Duramorph/Bupiv Spinals

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Good call Sevo. If your OBs want to use a PCA (I'm sure it's for billing reasons as much as pain control) then don't use IT MS. I wonder, are you giving Toradol? Another thing to think of however, you can bill for a post-op pain visit the next day if you give IT narcs (not sure if fentanyl counts due to duration) and collect a fair amount. If you are not doing this, you might want to check in on it. But I think it would be fraudulent if you are making post-op pain rounds on their pts that they wrote PCA orders for.
Just a thought.
 
sevoflurane said:
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.
Click to expand...

I think IT morphine plus a PCA is OK, the keys being the patient is the one hitting the button, and no basal.

The only respiratory problems I've seen with PCAs in any postop pain management scheme have been in patients who were getting basal rates.
 
pgg said:
I think IT morphine plus a PCA is OK, the keys being the patient is the one hitting the button, and no basal.

The only respiratory problems I've seen with PCAs in any postop pain management scheme have been in patients who were getting basal rates.
Click to expand...

I had suspected that PCA was the reason for no IT morphine, which I completely agree. The practice here is routine duramorph and NO PCA. I think either has the chance of respiratory depression, and combining them is asking for trouble. We have had more complication with PCA than duramorph (but in the non-obstetric population). Personally I think it's better patient care with duramorph than PCA, but if the OB wants to take all the risk and provide worse care that's their call.
 
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pgg said:
I think IT morphine plus a PCA is OK, the keys being the patient is the one hitting the button, and no basal.

The only respiratory problems I've seen with PCAs in any postop pain management scheme have been in patients who were getting basal rates.
Click to expand...

You are correct as I'm sure Sevo understands this as well. But what I believe Sevo is doing is minimizing "his" risk.

Another thing I thought about in Sevo's case is that his pts are obviously getting more narc's which inevitably make it to the neonate. So we are not only talking about the mommy's risk of response depression but now we have added the baby's as well.
 
Our OB’s always put them on PCA’s. Maybe its for billing? I don’t know. Honestly, I’m not complaining because if we place IT duramorph, we’d be responsible for post-op pain for 24hrs and the effectiveness of IT morphine sometimes lasts only 12 hrs. or even less which = a call at 3:00am.

We get a generous flat fee for C/S and labor epidurals (subsidized). So post-op rounds for IT MS is not really worth it to us as we are busy during the day and we don’t have a board runner or free standing pain service that is available to round on them. Bottom line, I sleep better knowing that I have opted out of IT duramorph when there is a PCA being used.

Ketafol20: you are absolutely correct when stating the reduction of "MY" risk 😉 as well as mothers.

Maybe we just need to take the bull by the horns and take over pain management for the 1st 24hrs and educate our OB’s as to the effectiveness of IT duramorph.

During residency I did one of my OB rotations at an outside hospital that had the 2nd largest OB volume in my state. 350-400 deliveries a month. Most of them received .15-.2mg of IT duramorph + 10-15 mcgs of fentanyl. They did very well post-op.

As Blade stated, 24 hour monitoring with pulse ox is a must, especially if a PCA is being used concomitantly with IT duramorph. My experience with 1000 or so C/S is that IT duramorph works extremely well. I don’t question IT duramorph as a superior method of analgesia. I’m 100% behind it. Just a little cautious with a PCA being used at the same time.. At this point in time, I don't like the idea of both running simultaneously.

I’ll also echo what Blade said in regards to patient selection. Obese parturients with thick neck/OSA should be looked at with a careful eye. Omission or a decrease of IT duramorph should be a consideration. I like POD’s .1mg dosage, but admittedly when I use IT MS, my standard has been .15 mg for many years.

Thank you for the replies.

Good discussion and review. 👍
 
morphine IT does act the spinal level - substantia gelatinosa, that's a fact (not just some thinking it). This is the bulk of the analgesic effect.

There is some stimulation of opioid receptors in higher brain centers, but this is really delayed. The reason it takes a while to start working is due to its hydrophilicity - slowing the diffusion from the CSF to the SG.

