

Pruritis, maternal respiratory depression and changes in Apgar score of babies do not occur with fentanyl.

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Perhaps they meant did not occur and it is just a language issue. Who knows?

pgg said:

Figure 26-5

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Great, however they didn't overlay the bupivacaine which nicely covers the "transition point"

Idiopathic said:

im not trying to improve the block with fentanyl, im giving it for the modest systemic effects (decreased shivering and mild relaxation/euphoria), which i appreciate to be significant. i consider this to be a risk-free addition to a spinal. itching is probably a ilttle more pronounced, but we give zofran pre-spinal and nubain post-spinal, both should help the itching.

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Why not give it systemically then? You will get the effect that you desire with less of the side effects you are trying to avoid.

- pod

pgg said:

Just curious - given a labor epidural, what are you all using for sections?

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2% lido until delivery then 5 mg morphine epidural and 5 mg IV. I would use chlorpro if we had access to it.

- pod

typically we are using fentanyl in our spinals for the externalization of the uterus after baby is our and they are suturing. I think literature supports that purpose because the bupi is somewhat inadequete for this purpose. Now if your surgeons learn how to do an operation without doing this then I think it can be avoided. The morphine usually hasn't kicked in yet. And yes our OBs are as slow as molasses (Ivory tower of Academic Medicine)
but to each his own

My cocktail: 12.5mg of bupi .75% 20mcg fentanyl and .2 of duramorph

Didn't you see the study looking at Duramorph for Sections? 100 micrograms works fine and some additional pain relief up to 200 micrograms. Anything more than 200 micrograms and the side-effects climb without additional benefit to the patient. Thousands and thousands of Sections using this SOLID study and I agree with them!!

Fentanyl is dealer's choice. May help the block for those of you using less than 10 mg Bupivacaine. Those using more than 10 mg Bup won't need it.

BLADEMDA said:

Fentanyl is dealer's choice. May help the block for those of you using less than 10 mg Bupivacaine. Those using more than 10 mg Bup won't need it.

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exactly!

pgg said:

Just curious - given a labor epidural, what are you all using for sections?

If fetal well being is in question, I use chloroprocaine and hold the opiates until cord clamping.

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If time allows, I pull the epidural cath and place a spinal. It takes no time at all but if time is critical I dose the epidural with 2% Lido while we are travel to the OR. That way it is setup before we enter the room.

If I remember right, Chloroprocaine is the one local that is not synergistic with fentanyl. Therefore, skip it and add MS at the end if you are pulling the cath.

Chlorprocaine and duramorph don't mix, and that's why we dose with lido w/bicarb

spinals -- usually 10mcg fentanyl plus 200mcg morphine and 12mg bupi. although for ortho spinals we usually do 25mcg fentanyl and 12mg bupi cause we are probably doing a knee and they have a femoral nerve catheter.
for crash sections w epidural usually just the 2% lido until the baby is out and then 5mg duramorph IT for postop pain. one attending uses chloroprocaine. i guess it seems a little faster but pushing the lido in the labor room and then rolling back to the OR they usually are good to go by the time we get there.

The reason to add fentanyl to the spinal is to help with the visceral pain/discomfort that occurs during a c-section (stretching uterus, externalizing it, etc).

Local anesthetic just isn't that great at addressing visceral pain. This is the reason why we add opioid to local anesthetic for epidural infusions. This is why bolusing fentanyl works better for stage 1 of labor and local works better for stage 2. There is also profound synergism between opioid/local for neuraxial anesthesia.

Morphine IT has an onset time of over an hour, so it doesn't really start working until after the c-section is over.

1.6 + epi + 0.2 works for me. The difference here is that the nurses know how to handle itching and nausea so it rarely generates calls. Where I trained and at my first job the nurses were not too bright and would call over and over for the same itch complaint. I also give everyone zofran + reglan and at the first sign of itchy scalp or "red sternum sign" I give IV benadryl. I was trained to use 0.4 but to be honest the near 100% incidence of "itching like I never itched in places I've never itched" was a big turn off.

Jeff05 said:

The reason to add fentanyl to the spinal is to help with the visceral pain/discomfort that occurs during a c-section (stretching uterus, externalizing it, etc).

