Astramorph

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turnupthevapor

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Since there has never been a reported case of delayed respiratory depression with a dose of less than .3mg of IT morphine. Do you all feel a need for any postoperative monitoring when .150 is given, would a jury of our peers agree?

Personally I would like to see a RN chart a POSS scale for the first 24 hours and notify an RRT if advancing sedation is recognized but this would involve protocols and RN buy in.

I hate to deprive my patients of IT morphine as it makes their first 18 hours after surgery a breeze.


thoughts?
 
In what settings are you guys doing IT morphine? Any significant side effects that surgeons telling you? Our hospital patient has to be admitted to ICU for epidural management, so would be nice to use this
 
My hospital only allows us to do it fod C sections. I’ve tried to do it for a total joint, but have been told the surgical floor is not equipped to monitor the patients.
 
I went to an ERAS talk at ASA. Some people are using for every big abdominal surgery with fantastic results.

We personally use only for C-section at my hospital but in residency used for liver resections. Works very well.
 
We use it for all our cardiac cases and 90% get extubated on the table.
 
FFP said:
This is Anesthesia 101. You give IT morphine, you monitor the patient for 24 hours.
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Ok FFP give me a 101 lesson on how you monitor your C-section patients after you use IT morphine? You can not tell me you have continuous SPO2 in the mother baby unit.
 
The pulse ox is at bedside. Not my fault if they don't use it. They know they have to monitor for respiratory depression for 24 hours.

I am just telling you what a lawyer or expert witness will say: "Why wasn't this patient monitored for 24 hours? That's what a prudent anesthesiologist would have done."

I don't have a horse in this race. I personally know too little about the pharmacokinetics of IT morphine to play this game with one of my patients. If I want long-acting neuraxial analgesia, I'll just do an epidural (or a CSE), or get a monitored bed.
 
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FFP said:
This is Anesthesia 101. You give IT morphine, you monitor the patient for 24 hours.
Click to expand...

What say you Mr anesthesia 101 teacher?

Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta-analysis.
Gehling M1, Tryba M.
Author information

Abstract
Intrathecal morphine is often used for postoperative analgesia after surgery. We performed a meta-analysis to obtain more detailed information on the frequency of side-effects in patients receiving intrathecal morphine in combination with spinal anaesthesia compared with placebo treated patients. We clustered the analysis to patients receiving placebo, less than morphine 0.3 mg (M < 0.3), or equal to or more than morphine 0.3 mg (M > or = 0.3) and calculated the risk ratios of morphine vs placebo. Twenty-eight studies investigating 46 morphine groups vs placebo were included. A total of 790 patients with intrathecal morphine and 524 patients who received placebo were analysed. Compared with placebo the lower dose of morphine resulted in an increase of nausea (RR 1.4, 95% CI 1.1-1.7), vomiting (RR 3.1, 95% CI 1.5-6.4) and pruritus (RR 1.8, 95% CI 1.4-2.2). The higher dose resulted in an increased risk ratio for pruritus (RR 5.0, 95% CI 2.9-8.6), but not nausea (RR 1.2, 95% CI 0.9-1.6) or vomiting (RR 1.3, 95% CI 0.9-1.9). Overall, intrathecal morphine did not increase respiratory depression. However, the higher dose of intrathecal morphine was associated with more episodes of respiratory depression (7/80) compared with the lower dose (2/247). Intrathecal morphine is associated with a mild increase in side-effects. With a dose < 0.3 mg we found there were no more episodes of respiratory depression than in placebo patients who received systemic opioid analgesia.
 
turnupthevapor said:
What say you Mr anesthesia 101 teacher?
Click to expand...
The answer was in my post, just above yours. As I said, I am not interested in debating this. This is like peripheral norepi for days, laparoscopic surgery with LMA etc. It's not a scientific question, it's a legal question. In other countries, they don't monitor for 0.1-0.2 mg of IT morphine. In this country, I don't play cowboy; not worth it, especially since a pulse ox is relatively cheap (and, in its absence, a nurse can do hourly monitoring of the RR).

One thing to remember: "The medical standard of care is typically defined as the level and type of care that a reasonably competent and skilled health care professional, with a similar background and in the same medical community, would have provided under the circumstances that led to the alleged malpractice." From: What Is the "Medical Standard of Care" in a Medical Malpractice Case?

Good luck.
 