FOr those of you doing MOCA - one of the new requirements is to monitor your practice style, change something and see if it makes a difference (and write about it). This could be a really good project. Just start adding a little fent to your spinals.


BLADEMDA said:
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.
Click to expand...
 
sevoflurane said:
Our OB’s always put them on PCA’s. Maybe its for billing? I don’t know. Honestly, I’m not complaining because if we place IT duramorph, we’d be responsible for post-op pain for 24hrs and the effectiveness of IT morphine sometimes lasts only 12 hrs. or even less which = a call at 3:00am.

We get a generous flat fee for C/S and labor epidurals (subsidized). So post-op rounds for IT MS is not really worth it to us as we are busy during the day and we don’t have a board runner or free standing pain service that is available to round on them. Bottom line, I sleep better knowing that I have opted out of IT duramorph when there is a PCA being used.

Ketafol20: you are absolutely correct when stating the reduction of "MY" risk 😉 as well as mothers.

Maybe we just need to take the bull by the horns and take over pain management for the 1st 24hrs and educate our OB’s as to the effectiveness of IT duramorph.

During residency I did one of my OB rotations at an outside hospital that had the 2nd largest OB volume in my state. 350-400 deliveries a month. Most of them received .15-.2mg of IT duramorph + 10-15 mcgs of fentanyl. They did very well post-op.

As Blade stated, 24 hour monitoring with pulse ox is a must, especially if a PCA is being used concomitantly with IT duramorph. My experience with 1000 or so C/S is that IT duramorph works extremely well. I don’t question IT duramorph as a superior method of analgesia. I’m 100% behind it. Just a little cautious with a PCA being used at the same time.. At this point in time, I don't like the idea of both running simultaneously.

I’ll also echo what Blade said in regards to patient selection. Obese parturients with thick neck/OSA should be looked at with a careful eye. Omission or a decrease of IT duramorph should be a consideration. I like POD’s .1mg dosage, but admittedly when I use IT MS, my standard has been .15 mg for many years.

Thank you for the replies.

Good discussion and review. 👍
Click to expand...

As I've stated I add 200 Micrograms of IT MSO4 to my SAB for Sections.
But, POD's 100 microgram dose has the MOST Peer reviewed evidence behind it, period. It simply doesn't do much for post op pain relief to add more than 0.1 mg. The only thing patients get in the studies is more itching.😱

Maybe, I've got to cut back on that IT MSO4? Then again, maybe not.😉
 
Jeff05 said:
morphine IT does act the spinal level - substantia gelatinosa, that's a fact (not just some thinking it). This is the bulk of the analgesic effect.

There is some stimulation of opioid receptors in higher brain centers, but this is really delayed. The reason it takes a while to start working is due to its hydrophilicity - slowing the diffusion from the CSF to the SG.

FOr those of you doing MOCA - one of the new requirements is to monitor your practice style, change something and see if it makes a difference (and write about it). This could be a really good project. Just start adding a little fent to your spinals.
Click to expand...

Go ahead and try it. I have. Made no difference just more itching. At least keep the dosage low if you are adding FENT and MSO4 IT.
 
Jeff05 said:
FOr those of you doing MOCA - one of the new requirements is to monitor your practice style, change something and see if it makes a difference (and write about it). This could be a really good project. Just start adding a little fent to your spinals.
Click to expand...

mmhmm and when it doesn't make a difference can I write that up and get my MOCA checkbox checked? Does "tested it, didn't see a difference, what I am doing is working fine, so I am not changing my practice style" count? :meanie:

Haven't done nearly as many sections as Blade, but during residency and moonlighting in fellowship I tested this very carefully and came to the conclusion that Blade has mentioned. If you are using an adequate dose of Bupi it doesn't make any difference. If you skimp on the Bupi, you might be able to get by with the addition of the fent, but you will get into trouble with an inadequate block more often. There are better adjuncts than fent with fewer side effects depending on your goal. With an adequate dose of bupi and 100 mcg of morphine the fent does nothing but make the patient itch worse. I stand by my statement it just doesn't make pharmacologic sense (or practical sense for that matter).



