Morphine
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If a patient is on intrathecal opioids, ensure it is handed over properly and that no opioids are given in the first 24 hours except for recovery analgesia unless reviewed by a doctor. If a patient has pain within 24 hours, review vital signs and pain score and may start PCA but ensure no background infusion after consulting a senior doctor. A single dose of epidural morphine can relieve pain for 12-24 hours but there is a risk of respiratory depression up to 18 hours later as the morphine circulates to the brain. Mandatory observations must be carried out hourly for the first 12 hours and then every 2 hours up to 24 hours post administration of a spinal opioid to monitor respiratory rate, oxygen saturation, and level of
Morphine
- 1. If the patientison intrathecal opioidmake Shure itshandedover.Make Shure no opioidis givenin the first24 hours,exceptthe recoveryanalgesiaunlessthe patientisreviewedbyadoctor. If the patienthaspainand require opioidanalgesiawithinthe first24 hoursreview the patientspain score,sedationscore andrespiratoryrate and the,if appropriate,the startthe PCA,butensure no backgroundinfusion after doublecheckwithsenior doctor Morphine In anaesthesiamorphine isusedtorelievepain.This isan effectof itsactionon the spinal cordto decrease the transmission of painful stimuli frombodytobrainand itsactionwithinthe brain itself. A single dose of epiduralmorphinemayrelieve painfor12-24 hours.The main riskof thistechnique isthat severe respiratorydepressionmayoccurup to 18 hoursafterthe initial injection becauseof the slowcirculationof cerebral spinal fluidwhichcarriesthe morphine uptothe brainto act onthe respiratorycentre. These are a mandatorysetof observationswhichmustbe carriedoutinthe 24hrs post administrationof anyspinal opioid,andfollow the pre-existingpainguidelinesforthe management of patientswhohave receivedspinalopioids. The observationsare carried out hourly for the first 12hrs post administrationof the spinal opioid and then2 hourlyupto 24hrs postadministration: - AVPUscale.Target: Alertor Voice. UnlesspatientasleepandRR>12. - Respiratory rate. Target >12. - Oxygensaturation. Target >95%. Complications Slowrespiratoryrate anda verysleepypatientwithpinpointpupils Oxygenshouldbe givenbyface mask andpositive pressureventilationof the lungsstartedif necessary. NALOXONE 100-400 microgramsmay be givenintravenouslyif available.
- 2. SPINAL ANAESTHESIA Spinal anaesthesiaisinducedbyinjectingsmallamountsof local anaestheticintothe cerebro spinal fluid(CSF).The injectionisusuallymade inthe lumbarspine below the level atwhichthe spinal cord ends(L2). Spinal anaesthesiais easy to performand has the potential to provide excellent operatingconditionsfor surgerybelowthe umbilicus. Local anaestheticsolutioninjectedintosubarachnoidspace blocksconductionof impulsesalongall nerveswithwhichitcomesincontact- motor,sensoryand autonomic Generallyautonomicandpainfibresare blockedfirstandmotorfibres last.This hasseveral importantconsequences.Forexample ,vasodilationanda drop in bloodpressure may occur when autonomic fibresare blocked and the patientmaybe aware of touch and yetnopain whensurgery starts. Local anaestheticfor spinal anaesthesia Bupivacaine (Marcaine) isthe local aestheticmostcommonly used;usuallylastfor2to 3 hours. An anotherlocal aestheticislignocaine Drugs to improve the qualityof block or for post operative pain relief Fentanyl,morphine.