How much morphine is too much??

[b eyes]

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.

[Kooky Korky, BSN, RN]

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?

oral morphine doesn't sound right, either in pre-op, presumably NPO pt

[Kooky Korky, BSN, RN]

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?

Really, why wasn't the ER doc in touch with Anesthesia? They should have jointly worked this out. And since it will likely occur again with other patients, why don't they have ongoing communication and a sort of standing order/protocol in place for these occasions?

[CraigB-RN, MSN, RN]

There normally no communication like that between OR and ED. It's already been stated but if the patient was awake and talking, then you were fine. In active acute pain, you can give huge quantities of opiates. And even in chronic pain patients. I've given Sickle Cell patients 75+ mg in a 24 hour shift.

There are ongoing studies about opiates and acute pain. One of the interesting protocols i've read involve a calculated MS dose based on weight and then repeating it by half every 7 min until the patient doesn't ask for more. It's up the patient you ask if if they say yes you give it to them. No documented cases of needing narcan as of yet.

As to the ETCO2, well in an ideal world. When dealing sedation due to medication its not an oxygen problem it's a ventilation problem. PER CMS regulations, the standard of care in the OR includes ETCO2. Very few ED have ETCO2 for every patient. The problem is that with that quantity of opiates you patient could be apnic for a couple of min before their SAO2 starts to drop. More of a problem with procedural sedation, than with single agent administration.

It's health to review and take in others perspectives. But don't agonize over it.