Inrathecal morphine for joint replacement

[Planktonmd]

Many years ago our group stopped using intrathecal morphine for post operative pain in hips and knees because of a high incidence of complications in this population: Hypotension, PONV, Itching and respiratory depression.
We simply did not want to be called constantly to deal with these issues.
Some of our more junior colleagues seem to still like intrathecal morphine in cases like bilateral knees, and sure enough we are seeing a return of the phone calls from the floor about various side effects especially hypotension.
Are you guys using intrathecal morphine in these patients?
What's your experience?

 

[mille125]

Many years ago our group stopped using intrathecal morphine for post operative pain in hips and knees because of a high incidence of complications in this population: Hypotension, PONV, Itching and respiratory depression.
We simply did not want to be called constantly to deal with these issues.
Some of our more junior colleagues seem to still like intrathecal morphine in cases like bilateral knees, and sure enough we are seeing a return of the phone calls from the floor about various side effects especially hypotension.
Are you guys using intrathecal morphine in these patients?
What's your experience?

All of these things can be issues. Most of my experience with intrathecal morphine is in the OB realm. I use a lot of epidural morphine when I see inpatient pain management consults. Itching happens but I have not seen any hypotension even though I readily admit that it is possible. How much intrathecal morphine are your colleagues using?

 

[isoman2000]

I will use it, about 100mcg, no real complaints, but I do 2-3 a month so not a huge n.

 

[Noyac]

We use it in every total joint we can. The surgeons love it as well. We give around 200 mcg and have standing orders for the floor nurses. The orders cover pruritis with nubain. Only abour 1/2 or less of the pts ever even ask for the nubain. The PONV is usually once the next day when PT tries to get them up from bed, then its gone. Very rarely will the PONV last longer than that. The hypotension is usually in the OR and is about a 20% drop from baseline sometimes more. We all just augment it with neo as needed. If it sticks around much after surgery I give IM ephedrine. The orders call for 24 hr pulse ox monitoring (not just intermittently). We have never had a case of resp dep to date. I believe it is the dose that determines this, under 400mcg. With the elderly we usually give about 100 mcg. Everyone starts on PO pain meds the next day and this is also when some of the PONV starts so I can't blame "all" nausea on the IT MS.

But most importantly, we educated the surgeons and nursing staff in regards to pain and SE's. The orders are thorough and the calls are nil. We do so many of these that all the nurses know exactly what to expect and how to deal with the SE's. I literally never get a call from them for anything. The pts even love it. They frequently say, " I never thought it could be this easy". Thats usually b/4 the real PT starts. We are now getting pts coming to us b/c friends have had a jt replacement and told them how easy it was. And this is sort of where I was going with the Adertisement thread I started. Our Total Jt program is interested in advertising some of the anesthetic management of totals.

We also do regional single shots for the TKA's, FNB and SCNB. The pts rarely ask for pain meds till the next day. And the nurses are so familiar with it that they know when the pts are going to start needing something, so they are on top of it.

 

[jetproppilot]

I've got a buddy in another practice who swears by adding 400mcg naloxone to the pt's IVF at maintenance rate.....not enough opioid antagonist to effect analgesia but enough to ameliorate itching/ N/V, he says.

Anybody tried that?

 

[dA pilot]

My total hips get 200 mcg of IT morphine and it works out very well, very little supplementation with a pca. Total knees get an epidural catheter/depodur or femoral nerve block/catheter depending on surgeon. IT morphine will not suffice. The passive motion machine is the killer.

 

[huktonfonix]

I would suspect the hypotension is from other reasons (blood loss, intravascularly depleted) and happens regardless. Its just that you dont get called about it unless you have the astramorph in because then you arent managing that aspect of the patient.

 

[lucy07]

Noyac, what are you using for your single shot blocks, and catheters for that matter. I always used 0.5% bupivicaine +/- clonidine in residency for the single shots and had really good results. The group that I just started with out of residency only uses ropivicaine,( 0.5% for the single shot and 0.2% for infusions,) and a lot more of my patients seem to have pain issues in the PACU.....
Despite the fact that I am using both ultrasound ( i know, don't even go there) and a twitch monitor.
Any thoughts? Thanks!