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Although I agree, medicolegally you're bound by the FDA package insert for morphine which states for intrathecal Administration

NOTE: INTRATHECAL DOSAGE IS USUALLY 1/10 THAT OF EPIDURAL DOSAGE. DURAMORPH SHOULD BE ADMINISTERED INTRATHECALLY BY OR UNDER THE DIRECTION OF A PHYSICIAN EXPERIENCED IN THE TECHNIQUE OF INTRATHECAL ADMINISTRATION AND WHO IS THOROUGHLY FAMILIAR WITH THE LABELING. IT SHOULD BE ADMINISTERED ONLY IN SETTINGS WHERE ADEQUATE PATIENT MONITORING IS POSSIBLE. RESUSCITATIVE EQUIPMENT AND A SPECIFIC ANTAGONIST (NALOXONE INJECTION) SHOULD BE IMMEDIATELY AVAILABLE FOR THE MANAGEMENT OF RESPIRATORY DEPRESSION AS WELL AS COMPLICATIONS WHICH MIGHT RESULT FROM INADVERTENT INTRAVASCULAR INJECTION. PATIENT MONITORING SHOULD BE CONTINUED FOR AT LEAST 24 HOURS AFTER EACH DOSE, SINCE DELAYED RESPIRATORY DEPRESSION MAY OCCUR. RESPIRATORY DEPRESSION (BOTH EARLY AND LATE ONSET) HAS OCCURRED MORE FREQUENTLY FOLLOWING INTRATHECAL ADMINISTRATION THAN EPIDURAL ADMINISTRATION.

You do you, but liability wise, it's a silly move.
 
Orin said:
Although I agree, medicolegally you're bound by the FDA package insert for morphine which states for intrathecal Administration

NOTE: INTRATHECAL DOSAGE IS USUALLY 1/10 THAT OF EPIDURAL DOSAGE. DURAMORPH SHOULD BE ADMINISTERED INTRATHECALLY BY OR UNDER THE DIRECTION OF A PHYSICIAN EXPERIENCED IN THE TECHNIQUE OF INTRATHECAL ADMINISTRATION AND WHO IS THOROUGHLY FAMILIAR WITH THE LABELING. IT SHOULD BE ADMINISTERED ONLY IN SETTINGS WHERE ADEQUATE PATIENT MONITORING IS POSSIBLE. RESUSCITATIVE EQUIPMENT AND A SPECIFIC ANTAGONIST (NALOXONE INJECTION) SHOULD BE IMMEDIATELY AVAILABLE FOR THE MANAGEMENT OF RESPIRATORY DEPRESSION AS WELL AS COMPLICATIONS WHICH MIGHT RESULT FROM INADVERTENT INTRAVASCULAR INJECTION. PATIENT MONITORING SHOULD BE CONTINUED FOR AT LEAST 24 HOURS AFTER EACH DOSE, SINCE DELAYED RESPIRATORY DEPRESSION MAY OCCUR. RESPIRATORY DEPRESSION (BOTH EARLY AND LATE ONSET) HAS OCCURRED MORE FREQUENTLY FOLLOWING INTRATHECAL ADMINISTRATION THAN EPIDURAL ADMINISTRATION.

You do you, but liability wise, it's a silly move.
Click to expand...

Good info, thanks. It does however not say what type of monitoring. I think sedation scale monitoring could suffice. I have a protocol where a POSS scale and respiratory assessment is charted q 1 hr for 12 and q2 for 12 with a RRT called for a POSS >2

Don't forget our bupi bottles say NOT for spinal right on them and we use that stuff daily all over the nation.
 
Yeah, most of anesthesia is "off label" and sometimes "anti label" as in the bupi spinal.

I don't mind if you don't, but you just have to justify the appropriateness of the monitoring to capture the event. It's really a non-event, except in the scenario where more systemic opioids, anxiolytics, muscle relaxers, etc, are given. Then you're just playing russian roulette and at some point it'll blow up. As long as you've got monitoring, I think it's something you can work with from the label, but then you also have to finagle the ASA guidelines

Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration:An Updated Report by the American Society of Anesthesiologists Task Force on Neuraxial Opioids and the American Society of Regional Anesthesia and Pain Medicine* | Anesthesiology | ASA Publications
They would support your regimen, but they might grumble about the scale usage for certain scenarios.

Recommendations for Detection and Monitoring for Respiratory Depression
  • Monitor all patients receiving neuraxial opioids for adequacy of ventilation (e.g., respiratory rate, depth of respiration [assessed without disturbing a sleeping patient]), oxygenation (e.g., pulse oximetry when appropriate), and level of consciousness.
  • Increased monitoring (e.g., intensity, duration, or additional methods of monitoring) may be warranted for patients at increased risk of respiratory depression (e.g., unstable medical condition, obesity, obstructive sleep apnea, concomitant administration of opioid analgesics or hypnotics by other routes, extremes of age)
Still, I agree this is overkill for the doses of IT opioid used
 
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