intrathecal morphine induced hypothermia

[MirrorTodd]

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Y'all ever seen this? Interesting case this last month. Healthy g1p0 undergoing elective cesarean. Standard spinal dose of 12mg but, 200mcg duramorph, 10mcg feet, and 100mcg epi. Not acute issues during the procedure. In the pacu, pt's temperature drops to 94-95 degrees F and remains there despite forced air warming gown/blanket thingy, warmed fluids etc. Pt's temp eventually returned to normal after several hours. The pt stated she felt fine throughout the ordeal and was not shivering at all.

 

[woopedazz]

I've only seen it in every case that doesn't use warming 🤔

 

[yossarian22]

Seen it 3-4 times, the patient will often say they are hot, and their temperature is usually 94-95. I used narcan for a few doses, but only because our hospital doesn’t carry nubain. Benzodiazepines have also been described as therapeutic as well.

 

[Planktonmd]

Y'all ever seen this? Interesting case this last month. Healthy g1p0 undergoing elective cesarean. Standard spinal dose of 12mg but, 200mcg duramorph, 10mcg feet, and 100mcg epi. Not acute issues during the procedure. In the pacu, pt's temperature drops to 94-95 degrees F and remains there despite forced air warming gown/blanket thingy, warmed fluids etc. Pt's temp eventually returned to normal after several hours. The pt stated she felt fine throughout the ordeal and was not shivering at all.

Yes, very common with intrathecal Hydromorphone but rare with Morphine, likely caused by direct effect on the hypothalamus. It is dose dependent too.

 

[MirrorTodd]

I've only seen it in every case that doesn't use warming 🤔

Not sure if serious. We don't even place skin temp probes on for cesareans, let alone bair huggers.

 

[pocafx]

We do lower bair hugger to just above the knee typically.....

 

[coffeebythelake]

Y'all ever seen this? Interesting case this last month. Healthy g1p0 undergoing elective cesarean. Standard spinal dose of 12mg but, 200mcg duramorph, 10mcg feet, and 100mcg epi. Not acute issues during the procedure. In the pacu, pt's temperature drops to 94-95 degrees F and remains there despite forced air warming gown/blanket thingy, warmed fluids etc. Pt's temp eventually returned to normal after several hours. The pt stated she felt fine throughout the ordeal and was not shivering at all.

Seen this before.
Give some versed
Fixes it in minutes

 

[fakin' the funk]

A

Y'all ever seen this? Interesting case this last month. Healthy g1p0 undergoing elective cesarean. Standard spinal dose of 12mg but, 200mcg duramorph, 10mcg feet, and 100mcg epi. Not acute issues during the procedure. In the pacu, pt's temperature drops to 94-95 degrees F and remains there despite forced air warming gown/blanket thingy, warmed fluids etc. Pt's temp eventually returned to normal after several hours. The pt stated she felt fine throughout the ordeal and was not shivering at all.

This is almost certainly just spinal anesthetic-mediated hypothermia - mostly due to the LA - redistribution, radiation, conduction. No need to blame the morphine alone.
1) did you do active warming during CS?
2) did you measure a core temp during CS?
3) how long was this CS?

Active warming doesn't actually transfer a lot of heat. So if there is truly a heat deficit, it takes a while to correct hypothermia.

 

[MirrorTodd]

I'd like to say that's the case, except that she was the only woman this month who had consistent hypothermia for hours after the pacu...even after the spinal had worn off and she was able to move legs etc. And I hadn't seen it during my two months as a ca1 either. We generally don't do core or skin temp, most women will get warm sheets or blanket spread across their chest once the drapes are up.

A


This is almost certainly just spinal anesthetic-mediated hypothermia - mostly due to the LA - redistribution, radiation, conduction. No need to blame the morphine alone.
1) did you do active warming during CS?
2) did you measure a core temp during CS?
3) how long was this CS?

Active warming doesn't actually transfer a lot of heat. So if there is truly a heat deficit, it takes a while to correct hypothermia.

