How much morphine is too much??

Specialties Emergency

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Specializes in ER, Med-surg, ICU.

The other day in ER, I had a patient with a ruptured appy. Waiting 2 hours for surgery to take him, the patient was experiencing pain consistently rating it between 5 and 10. Pt was alert/orineted, VS, 101.5, HR 116, Systolic BP 140's, O2 saturation 98%. Over the 2 hours he got a total of 32 mg of morohine as the doctore ordered 4 mg q10 min prn pain. VS were as above when surgery came to take him yet they were upset at the amt. of moprhine the patient received. What would you have done differently? Different med? Also said he should have been on a ETCO2 monitor. I am not sure how to have treated this patients pain. Kowing full when I would never acheive pain free with him, but trying to get him somewhat comfortable. Pt was 22 with no med problems. Just not sure what I should have done differently. CRNA angry because of dose received and I anesthesia requirements, breathing, etc.

Thanks for your input.

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Specializes in Cath Lab/ ICU.

Let's see...hot appy, vss, orders received for ms 4mg q10 min..... I would have given him ms 4mg q10 mins.

Tell the OR team to suck it! If they wanted him to receive less pain meds then they should have come in and take him to surgery sooner.

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Specializes in ER, ICU.

If the MS wasn't working did you consider dilaudid or fentanyl? They are both much stronger and don't require as much, and don't have the hemodynamic issues. Once his anxiety was relieved (i.e. under anesthesia) he had the potential for his pressure to crump. Did the MD order for 4 q10 have a limit? I wouldn't expect an open ended order... To answer your question the patient was safe but the dosage made everyone uncomfortable so that has to be considered.

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Specializes in ER, ICU.
Let's see...hot appy, vss, orders received for ms 4mg q10 min..... I would have given him ms 4mg q10 mins.

Tell the OR team to suck it! If they wanted him to receive less pain meds then they should have come in and take him to surgery sooner.

I had to laugh, God if you could get away with that...

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Specializes in Cath Lab/ ICU.

Yeah I know. I'm not an ER nurse so I know it's impossible to give your pt q10 min meds. Just trying to make a point. I would have told the OR team, or CRNA to bring up an issues R/T med orders with the Doc.

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Anestheisa should take that up with the ordering clinician if they would wish. You did your job and your part. Your patient was breathing and vitals stable.

I likely would have asked to switched to Dilaudid since the morphine didn't seem to be doing anything for the patient. I know from personal experience (with my appy) that 8 of Morphine and I didn't have a clue that anything had been given. 0.5mg of Dilaudid and I was apenic.

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

Definitely would have asked to switch up the pain meds -- clearly the morphine wasn't the ticket.

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Specializes in ER, Med-surg, ICU.

Hi and thanks for replying..first, no the morhine did not have a limit. Just our discretion hence pain level, VS, Pts LOC. Pt fully alert and so uncomfortable. So using dialudid or fentanyl would not have created the same issues regarding anesthesia because now they have to deal with two different narcotic medications, or would that have been more appropriate because of less dosing?

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Hi and thanks for replying..first, no the morhine did not have a limit. Just our discretion hence pain level, VS, Pts LOC. Pt fully alert and so uncomfortable. So using dialudid or fentanyl would not have created the same issues regarding anesthesia because now they have to deal with two different narcotic medications, or would that have been more appropriate because of less dosing?

They wouldn't have had an issue if they patient had received two different kinds of opiates as they have 3 very different half-life profiles. Their issue (probably) was with the dose that had been received. They were probably anticipating it being difficult to wake the patient, to obtain an appropriate ETCO2 for extubation, and the possibility of having to take the patient to PACU intubated and on the vent until awake.

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Specializes in ER, Med-surg, ICU.

Also the boy had been ruptured for about three days the surgeon felt. I really don't feel pain relief was even acheivable for him. But thanks, next time I am giving frequent doses of morphine, will ask for something stronger. I just remember the CRNA being angry once because a patient on the floor had been receiving dialudid prior to surgery and again thought she had been given too much despite stable VS etc.. I beleive the patient had received 3 or 4 mg through the night shift. So I am wondering is there a limit prior to a patient having anesthesia? Is there something I should be considering that I am clearly not aware of?

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Specializes in ER, Med-surg, ICU.
They wouldn't have had an issue if they patient had received two different kinds of opiates as they have 3 very different half-life profiles. Their issue (probably) was with the dose that had been received. They were probably anticipating it being difficult to wake the patient, to obtain an appropriate ETCO2 for extubation, and the possibility of having to take the patient to PACU intubated and on the vent until awake.

OK thank you. Makes sense to me now. I felt terrible but on my end, what I was doing was OK, not fully understanding anesthesias end.

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OK thank you. Makes sense to me now. I felt terrible but on my end, what I was doing was OK, not fully understanding anesthesias end.

Don't feel bad. You didn't do anything to harm your patient. Next time ask for an order for Dilaudid to see if that takes care of the pain.

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