How much morphine is too much??

b eyes · Apr 10, 2011

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!

Gotcha! Thank you again!

allnurses Guide · Apr 10, 2011

The provider who made an open ended order with opioid every 10 minutes and no limit needs a good whack upside the head - liability anyone? OP you have got to use your brain - no, there's no magic number necessarily that anesthesia would be happy with, but giving someone that much morphine may be ok while they are huge pain but once you anesthetize them, waking up is going to be a rather large potential problem (morphine duration of action is up to 4hrs). You should try and ask yourself when giving meds why you are doing it. If they are in seriously that much pain that you had to give 8 consecutive doses within 2 hours with no/minimal relief, you need to be calling the physician sooner.

Psqrd · Apr 10, 2011

I am an ED nurse as well and see only a couple of issues, yes that is a high dose of morphine but the flip side is that if you go over it is easily rectified with narcan..however your patient being alert, oriented and ambulatory tells me that he has a high tolerance to morphine and thus I would have been looking for something else..the other issue to consider is that if his pain was that extreme..this would have been a huge red flag and I would have been pullng a doc in and calling the OR to expedite as this is an indication that something is turning real bad for this patient. A two hour wait for a ruptured appy is WAY too long and I certainly hope you were dumping antibiotics in this guy fast. I think of q10 minute pain meds and I know i have at least 2 or 3 other patients that wont be getting any care at all as all I would be doing is running from the pyxis to this guy and back again.

hotstuff · Apr 10, 2011

I don't understand the anesthetic implications here? I can understand how morphine has the potential to decrease respiritory function, but surely the pt wound be intubated and ventilated in theatre, so what's the issue? Whilst 32mg does sound like a large dose, I would imagine a fit healthy young man should be fine with it. :)

woknblues · Apr 10, 2011

A two hour wait for a ruptured appy is WAY too long and I certainly hope you were dumping antibiotics in this guy fast. I think of q10 minute pain meds and I know i have at least 2 or 3 other patients that wont be getting any care at all as all I would be doing is running from the pyxis to this guy and back again.

This is a great point as well. A suspected 3 day rupture followed by a 2 hr wait?

OP, he was ambulatory and vss. You did fine. I am sure that regardless of the open ended order, you would have held off and recalled at some point. To the flack you got, maybe you should have done the surgery yourself before you handed him over, to save them the trouble.

b eyes · Apr 10, 2011

I am an ED nurse as well and see only a couple of issues, yes that is a high dose of morphine but the flip side is that if you go over it is easily rectified with narcan..however your patient being alert, oriented and ambulatory tells me that he has a high tolerance to morphine and thus I would have been looking for something else..the other issue to consider is that if his pain was that extreme..this would have been a huge red flag and I would have been pullng a doc in and calling the OR to expedite as this is an indication that something is turning real bad for this patient. A two hour wait for a ruptured appy is WAY too long and I certainly hope you were dumping antibiotics in this guy fast. I think of q10 minute pain meds and I know i have at least 2 or 3 other patients that wont be getting any care at all as all I would be doing is running from the pyxis to this guy and back again.

Yes, thank you for your input. He was getting antibiotics. The OR was aware of him, surgeon, CRNA, and OR nurses, Scrub tech, etc. Everybody was aware. I think the only thing I couyld have and should have done is get a different medication order. My question however, was when a patient is going to the OR and going to get anesthesia, is there a cap on how much narcotic to give? This was the issue, whether it is morphine, dilaudid, fentanyl, and the patient is tolerating the med as mine was, when do I look at anesthesia concerns regarding too much. so lets say VS are stable, pt alert/oriented, rating pain 5/10, kinowing full well pain relief is not going to be an option for him, do I give more, or do I start to say, OK, Pt is going to be going under general anesthetic in 1/2 hour. Need to be careful what I give here. That is what I am not understanding. Am I making my concern clear here for you all?

Who?Me? · Apr 10, 2011

I won't get into a ER/OR contest here--happens everywhere since most nurses do forget that the other department is usually working hard as well....

but Fentanyl or Dilaudid might have worked better for this kid. After 30 minutes of this I would have got the ER doc to write for something else. If they didn't want anything else ordered I would just have kept documenting pain levels, meds given, and response to pain meds to CYA.

Since I work with CRNA's every day, some have a doc complex. "I give anesthesia therefore I know all and BTW I was an ICU/ER/Flight nurse before I was a CRNA so I really do know all." But if they seem receptive to talking to you, rather than they are just making snide comments about your nursing care, ask what would work better for these patients in the future and so it won't interfere with anesthestics.

The morphine amounts you gave were reasonable--patient just needed O2 Sat monitoring related to the sedative effects of all pain meds.

beth66335, BSN, RN · Apr 10, 2011

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.

Tell them to take it up with the doctor that ordered it!

AggieNurse99, BSN, RN · Apr 10, 2011

My experience being limited to the floor & outpatient... My problem with 32 mg of Morphine in 2 hours is the cumulative effect on the respiratory and nervous systems. I've had s/p lap chole's come up after PACU gives them 20-25 mg Morphine and then RRT/narcan within 2 hours of arrival to the room. 3 separate times! We tend to limit our thoughts for patient care to what happens in our unit and not consider later effects.

MassED, BSN, RN · Apr 10, 2011

Yes, thank you for your input. He was getting antibiotics. The OR was aware of him, surgeon, CRNA, and OR nurses, Scrub tech, etc. Everybody was aware. I think the only thing I couyld have and should have done is get a different medication order. My question however, was when a patient is going to the OR and going to get anesthesia, is there a cap on how much narcotic to give? This was the issue, whether it is morphine, dilaudid, fentanyl, and the patient is tolerating the med as mine was, when do I look at anesthesia concerns regarding too much. so lets say VS are stable, pt alert/oriented, rating pain 5/10, kinowing full well pain relief is not going to be an option for him, do I give more, or do I start to say, OK, Pt is going to be going under general anesthetic in 1/2 hour. Need to be careful what I give here. That is what I am not understanding. Am I making my concern clear here for you all?

that is up to the prescribing doc. If there's an issue with how much and which med, it's not up to you do be the deciding person. The doctor is, they are responsible. So they are barking up the wrong tree when a certain med and dose is ordered that they don't like, so redirect them to the doc.

sweetnepenthe · Apr 11, 2011

The patient would indeed be intubated during the surgery, unless it is done under spinal, which I have done for some appys, but the anesthetic issue is awakening the patient after the surgery is done and getting him extubated.

Sounds like it would not have been a huge problem with this particular patient, but you never know. Having to keep a post-op intubated and on a vent is expensive, not to mention scary for the patient if it is unexpected.

CRNA 1982 is right on with his/her posts, as is meanbrett.

**canoehead, BSN, RN** · Apr 14, 2011

My personal experience is that if 10mg morphine doesn't work, more morphine won't help as much as switching to another drug. So I update the doc after every 10mg re pain level, and chart that we discussed pain control for the patient. I've also found that sometimes the dose that finally helps the pain lets them relax enough to decrease muscle spasms, and they might get sleepy all of a sudden. Especially if we've just switched from an ineffective drug to a new one. (Silent patients are dangerous patients.)

I've given as much as 35mg of morphine over 2 hours to a small woman with a kidney stone. I put my patients on the moniter after 10mg, sooner if they get sleepy. She required O2, but was still squirming and moaning. I think we need to titrate to effect with pain meds, and keep the doc in the loop. If the patient is going to the OR it doesn't change my pain control plan, I send them sleepy but waking to voice, maintaining their own airway with O2 prn. I love to hear from the CRNA's about how it affects their intraop management-we don't hear much after patients leave the ER.