SINGLE PERIOPERATIVE DOSE

INTRATHECAL MORPHINE

Rebecca Tapper
Acute Pain Service
Auckland City Hospital
Objectives

To understand:
 Nursing responsibilities for a patient post
single shot intrathecal morphine
intraoperatively
 Potential complications
 Safety issues
 Other regional techniques commonly used in
the hospital
ADHB Guidelines

 Pain - Intrathecal Morphine – Single

Perioperative Dose in Adults
 Medication Administration

ADHB intranet > policies & guidelines library > pain

management
INTRATHECAL

 through the theca of the

spinal cord into the
subarachnoid space.
 Theca = sheath
INTRATHECAL MORPHINE

 Single dose
 Prescribed & administered by an
anaesthetist
 Usually between 100-300mcgs
AIMS OF INTRATHECAL MORPHINE

 To provide prolonged post op analgesia

 Reduce opiate requirements post operatively
 Small doses minimise side effects
HYDROPHILIC PROFILE OF
MORPHINE

 Minimal systemic uptake from CSF allowing

for a longer duration of action.
 A portion of drug binds to the spinal cord
opioid receptors (site of action),
 Rostral spread of CSF means any remaining
morphine will be carried to opioid receptor
sites away from site of injection
i.e. brainstem and respiratory centre
SAFETY

 Low dose used. Usually between 100-300mcgs

 Red sticker on stat page of patient’s medication
chart
 Handed over to ward staff
 Other opioids can be given but with caution
 Extra caution in elderly patients
 Potential for delayed respiratory depression for 7-24
hours post administration
NURSING INTERVENTIONS

Patient Identification
 Red Intrathecal Morphine alert sticker
attached to stat page of medication chart
before patient leaves PACU
 Handed over by PACU Nurses to ward
nurses
 Documented on Anaesthetic sheet and in
patient’s notes
NURSING INTERVENTIONS

Patient Monitoring
 Q1h resp rate & sedation score for 24hrs
post administration
 Resp rate must be measured for a full minute
 Supplementary O2 (2L) must be
administered for the 1st 24hrs
 Patient must have IV access for 1st 24hrs
RESPIRATORY RATE <8/min

If rousable:
 Maintain rousability
 Encourage deep breathing
 Check oxygen saturations
 Inform Acute Pain Service & medical team
If unrousable:
 Implement basic life support measures
 Call a code red
 Administer stat dose of Naloxone (as per orange sticker)
 Inform medical team
 Inform Acute Pain Service
SEDATION IS THE MOST
RELIABLE INDICATOR OF
OPIOID TOXICITY!
IT Morphine Sticker
IV NALOXONE

 Naloxone IV 400mcgs (1ml ampoule) made

up to 10ml with normal Saline
 Concentration = 40mcgs/ml
 Administer 200mcgs IV stat
SIDE EFFECTS & MANAGEMENT

 Nausea & Vomiting

PONV cascade, Naloxone
 Pruritus
Ondansetron, Naloxone
 Urinary retention
Monitor output
BREAKTHROUGH PAIN

 Opiates can be given but with caution during

the 1st 24 hours
 Give regular Paracetamol & NSAIDs if
prescribed
 OTHER
ANAESTHETIC INFUSIONS
SPINAL

 Effective & predictable

 Small quantity of anaesthetic
 Widespread dense motor block of lower body

But:
 Headaches (6 – 16%)
 Blood pressure drop
SPINAL

Epidural
space Subarachnoid
space

Anterior
INDICATIONS

 Obstetric - Labour and C-section

 General surgery - Hernia repair
 Orthopaedic - Hip & knee surgery
 Urological surgery –TURP, Stents
 Short, predictable, uncomplicated surgery
REGIONAL LOCAL ANAESTHETIC
INFUSIONS

 Excellent analgesia
 Few systemic side effects
 Ropivicaine or Bupivicaine
 Administered via yellow epidural tubing + CADD
pump or disposable self infusing pump
 Continuous infusion or patient controlled bolus
 ADHB Guideline: Regional Local Anaesthetic
Infusions – Adult
ADHB intranet > policies & guidelines library > pain
management
TYPES OF NERVE BLOCKS

 Interscalene (shoulder, clavicle, humerus)

 Brachial plexus (all the nerves of the arm)
 Extra & intrapleural / paraverterbral (thoracic & upper
abdominal)
 Rectus sheath (abdominal)
 TAP blocks (abdominal)
 Femoral (femur, anterior thigh, knee)
 Sciatic (surgery at and below knee)
 Popliteal (ankle, archilles tendon, foot)
MONITORING

 Vital signs and pain scores ½ hourly for 4 hours then 4 hourly if
stable
 Insertion site 8 hourly for:
• Erythema
• Exudate
• Sudden increased pain
• Leakage
 Pressure area cares/ risk assessment
 Check prescription & pump settings at each shift and on patient
handover
 Ensure IV access whilst in progress and for 4 hours after
stopping
POTENTIAL COMPLICATIONS

 Motor block
 Dense sensory block
 Anaesthetic toxicity
 Nerve trauma
 Failure
 Infection
 Haematoma
 Pneumothorax
 TOXICITY

Cardiovascular depression
(bradycardia, other
arrhythmia's, hypotension)

Respiratory arrest

Convulsions

Unconsciousness

Twitching of mouth and

fingers

Light-headedness and visual disturbances

Parasthesias around the mouth and tongue