Neuraxial morphine

[Gaseous Clay]

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Curious to all our OB gurus if your institution follows these recommendations for respiratory monitoring post op. I have used 0.2/3 mg doses for years but wondering if I am using an outdated dosage and if people are getting better results with less. Thanks for any feedback!

 

[MirrorTodd]

View attachment 342868

Curious to all our OB gurus if your institution follows these recommendations for respiratory monitoring post op. I have used 0.2/3 mg doses for years but wondering if I am using an outdated dosage and if people are getting better results with less. Thanks for any feedback!

Our little protocol calls for anywhere from 0.1-0.25mg duramorph for spinals for our cesareans. Most people go lower in an effort to reduce the itchiness side effect, especially since we were out of nubain for quite a while.

 

[Southpaw]

Curious to all our OB gurus if your institution follows these recommendations for respiratory monitoring post op. I have used 0.2/3 mg doses for years but wondering if I am using an outdated dosage and if people are getting better results with less. Thanks for any feedback!

I'm at a high volume OB center and work with a former SOAP president. I don't say that to brag, just to give you some background on where this comes from since it's mostly anonymous here. We follow those recommendations and our epidural/spinal dosing for duramorph is in the low range.

 

[Gaseous Clay]

Meaning most use 0.15/2 or 3 mg dosing?

And definitely don't see it as bragging, just gives you a little more internet cred!

 

[Southpaw]

Meaning most use 0.15/2 or 3 mg dosing?

And definitely don't see it as bragging, just gives you a little more internet cred!

The norm is 0.1/3

 

[DocVapor]

Our spinal opiate ordersets include this type of respiratory monitoring automatically for any dose.

I generally use .2 mg in low risk patients and decrease to .15 for my obese ladies (BMI >40... which is like 75% of my patients.)

These recs are cool and all, but really, how many of you think the nurses actually do this high level of monitoring vs just put a number in the flowsheet.

P.S. what is "continual intermittent pulse oximetry"

 

[abolt18]

My former chair is a big-wig in OB anesthesia and he was all about "150mcg duramorph for everyone".

 

[deleted697535]

Everyone gets 1.5 epidural and 0.15 spinal. Id say 95% of our anesthesia staff do the same out of probably 120 odd in our dept

 

[Gaseous Clay]

Everyone gets 1.5 epidural and 0.15 spinal. Id say 95% of our anesthesia staff do the same out of probably 120 odd in our dept

Do you do continuous monitoring or just q3 hrs as above?

Also for those who do intermittent vitals instead of continuous, what if the patient is hurting within a few hours post op and they want to start their pain meds before 24 hours?

 

[deleted697535]

Do you do continuous monitoring or just q3 hrs as above?

Also for those who do intermittent vitals instead of continuous, what if the patient is hurting within a few hours post op and they want to start their pain meds before 24 hours?

Well i just check the epic order set box... Nothing more complicated than that

 

[deleted875186]

I typically did 0.2 - 0.3 mg, sometimes less if concerned about itching, I can’t imagine anything less than 0.15mg working that well, I remember papers showing 0.3 mg being the ultimate dose for best analgesia and limited side effects, also, I think the monitoring for respiratory depression is bologna, comes from back in the day when ultra high spinal doses were given.

 

[Mman]

I typically did 0.2 - 0.3 mg, sometimes less if concerned about itching, I can’t imagine anything less than 0.15mg working that well, I remember papers showing 0.3 mg being the ultimate dose for best analgesia and limited side effects, also, I think the monitoring for respiratory depression is bologna, comes from back in the day when ultra high spinal doses were given.

I see a decent amount of itching with doses in the 0.15-0.2 range, can't imagine 0.3 mg having "limited" side effects.

 

[deleted875186]

I see a decent amount of itching with doses in the 0.15-0.2 range, can't imagine 0.3 mg having "limited" side effects.

Sometimes itching, but also great pain relief, so nubain works wonders. 0.3 mg is definitely more efficacious than 0.1 or 0.15 mg.