 

[Noyac]

Noyac, what are you using for your single shot blocks, and catheters for that matter. I always used 0.5% bupivicaine +/- clonidine in residency for the single shots and had really good results. The group that I just started with out of residency only uses ropivicaine,( 0.5% for the single shot and 0.2% for infusions,) and a lot more of my patients seem to have pain issues in the PACU.....
Despite the fact that I am using both ultrasound ( i know, don't even go there) and a twitch monitor.
Any thoughts? Thanks!

I use 0.5% ropiv for single shots and 0.2% ropiv for catheters. I don't add anything to it.

 

[DET0897]

I've got a buddy in another practice who swears by adding 400mcg naloxone to the pt's IVF at maintenance rate.....not enough opioid antagonist to effect analgesia but enough to ameliorate itching/ N/V, he says.

Anybody tried that?

Routinely. It's my first choice intervention for itching. 0.4mg Narcan added to whatever maintenance IVF. Have yet to see this concentration have significant effect on pain relief, but nearly always works for the itching, especially in the face.

 

[coprolalia]

We simply did not want to be called constantly to deal with these issues.

Nalbuphine 5-10mg q4h PRN for itching.

No calls. (And, respiratory depression? How much intrathecal morphine are you giving?)

-copro

 

[Planktonmd]

Unfortunately, where I am once you let the nurses know that you gave intrathecal morphine they will attribute everything that happens to the patient from that point on to your morphine and they will call you about it.
It takes too much effort to educate people and that's why we abandoned intrathecal morphine in the past.

 

[Planktonmd]

I've got a buddy in another practice who swears by adding 400mcg naloxone to the pt's IVF at maintenance rate.....not enough opioid antagonist to effect analgesia but enough to ameliorate itching/ N/V, he says.

Anybody tried that?

We add 0.4 mg of Naloxone to every IV bag in OB patients who had a C section under spinal with morphine.
This practice although not very scientific appears to be very popular.

 

[Hawaiian Bruin]

Before 3 weeks ago I had no idea that intrathecal morphine even existed, now that I've done quite a few of these I absofrigginglutely love it.

200-300 mcg seems to be what is used around here.

We had a surgeon BEG us for it today for a nephrectomy after one we did yesterday.

BEG.

I've never seen that before.

We also have a very thorough duramorph order set, which seems to allay most nursing concerns.

One thing though- using duramorph mandates admission to step-down rather than the floor, and I wonder how that works out financially for the patient and the hospital.

 

[Noyac]

Unfortunately, where I am once you let the nurses know that you gave intrathecal morphine they will attribute everything that happens to the patient from that point on to your morphine and they will call you about it.
It takes too much effort to educate people and that's why we abandoned intrathecal morphine in the past.

If your order form is complete enough the nurses don't have any reason to call you. What other things are they attributing to the IT MS?

 

[Noyac]

Before 3 weeks ago I had no idea that intrathecal morphine even existed, now that I've done quite a few of these I absofrigginglutely love it.

200-300 mcg seems to be what is used around here.

We had a surgeon BEG us for it today for a nephrectomy after one we did yesterday.

BEG.

I've never seen that before.

We also have a very thorough duramorph order set, which seems to allay most nursing concerns.

One thing though- using duramorph mandates admission to step-down rather than the floor, and I wonder how that works out financially for the patient and the hospital.

He's begging you now but I guarantee he will be blaming you latter if there is any urinary retention.

 

[huktonfonix]

spinal astramorph is essentially a poor mans epidural. I used to use thoracic epidurals all the time during residency with spinal astramorph primarily for C sections. Now I rarely use a thoracic epidural. Instead I use the astramorph. I agree with plankton that a lot of it has to do with your nursing staff and their knowledge/comfort level. Admittedly some of it is also the fact that we have no pain service here to manage the epidurals and its just easier to use spinal morphine.

 

[Noyac]

spinal astramorph is essentially a poor mans epidural. I used to use thoracic epidurals all the time during residency with spinal astramorph primarily for C sections. Now I rarely use a thoracic epidural. Instead I use the astramorph. I agree with plankton that a lot of it has to do with your nursing staff and their knowledge/comfort level. Admittedly some of it is also the fact that we have no pain service here to manage the epidurals and its just easier to use spinal morphine.