Local anesthetic just isn't that great at addressing visceral pain. This is the reason why we add opioid to local anesthetic for epidural infusions. This is why bolusing fentanyl works better for stage 1 of labor and local works better for stage 2. There is also profound synergism between opioid/local for neuraxial anesthesia.

Morphine IT has an onset time of over an hour, so it doesn't really start working until after the c-section is over.

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How many have you done with 11-12 mg Bup plus Duramorph 200 micrograms? Have you tried 50 in each group yourself (with and without fentanyl)/ Better yet, I bet if I blinded you to the patients you wouldn't be able to tell the difference in complaints.

Jeff05 said:

The reason to add fentanyl to the spinal is to help with the visceral pain/discomfort that occurs during a c-section (stretching uterus, externalizing it, etc).

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well said.

Now you made me curious and I don't have time right now to do a search so I will ask here and check back later.

With synergism aside (because synergism means that they enhance the actions of each other and not necessarily work on different levels, somatic vs visceral) has anyone done a study to see if IT fentanyl is better at treating the visceral pain than IV? My suspicion is YES, IT is better than IV.

http://www.ncbi.nlm.nih.gov/pubmed/10834777

Adding Fentanyl or Duramorph to the Bupivacaine mixture does matter. Remember, some think the action of the opioid occurs at the spinal level so Duramorph may begin to have an effect EARLIER than 30-60 minutes. In addition, some data shows only a 6.25 microgram dosage of Fentanyl is needed to get that spinal synergy. I suspect there is some spinal action of the Duramorph earlier than 30 minutes particularly since the amount need to cause that synergy is so low.

If you are happy adding Fentanyl to your mixture so be it. I'm just not convinced that you need it provided 12mg Bup and Duramorph are given IT.

Bupivacaine:
Common hyperbaric bupivacaine doses range between 7.5mg and 15mg (1.5ml to 3ml of 0.5%) however 71% of
mothers who received less than 10mg of hyperbaric bupivacaine alone complained of inadequate analgesia [9]. In a
study comparing 12 mg of hyperbaric bupivacaine and 18 mg of hyperbaric ropivacaine, none of the mothers receiving
12 mg of hyperbaric bupivacaine required supplemental analgesia [6]. Another study which aimed to reduce the dose of
intrathecal bupivacaine by the addition of fentanyl found that bupivacaine alone at doses less than 12.5 mg could not
abolish visceral pain [10].


Similarly 11mg of hyperbaric bupivacaine plus 0.2mg of morphine required no conversions to general
anaesthesia or supplemental analgesia [4].

Results indicate that the addition of 6.25 [mu]g fentanyl to hyperbaric bupivacaine for spinal anesthesia improves intraoperative analgesia and provides analgesia into the immediate postoperative period with no adverse effects on mother or neonate.

http://journals.lww.com/anesthesiol...ioperative_Analgesia_with_Subarachnoid.9.aspx

IN a nutshell if you like adding Fentanyl fine. You just need a swirl though plus the duramorph and sufficient Bupivacaine (I don't give less than 10 mg).

Some delete the Fentanyl like me because we use a bigger dose of IT Bup and Duramorph 200 micrograms. If you are in the low dose BUP camp then keep adding that Fentanyl because you are going to need it.

i add it because its cheap and easy and risk free and my patients do better. i dont need a study

Idiopathic said:

i add it because its cheap and easy and risk free and my patients do better. i dont need a study

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Well that solves it.

.

sevoflurane said:

When I use duramorph in my spinals (rarely): 150 mcgs.

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Why not?

periopdoc said:

My theme song for L&D is "Feels Like The First Time." (My personal theme song and nickname is Dr. Feelgood)

- pod

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Hey, you must be quoting the Head and the Heart!

[YOUTUBE]http://www.youtube.com/watch?v=huq4rIfgsa4[/YOUTUBE]

DrN2O said:

Why not?

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We don't manage pain on our post op c/s. Our OB/GYN are PCA heavy hitters. I'm afraid that the onset of the IT duramorph will coincide with the first couple of PCA boluses.

My concern is respiratory depression when I'm at home sleeping or downstairs doing another case.

I use 12-13 mg of bupi + fentanyl which gives them great pain control for a couple of hours post-op (although the fent will likely be gone by then).

The books speak of 2ndary respiratory depression as well. I am not familiar with the literature and the amounts of IT duramorph + PCA which would cause 1ry or 2ndary resp depression, so I keep it safe and simple.