- pod
 
periopdoc said:
I stand by my statement it just doesn't make pharmacologic sense (or practical sense for that matter).
- pod
Click to expand...


😛 😉 😛


img0964m.jpg


BLADEMDA said:
I'm glad you guys are good at adding EXACTLY 150 micrograms of IT MSO4.
Click to expand...

150 mcgs... EXACTLY. 😀😉

FWIW, I hardly EVER see itching with the fentanyl doses I use.

I have seen plenty of itching with .2 of MS.

I don't know about .1mg.

I bet not much.
 
To the OP,
With regard to dosing, I have gone through a transition over the last 4 years. I started low with duramorph and fent and about 1.6 of Bup. cause that's what we did as residents. When I got "here", I asked what others were doing and did that. Higher duramorph and bup and no fentanyl. I think that is not the best recipe, but that is what "they" were doing. I have been a here a while now, and I have done a little research, all well summarized in the discussion above. Now I do generally roughly 1.6-1.8 of Bup with about 250 mcg of Duramorph. No Fent.
Why?
Well, 1.6 to 1.8 works. No epi. I find the addition of epi drops the bp more severely. I don't need a denser or more long lasting block than about 1.6mL of 3/4 bup so there is no upside to using epi.
250 mcg of Duramorph.
why? cause everyone was itching that was getting 500mcg from the old guys. So I thought I'd cut my dose in half. Now I will go even lower because of this thread. Our standard orders allow for Morphine and Toradol IV for breakthrough pain. We get more money if give Duramorph and round on the patients the next day.
No fent. Why? Cause you have to open another vial of meds and carefully measure it while the pt is waiting. THen you have to chart it and deal with the waste etc. The BS ain't worth the minimal upside of intraop euphoria.
Were it my wife, I'd want her to get the Fent.

Now, the really important thing is what does the newbie do in her first private practice group? You do what the group has done for years. Find out if it works as well or better than what you were trained to do. If, after you have gained credibility with the nurses and other staff, you feel that the way you were taught was better, then go ahead and try it that way.

I have done a very good job at my new job. Half the battle is "getting along." Don't rock the freaking boat. In my first year I was actually approached and told explicitly by some of the partners that they like the way I tried to learn to do things their way. My practice is now a hybrid between what I was taught in residency and what I have learned here--much of which works way better "here". If I went back "there" I would be back doing more TIVAs, and other exotic tailored anesthetics.

Keep your head down, your opinions to yourself, work hard, always volunteer to work late or on the weekends if needed, and you too will be a valued, and respected member of the anesthesia staff. At that point you can begin to respectfully express some of your opinions and suggest new ways of doing things.

Tuck
 
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trinityalumnus said:
What I wouldn't give to have those flip-top vials. We're still using ampules with breakaway glass tops. Great for shredding fingertips. And I wonder about microscopic particles of broken glass getting into the spinal syringe even with use of the filter straw and filter needle, and into the CSF.



.
Click to expand...

I too wonder about the micro glass particles getting into the CSF. The glass Fentanyl vials are very easy to crack into many tiny glass particles. Yes, the filter helps but I'm not sure if I'd want my wife getting that Fentanyl from a glass vial into her CSF especially since it really doesn't add much to a good Bup/IT MSO4 SAB.

I may start going the TB syringe route with the Duramorph and decrease my dose to 150 micrograms or so.