You placed thoracic epidurals for c/s?

 

[Hawaiian Bruin]

spinal astramorph is essentially a poor mans epidural.

Definitely agree, and it's why I didn't know about this at the "Big House" where Acute Pain places/manages epidurals, and had to go out into the community to get exposed to it.

He's begging you now but I guarantee he will be blaming you latter if there is any urinary retention.

No doubt, but it was still the damndest thing I've ever seen.

I know the side effects can be potentially nasty, but not unmanageable, and despite my admittedly low N, I've decided that I love this stuff.

 

[Noyac]

No doubt, but it was still the damndest thing I've ever seen.

I know the side effects can be potentially nasty, but not unmanageable, and despite my admittedly low N, I've decided that I love this stuff.

Back in residency I had this hard nosed attending who did things slightly different than everyone else. I was in the urology room one day with 2 radical prostatectomies to do. He said do a spinal and put 1 mg of duramorph.

Well of course I did it. And those 2 guys didn't touch their PCA's the whole time they were in the hospital. But the amazing thing is that they didn't complain of itching either which beats the hell out of me. Pretty cool experiment I'd say. Impressed the hell out of me and the surgeons.

 

[huktonfonix]

You placed thoracic epidurals for c/s?

Naw, Im on call now and just too lazy to type separate sentences.

 

[SleepIsGood]

Back in residency I had this hard nosed attending who did things slightly different than everyone else. I was in the urology room one day with 2 radical prostatectomies to do. He said do a spinal and put 1 mg of duramorph.

Well of course I did it. And those 2 guys didn't touch their PCA's the whole time they were in the hospital. But the amazing thing is that they didn't complain of itching either which beats the hell out of me. Pretty cool experiment I'd say. Impressed the hell out of me and the surgeons.

1 mg! not 0.1 mg?

You did mean intrathecal space, not epidural space right?

 

[jetproppilot]

1 mg! not 0.1 mg?

You did mean intrathecal space, not epidural space right?

YA KNOW, DUDE, I'm thinkin' the same thing.....which is...

WTF?

A MILLIGRAM?

Intrathecal?

Twelve years into this biz, though, I recognize the privelege(sic?) of learning from other people's styles, and how other people's styles may be better than my style, and benefit the patient more than my style.

This anesthesia biz can be done a million ways.

900,000 of that million are safe and within standard of care.

So, yeah, a MILLIGRAM of morphine intrathecal strikes me.

I give a cuppla hundred mikes routinely in spinals, mostly C sections.

I say its too much.....but then I catch myself.....thousand/million ways to skin a cat.......who am I to say its "too much?"

I'm just another PP anesthesiologist-schmoe performing my trade like I was taught......

What if it provides superior analgesia without sinister side effects compared to two hundred or three hundred micrograms of intrathecal morphine?

Noy, would you ever consider blowing in a milligram on say, a total joint?

 

[Noyac]

Yep, 1 mg (1000 mcg) intrathecally.

I never did this again but I can tell you, it can be done and has been done.

Personally, I think its too risky.

 

[BLADEMDA]

Yep, 1 mg (1000 mcg) intrathecally.

I never did this again but I can tell you, it can be done and has been done.

Personally, I think its too risky.

You all are just gonna love this post. Some of the old guys (late 60's) before they retired loved spinal duramorph. They subscribed to the theorythat if a little is good then more is better. Two of them ROUTINELY used 0.8-1.0 mg for open AAA's and Thoractomy while us "younger guys" never ventured further than 0.5 mg. I saw at least a hundred patients over the years get the 0.8-1.0 mg dose. They all went to the ICU for the next 48 hours and none of them complained of anything. Most were sedated but could respond when stimulated. Of the two groups the thoracotomy patients seemed more alert at the higher dose 1.0mg than the AAA's.

I myself routinely use 0.5 mg for AAA's and Nephrectomy patients particulary on those who drink a lot. The complaints are minimal and if I get any from the nurses I just add a little narcan to the maintainence fluid for 24 hours. That seems to do the trick.