 

[DrOwnage]

Had a patient yesterday who was Covid positive, symptomatic. Was 91% on RA, 98% on 2L nasal cannula. I opted not to put any duramorph or fentanyl in her spinal due to concerns of her respiratory status getting worse. You guys put duramorph in Covid positive patients?

 

[Gaseous Clay]

Had a patient yesterday who was Covid positive, symptomatic. Was 91% on RA, 98% on 2L nasal cannula. I opted not to put any duramorph or fentanyl in her spinal due to concerns of her respiratory status getting worse. You guys put duramorph in Covid positive patients?

Versus a PCA? Valid concern but I’d be fine with the spinal morphine.

 

[DrOwnage]

Usually don't put our C/S patients on PCA. Normally toradol, tylenol, oxycodone.

 

[deleted875186]

Had a patient yesterday who was Covid positive, symptomatic. Was 91% on RA, 98% on 2L nasal cannula. I opted not to put any duramorph or fentanyl in her spinal due to concerns of her respiratory status getting worse. You guys put duramorph in Covid positive patients?

I also would not add duramorph. I think there’s absolutely no way it’s going to cause harm, but in case the patients respiratory status worsens I don’t want any blame on me.

 

[OneFellSwoop]

I also would not add duramorph. I think there’s absolutely no way it’s going to cause harm, but in case the patients respiratory status worsens I don’t want any blame on me.

Honestly, This has to be the worst use of this CYA excuse I’ve ever seen. do the right thing for the patient and use duramorph. There’s a way higher chance of respiratory depression from IV narcs than from duramorph. In the end, you’re just as likely to be blamed for not doing it and the consequences that arise. I’d almost always use duramorph in a respiratory compromise patient, Covid or otherwise.

Damned if you do and damned if you don’t…story of our professional lives.

 

[deleted875186]

Honestly, This has to be the worst use of this CYA excuse I’ve ever seen. do the right thing for the patient and use duramorph. There’s a way higher chance of respiratory depression from IV narcs than from duramorph. In the end, you’re just as likely to be blamed for not doing it and the consequences that arise. I’d almost always use duramorph in a respiratory compromise patient, Covid or otherwise.

Damned if you do and damned if you don’t…story of our professional lives.

Really? Than why does the ASA publish ridiculous standards for close monitoring of patients that get low dose duramorph neuraxial, when no such close monitoring exists for PCA or as needed IV opioids. My hosptial in residency wouldn’t let us give duramorph for total joints because they couldn’t adhere to the monitoring standards on the surgical floor. I agree PCA causes more harm from respiratory depression than low dose duramorph in a spinal. Unfortunately neuraxial opioids are treated as a high risk medication.

 

[psychbender]

I also would not add duramorph. I think there’s absolutely no way it’s going to cause harm, but in case the patients respiratory status worsens I don’t want any blame on me.

I have done several of those cases, and included intrathecal or epidural duramorph for all of them. Risk of respiratory depression from low dose neuraxial opioid is low, and the splinting, atelectasis, increased oxygen requirement pathway from suboptimally treating their pain is worse for them.

Regarding the double standard with PCAs, some hospitals are coming around on monitoring for these, after having unfortunate events. The last few places I've worked, all floor patients with PCAs were on continous pulse-ox and/or ETCO2 monitoring.

 

[OneFellSwoop]

Really? Than why does the ASA publish ridiculous standards for close monitoring of patients that get low dose duramorph neuraxial, when no such close monitoring exists for PCA or as needed IV opioids. My hosptial in residency wouldn’t let us give duramorph for total joints because they couldn’t adhere to the monitoring standards on the surgical floor. I agree PCA causes more harm from respiratory depression than low dose duramorph in a spinal. Unfortunately neuraxial opioids are treated as a high risk medication.

Yep. I’d certainly adhere to the monitoring standards but while I’ve been out less than 10 years, I certainly have appreciated way more complications from IV narcs than duramorph, despite the double standard with our society’s recommendation.

 

[vector2]

Never had a problem with PCAs. Otoh, PLENTY of problems with nurse administered opioids in the ICU.