How much morphine is too much??

Specialties Emergency

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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.

Specializes in ER, Med-surg, ICU.
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.

Thank you and I will. I have been racking my brain looking up meds for two days, trying to find dose limits, etc and not coming up with much. yu have been a tremendous help!

Should have known to contact allnurses first!

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Specializes in ER.

Anesthesia always balks about meds given prior to being anesthetized. Always. Boo on them. You're taking care of their pain in the ED. They can adjust appropriately. That's what they do. Good for you for monitoring your patient while giving Morphine. And usually, we give Dilaudid and 1mg = 6mg of Morphine, so if you gave 2 mg of IV Dilaudid, would they still be P--issy? Yes.

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Specializes in ER.
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.

yes they do have the hemodynamic issues. Fentanyl not so much, but Dilaudid certainly so.

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Specializes in ER.

I really wouldn't worry about it. You're doing your job. Sure, you could have asked the resident/attending, whomever, to order something else, but in reality, that may not happen or they may not like your suggestion. It's not that much Morphine. They would be more concerned if you overloaded them with Dilaudid and couldn't wake the patient.

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Specializes in OR; Telemetry; PACU.

Yes I would have asked to try something else. That's a lot of morphine to go into surgery with. Anesthesia would have a more difficult time keeping the patient safe with that amount on board. Fentanyl is potent, but is much shorter acting and is a bit more "predictable" if you will. Also how much did anxiety play into the situation? Versed with Fentanly may have been an option...but it depends on the doc's wishes. And I know the floor and ER don't like to be at the "mercy" of the OR but there's a lot going on behind the scenes and believe me, we would come and get the patient and get things started asap if we could.

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Specializes in Hospice.

A lovely thing about pain and pain meds: pain is a natural opioid antagonist. I agree with previous posters- if they had a problem, they need to speak with the ordering MD. I work in hospice, so it is a little different, but I have seen people on 200 mg of dilaudid an hour. There is no narcotic ceiling on a pt with stable vital signs still experiencing pain. I would expect the morphine to make some kind of difference after 2 doses, and probably would have liked to try a different med. However, lots of people just have a natural high opioid tolerance.

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Specializes in ER, Med-surg, ICU.
Yes I would have asked to try something else. That's a lot of morphine to go into surgery with. Anesthesia would have a more difficult time keeping the patient safe with that amount on board. Fentanyl is potent, but is much shorter acting and is a bit more "predictable" if you will. Also how much did anxiety play into the situation? Versed with Fentanly may have been an option...but it depends on the doc's wishes. And I know the floor and ER don't like to be at the "mercy" of the OR but there's a lot going on behind the scenes and believe me, we would come and get the patient and get things started asap if we could.

OK I understand . Another question, If the patient is still experiencing this type of pain after two or three doses of dilaudid, do I give more? I know how to monitor my patient in the ER as far as when to give meds and when to hold off, but I do not understand when enough is enough knowing they are going to get anesthesia.

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OK I understand . Another question, If the patient is still experiencing this type of pain after two or three doses of dilaudid, do I give more? I know how to monitor my patient in the ER as far as when to give meds and when to hold off, but I do not understand when enough is enough knowing they are going to get anesthesia.

I think sometimes you tend to need to have a conversation with the patient/family and set realistic expectations for pain control. Many folks do not understand that we cannot control 100% of your pain and that you're not going to be pain free (Especially in the post-surgical population. It's amazing how many folks think that it will be totally pain free).

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Specializes in ER, Med-surg, ICU.

You are so right! I agree with you 100%. Always a difficult situation for nurse, family and patient.

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Specializes in Anesthesia.

Morphine 32 mg IV over 2 hours does seem like a pretty big dose BUT I would not freak out over it. The guy was a young guy and could probably handle it. I would probably just induce without narcotic and see how he does without any intra-op opioid; of course I would give it it he were asking for it. None of us were there to see the kid and how he reacted, so it is hard for any of us to comment on whether it was too much.... but being completely honest with yourself, "how was the boys LOC after the 32 mg?" Was he sleeping, responsive to verbal comments, obtunded etc. If I rolled into the ER to pick up a hot appy and the pt. was totally narcotized and then told that he received 32 mg Morphine, I may have said the same thing as the CRNA. EtC02 might be appropriate for a pt. receiving 32 mg morphine, especially if you are taking care of multiple pts. in the ER and cannot give this pt. one on one care. Just my $0.02

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Specializes in ER, Med-surg, ICU.
Morphine 32 mg IV over 2 hours does seem like a pretty big dose BUT I would not freak out over it. The guy was a young guy and could probably handle it. I would probably just induce without narcotic and see how he does without any intra-op opioid; of course I would give it it he were asking for it. None of us were there to see the kid and how he reacted, so it is hard for any of us to comment on whether it was too much.... but being completely honest with yourself, "how was the boys LOC after the 32 mg?" Was he sleeping, responsive to verbal comments, obtunded etc. If I rolled into the ER to pick up a hot appy and the pt. was totally narcotized and then told that he received 32 mg Morphine, I may have said the same thing as the CRNA. EtC02 might be appropriate for a pt. receiving 32 mg morphine, especially if you are taking care of multiple pts. in the ER and cannot give this pt. one on one care. Just my $0.02

Thanks for your input. The patient was completely alert. got up out of the bed and into a wheelchair independently to go to OR. Able to answer all questions for me and talking to his family appropriately. He was my only patient at the time, which made it able for me to give him the one on one care he needed. Thank you for helping me to better understand the OR perspective. I would not ever continue to medicate someone who was obtunded or sleeping. The patient continued to rate his pain at a five or greater asking for some relief. I did the only thing I could do besdies get a different med which I should have done sooner.

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Specializes in Anesthesia.
Thanks for your input. The patient was completely alert. got up out of the bed and into a wheelchair independently to go to OR. Able to answer all questions for me and talking to his family appropriately. He was my only patient at the time, which made it able for me to give him the one on one care he needed. Thank you for helping me to better understand the OR perspective. I would not ever continue to medicate someone who was obtunded or sleeping. The patient continued to rate his pain at a five or greater asking for some relief. I did the only thing I could do besdies get a different med which I should have done sooner.

So don't sweat it! You did fine, don't worry about what the CRNA said. If the pt. needs a lot of opioid then give them what they need!

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