Again ,the Peer reviewed evidence doesn't support dosages above 100 micrograms of IT MSO4. Dosages above 200 Micrograms can caused an increased risk of Respiratory Depression and will increase itching.
 
tucker27705 said:
To the OP,
With regard to dosing, I have gone through a transition over the last 4 years. I started low with duramorph and fent and about 1.6 of Bup. cause that's what we did as residents. When I got "here", I asked what others were doing and did that. Higher duramorph and bup and no fentanyl. I think that is not the best recipe, but that is what "they" were doing. I have been a here a while now, and I have done a little research, all well summarized in the discussion above. Now I do generally roughly 1.6-1.8 of Bup with about 250 mcg of Duramorph. No Fent.
Why?
Well, 1.6 to 1.8 works. No epi. I find the addition of epi drops the bp more severely. I don't need a denser or more long lasting block than about 1.6mL of 3/4 bup so there is no upside to using epi.
250 mcg of Duramorph.
why? cause everyone was itching that was getting 500mcg from the old guys. So I thought I'd cut my dose in half. Now I will go even lower because of this thread. Our standard orders allow for Morphine and Toradol IV for breakthrough pain. We get more money if give Duramorph and round on the patients the next day.
No fent. Why? Cause you have to open another vial of meds and carefully measure it while the pt is waiting. THen you have to chart it and deal with the waste etc. The BS ain't worth the minimal upside of intraop euphoria.
Were it my wife, I'd want her to get the Fent.

Now, the really important thing is what does the newbie do in her first private practice group? You do what the group has done for years. Find out if it works as well or better than what you were trained to do. If, after you have gained credibility with the nurses and other staff, you feel that the way you were taught was better, then go ahead and try it that way.

I have done a very good job at my new job. Half the battle is "getting along." Don't rock the freaking boat. In my first year I was actually approached and told explicitly by some of the partners that they like the way I tried to learn to do things their way. My practice is now a hybrid between what I was taught in residency and what I have learned here--much of which works way better "here". If I went back "there" I would be back doing more TIVAs, and other exotic tailored anesthetics.

Keep your head down, your opinions to yourself, work hard, always volunteer to work late or on the weekends if needed, and you too will be a valued, and respected member of the anesthesia staff. At that point you can begin to respectfully express some of your opinions and suggest new ways of doing things.

Tuck
Click to expand...

Tuck,

You have followed JPP's advice to the CORE. Hence, you are doing well in PP and Partnership awaits.

Great post.
 
dhb said:
've never heard of any reports of this and we only have glass vials for narcs
Click to expand...

Yeah, I'm not so sure there's reason to be concerned. I use the filter needle or straw because we have them and that's what I was taught to do it, and I was taught to fear microscopic glass shards injected in the spine. Dogma?

There's an entire product line (filtered needles) to address an issue that may not actually even be a problem.


tucker27705 said:
Were it my wife, I'd want her to get the Fent.
Click to expand...

Good enough for a family member, good enough for everybody?

I went through the same kind of evidence-based rationalization for anti-emetics. I used to think of risk factors for PONV, then tailor the number of drugs given to that rational count of risk factors. Then I thought one day, if this was my daughter at similarly low risk for PONV, would I give her the Zofran anyway, even though I already gave dexamethasone? The answer was sure, why not. PONV sucks, Zofran is cheap and safe. And so I gave the finger to the PONV risk-factor counts, and now I aggressively prophylax everyone. Call me a Zofran-wasting unthinking protocol-nurse if you will. 🙂
 
pgg said:
Yeah, I'm not so sure there's reason to be concerned. I use the filter needle or straw because we have them and that's what I was taught to do it, and I was taught to fear microscopic glass shards injected in the spine. Dogma?

There's an entire product line (filtered needles) to address an issue that may not actually even be a problem.




Good enough for a family member, good enough for everybody?

I went through the same kind of evidence-based rationalization for anti-emetics. I used to think of risk factors for PONV, then tailor the number of drugs given to that rational count of risk factors. Then I thought one day, if this was my daughter at similarly low risk for PONV, would I give her the Zofran anyway, even though I already gave dexamethasone? The answer was sure, why not. PONV sucks, Zofran is cheap and safe. And so I gave the finger to the PONV risk-factor counts, and now I aggressively prophylax everyone. Call me a Zofran-wasting unthinking protocol-nurse if you will. 🙂
Click to expand...

Generic Zofran costs the hospital $1-$1.75 per dose. Decadron costs less than $1.00
 
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