 

[deleted875186]

A


This is almost certainly just spinal anesthetic-mediated hypothermia - mostly due to the LA - redistribution, radiation, conduction. No need to blame the morphine alone.
1) did you do active warming during CS?
2) did you measure a core temp during CS?
3) how long was this CS?

Active warming doesn't actually transfer a lot of heat. So if there is truly a heat deficit, it takes a while to correct hypothermia.

Persistent hypothermia is well know to be caused by the intrathecal morphine. IV midazolam works like a light switch for this, it’s unbelievable.

 

[Iso4ane]

Seen it. Like people said, midazolam is the treatment.
Patient states they feel hot, but are hypothermia.

 

[NoodleIncident]

Related to the intrathecal Duramorph. Instead of feeling cold and asking for blankets, the patient feels hot and is flushed. Give Ativan 0.5-1mg and temp normalizes quickly.

 

[fakin' the funk]

Well I'll be damned.

 

[deleted162650]

Well I'll be damned.

I’d never heard of this either.

Happy to say I learned something today.

2) did you measure a core temp during CS?

I would also like to learn how you check core body temps on awake patients having c-sections under spinal.

(Hoping you don’t say rectal)

 

[fakin' the funk]

I would also like to learn how you check core body temps on awake patients having c-sections under spinal.

You can't... Unless maybe you have a temperature sensing Foley, but would wonder about the validity. But skin temp is worthless regardless. My buried point was, if pt is hypothermic in PACU and you can't or don't measure temperature before then, impossible to know if it was intraop losses or otherwise.

 

[abolt18]

Mind blown today. Thanks for this little nugget. Sure it'll come in handy one day.

 

[Planktonmd]

You can't... Unless maybe you have a temperature sensing Foley, but would wonder about the validity. But skin temp is worthless regardless. My buried point was, if pt is hypothermic in PACU and you can't or don't measure temperature before then, impossible to know if it was intraop losses or otherwise.

Tympanic temperature is very close to core temperature

 

[deleted875186]

You can't... Unless maybe you have a temperature sensing Foley, but would wonder about the validity. But skin temp is worthless regardless. My buried point was, if pt is hypothermic in PACU and you can't or don't measure temperature before then, impossible to know if it was intraop losses or otherwise.

Correct. The duramorph hypothermia is always picked up in PACU when the patient never warms up.

 

[deleted162650]

Has anybody fleshed out the physiology on this one - and why in hell a benzo corrects opioid induced hypothermia???

I think I might be hard pressed to hit a woman with midaz in PACU during her skin to skin time with her brand spankin’ newborn.

I admit I’ve never seen or even heard of this phenomenon, and I do a good bit of OB.

 

[NoodleIncident]

It was new to me as well, but a partner of mine who graduated 3-4 years after me was asked this in his oral boards.

 

[deleted697127]

Has anybody fleshed out the physiology on this one - and why in hell a benzo corrects opioid induced hypothermia???

I think I might be hard pressed to hit a woman with midaz in PACU during her skin to skin time with her brand spankin’ newborn.

I admit I’ve never seen or even heard of this phenomenon, and I do a good bit of OB.

Use Ativan

 

[BobLoblaw78]

I’d never heard of this either.

Happy to say I learned something today.



I would also like to learn how you check core body temps on awake patients having c-sections under spinal.

(Hoping you don’t say rectal)

Use disposable forehead temp stickers. They say adjusted for core temperature, so you know that it is accurate!

 

[abolt18]

Mind blown today. Thanks for this little nugget. Sure it'll come in handy one day.

Here I am 3 years later. Called for hypothermic patient s/p C-section with duramorph. Temps in 94s despite being under a bair hugger for hours and her room being a million degrees (not sure why they waited so long to call). She's completely miserable, sweating and feels like she's burning up. I immediately remembered this thread and looked it up.

2mg midazolam and 30 minutes later getting 96-97F.

Thanks guys!


Edit: Apparently a dose of nalbuphine may work as well.