- Joined
- Jul 20, 2005
- Messages
- 241
- Reaction score
- 2
CASE 1: Have you guys ever seen someone get very sedated about 2-6 hours after an intrathecal dose of morphine? I did a TKA yesterday in an spry 70 year old lady with a spinal and 0.2 of intrathecal morphine. Little propofol for the case - no IV narcs whatsoever.
In PACU, (about two hours after injection) she is very sleepy (but arousable) and nauseated. About four hours after, the same, but when she wakes up she gets very nauseated and diaphoretic. I do some general examining and questioning for other issues like a cardiac event (EKG), hypovolemia, bleeding into the knee, electrolytes, chest pain, SOB just to rule out any wierdness. Spinal has worn off, but she is still very sleepy and very nauseated and no IV narcotics given yet.
Well, I give a little Nubain to see what a little reversal will do, and it actually perks her up a little and really helps with the nausea. I considered a Narcan drip, but in this little community hospital, this requires ICU admission, so I send her off to IMC overnight to watch her sats. I haven't seen such extreme sensitivity to intrathecal morphine before.
Case #2: Hypercoagulable pregnant girl comes in. She has been on full anticoagulation dose of Lovenox, stopped for 24 hours - they have given her 7000 U of heparin SQ. (sort of a random dose, in my opinion). I say when she wants an epidural, just send off a PTT and if its OK, we are good to go. But one partner says 7000 U is a prophylactic dose, no need to check anything and another partner says we need to check platelets and INR and PTT because of her history of Lovenox, hypercoag history and higher than normal dose of SQ heparin. Thoughts?
In PACU, (about two hours after injection) she is very sleepy (but arousable) and nauseated. About four hours after, the same, but when she wakes up she gets very nauseated and diaphoretic. I do some general examining and questioning for other issues like a cardiac event (EKG), hypovolemia, bleeding into the knee, electrolytes, chest pain, SOB just to rule out any wierdness. Spinal has worn off, but she is still very sleepy and very nauseated and no IV narcotics given yet.
Well, I give a little Nubain to see what a little reversal will do, and it actually perks her up a little and really helps with the nausea. I considered a Narcan drip, but in this little community hospital, this requires ICU admission, so I send her off to IMC overnight to watch her sats. I haven't seen such extreme sensitivity to intrathecal morphine before.
Case #2: Hypercoagulable pregnant girl comes in. She has been on full anticoagulation dose of Lovenox, stopped for 24 hours - they have given her 7000 U of heparin SQ. (sort of a random dose, in my opinion). I say when she wants an epidural, just send off a PTT and if its OK, we are good to go. But one partner says 7000 U is a prophylactic dose, no need to check anything and another partner says we need to check platelets and INR and PTT because of her history of Lovenox, hypercoag history and higher than normal dose of SQ heparin. Thoughts?