I find the thoracotomy patients dont get much more than 18 hours of pain relief even with high dose duramorph. This group seems to need a high lumbar/thoracic epidural or a continuous paravertebral block (epidural catheter at T5/T6 in the paravertebral space). The acute pain persists for 48-72 hours.

Now, I am familiar with all the literature of epidural/spinal duramorph. But, in the real world you can try different things and in my opinion, the 500 microgram dose works better on the JPP's of the world particularly for the most painful surgeries.

 

[mille125]

Yep, 1 mg (1000 mcg) intrathecally.

I never did this again but I can tell you, it can be done and has been done.

Personally, I think its too risky.

Lord

 

[Noyac]

Lord

YES!

Can I help you?

 

[Coastie]

I've got a buddy in another practice who swears by adding 400mcg naloxone to the pt's IVF at maintenance rate.....not enough opioid antagonist to effect analgesia but enough to ameliorate itching/ N/V, he says.

Anybody tried that?

Yep, totally works.

 

[mille125]

YES!

Can I help you?

prayer is what I suggest when the lawyers come knocking....

 

[ncdoc1974]

Yep, 1 mg (1000 mcg) intrathecally.

I never did this again but I can tell you, it can be done and has been done.

Personally, I think its too risky.

I think there are some pretty good studies on this (I am too lazy to look them up right now) but I remember the conclusion was that with IT morphine, anything greater that 200mcg did not result in superior pain relief, but did increase the rate of side effects in a dose dependent manner...

 

[Noyac]

I think there are some pretty good studies on this (I am too lazy to look them up right now) but I remember the conclusion was that with IT morphine, anything greater that 200mcg did not result in superior pain relief, but did increase the rate of side effects in a dose dependent manner...

Your right but I remember the dose being around 400mcg where all you get is SE's without any further pain control.

 

[Noyac]

prayer is what I suggest when the lawyers come knocking....

You don't read so well, do you!

 

[Planktonmd]

Your right but I remember the dose being around 400mcg where all you get is SE's without any further pain control.

While this might be true in the narcotic naive patient I think that patients who are on Narcotics chronically tolerate higher doses of intrathecal morphine.
We do 1-2 mg IT morphine test dose routinely before placing morphine pumps for chronic pain.

 

[BLADEMDA]

I think there are some pretty good studies on this (I am too lazy to look them up right now) but I remember the conclusion was that with IT morphine, anything greater that 200mcg did not result in superior pain relief, but did increase the rate of side effects in a dose dependent manner...

That 200 microgram study was for c sections. AAA's and thoracotomy patients are a different group. They need more duramorph. For example I would give 5 milligrams or more epidurally for a AAA. In my experience 200 micrograms via the csf is an inadequate dose for these types of patients

 

[Noyac]

Yes it is important for us to be sure that we are talking about the same pt population. A c/s is very different from a AAA or thoracotomy w/c is different from narcotic tolerant pts.

Possibly, mille could enlighten us with more of his wisdom

 

[MDEntropy]

Intrathecal opiates causing significant hypotension? I think this side effect is 2/2 local anesthetic not the the opiate. After the patient is back on the floor, the LA effect should be gone. Intrathecal morphine will cause resp depression, n/v, pruritus, and even urinary retention for nearly a day but it isn't causing hypotension. If the nurses know this, they will call the primary caretaker for this matter.

 

[Planktonmd]

Intrathecal opiates causing significant hypotension? I think this side effect is 2/2 local anesthetic not the the opiate. After the patient is back on the floor, the LA effect should be gone. Intrathecal morphine will cause resp depression, n/v, pruritus, and even urinary retention for nearly a day but it isn't causing hypotension. If the nurses know this, they will call the primary caretaker for this matter.

What if the "primary caretaker" tells them to call you because this hypotension is caused by your IT morphine?

 

[MDEntropy]

What if the "primary caretaker" tells them to call you because this hypotension is caused by your IT morphine?

Just tell your ortho guys that IT morphine is as likely to cause hypotension as it is to cause compartment syndrome and non-union...in other words, it doesn't. They may not like to read but they learn very quickly especially if things are simplified and presented in nearly absolute terms.