Thoughts?

http://journals.lww.com/anesthesiol..._pharmacology_of_intrathecal_morphine.10.aspx

Conclusion: ITMS produced dose-related analgesia and respiratory depression in nonsurgical healthy, young, adult male volunteers. Respiratory depression was significant after 0.2 or 0.4 mg and profound and prolonged after 0.6 mg. No clinical signs or symptoms, including respiratory rate, reliably indicated hypoxemia. Pulse oximetry reliably detected hypoxemia after ITMS, and supplemental nasal oxygen (2 L/min) effectively corrected this hypoxemia.

Now add a PCA to the above and I think you may be asking for trouble...

Although my dose is not .2 but rather .15...

But again, these individuals were getting resp depression with as little as .2 mg of duramorph W/O PCA

First do no harm.

I'd be interested in others experience with post op PCA's after IT duramorph.

Unconsciousness and severe respiratory depression following intrathecal morphine analgesia for lumbar spinal surgery:

http://www.acutepainjournal.com/article/S1366-0071(07)00101-5/abstract

Neuraxial opioids have contributed to improved analgesia during labor and after cesarean delivery. The analgesic benefits derived from neuraxial opioids far outweigh the risks of a rare respiratory depression event; a risk that is not significantly increased with neuraxial compared with parenteral opioid administration. In the obstetric population, although neuraxial opioids are associated with a very low risk of clinically significant respiratory depression, it does occur, and may have fatal consequences.8 If we identify patients at risk and adequately monitor their ventilation, oxygenation, and level of consciousness, we will be able to decrease the risk of adverse outcomes. Despite the rarity of respiratory depression in the obstetric population, we must be prepared to diagnose and treat this potentially deadly complication.

http://www.anesthesia-analgesia.org/content/107/3/956.full

If PCA's were scratched out of the equation for the first 24hrs. I'd do my usual .15 mg of duramorph. The addition of PCA post op by the OB/GYN's keeps me from giving it. What do you guys think? Anybody think I'm a bit overly cautious?

http://www.springerlink.com/content/50q7l3068r152763/

Go ahead an click on the above link. My personal experience (ten thousand Sections?) is that the real incidence of Resp. Depression is very low. In fact, if you use common sense (Morbid Obesity and Sleep Apnea based on questions) the incidence is less than 1-2%. On the high risk group I either delete the IT MSO4 or request additional monitoring for 24 hours.

Sevo, I've got no issues with your technique and it's a sound one. But, our OB Docs prefer the IT MSO4 so I give 200 micrograms with the Bup.
If I was going to add the Fentanyl then I would use less than 25 micrograms but I haven't found much difference with or without Fentanyl in those patients getting Bup 12mg + IT MSO4 200 micrograms. There is a paucity of data comparing BUP 12 mg + IT MSO4 vs. BUP 12 mg + IT MSO4 + IT fentanyl. My bet is there wouldn't be a statistical difference between these groups.

http://www.sleepdt.com/the-stop-bang-questionnaire-predicts-postop-problems-from-sleep-apnea/

For the OB population the STOP questions are more appropriate than the BANG ones. I'm sure most of you have heard of STOP/BANG right?

There are spare outcome data to guide the selection and frequency of respiratory monitoring. Routine continuous pulse oximetry (while appropriate for the obstetric patient with risk factors such as obesity) may be unnecessary in healthy postcesarean patients when small doses of opioids (e.g., intrathecal morphine ≤0.2 mg, epidural morphine ≤4 mg) are used. Although intermittent respiratory monitoring may miss transient episodes of desaturation and bradypnea, respiratory depression typically progresses slowly, often preceded by increasing maternal sedation. Regular assessments (e.g., hourly) and vigilant nursing observations of respiratory effort, respiratory rate, or unusual somnolence are probably adequate in low-risk obstetric patients.22,83–85 Nursing staff should be adequately trained in detecting and treating opioid-induced respiratory depression, and an anesthesia care provider should be readily available to manage complications that may arise.


Morphine is currently the "gold-standard" neuraxial opioid for postcesarean analgesia. It provides effective postoperative analgesia for 12–24 h.21 The incidence of respiratory depression after neuraxial morphine administration ranges from 0% to 0.9% (Table 2).22–26 No studies reported serious sequelae,

a much bigger problem in the elderly and when IV narcotics are added, IMO