Respiratory depression

akulahawkRN, ADN, RN, EMT-P · Dec 28, 2014

The IV route allows for the fastest onset of these meds. When you give them IV push, you're basically making all the meds available immediately. (Just a little reminder, just in case.) The onset of these drugs can be very fast and you can start getting side effects, like respiratory depression, very quickly as well.

What would happen if you suddenly aren't breathing 14 times per minute and are now breathing, say, 4 times per minute? Of course as the meds "wear off" the breathing rate will return (eventually) to normal... but speaking doesn't necessarily mean out of danger.

Also remember that naloxone works on opiates and not on benzodiazepines. If your patient has been given opiate meds for pain control and they're given a dose of naloxone, you could be removing their pain control for a while and therefore your patient could end up in considerable pain. The stuff is titratable...

KelRN215, BSN, RN · Dec 28, 2014

This is why you escalate the doses per protocol/titrate to effect. If you do that, it's unlikely the patient will have respiratory depression. I have given as much as 100 mg/hr of morphine to an 8 year old weighing 24 kg with no respiratory depression because the doses were escalated appropriately. That was along with high doses of Ativan.

Also, when you say these are palliative patients- are they end of life/actively dying/comfort care only? I can't imagine ever giving Narcan to an end of life patient and bringing their pain back.

Kissy1818 · Dec 28, 2014

Yeah we don't use to high doses like 5mg oxynorm or morphine 10mg is what I've seen. We give the narcotics to palliative and non palliative only seen benzos like midazolam given in palliative care. We had a patient where after about an hour of reduced resps but sats maintained on nrb mask he came round resps normal ahaould I be looking for signs of respiratory failure or acidosis? As an initial assessment would pulse and bp change? Thanks this infor has helped alot

Kissy1818 · Dec 28, 2014

Also what would you do in the case of palliative patients who's resps decrease as it does seem naloxone or the reverse of benzoa isn't used? Would we skip next doses

KelRN215, BSN, RN · Dec 28, 2014

I wouldn't. The focus is palliation, you don't want to get behind on managing the patient's pain. How frequently are you giving these meds? Morphine has a short half life. Again, this is why you titrate palliative meds to effect. 5 mg of oxy is nothing and 10 mg of morphine isn't that impressive a dose for a palliative patient, either.

MunoRN, RN · Dec 29, 2014

It's important to understand why we typically give opiates to comfort care patients, particularly that respiratory depression is part of why we give opiates, rather than being something we're intending to avoid completely.

"Palliative care" includes a wide variety of treatments and goals. Palliative care is the treatment of symptoms, which can be symptoms related to a condition that is not terminal, or treatment where the patient still wishes to artificially prolong life even at the expense of comfort, or comfort only. I get the impression you're referring to the "comfort measures only" type of palliative care.

A common indication for opiates in end of life care is dyspnea, aka "air hunger". Dyspnea is based on the balance of an equation: the perceived effort/effect of breathing that the body requires is on one side of the equation and the perceived ability meet that requirement on the other. When the perceived need to breath exceeds the perceived ability to meet that need then dyspnea is present. (breathing refers to both ventilation and respiration).

So to decrease dyspnea you can manipulate the factors on either side of that equation; you can either improve the body's ability to breath, or decrease the perceived need to breath which is what respiratory depression is.

Morphine does have some ability to decrease the body's need to breath, by vasodilating, indirectly reducing air constriction, PA dilation etc. But we know that morphine typically isn't capably of completely counteracting the various conditions that increase the drive to breath, particularly at the end of life. Hypoxia, acidosis, hypercapnea, etc are all expected conditions that occur at the end of life, which is why we don't typically try to reverse these processes in a comfort measures only patient and why we tolerate things that may exacerbate these processes if they are necessary to provide adequate comfort.

Since morphine can't completely counteract processes that increase the drive to breath, we also use it for it's other effect, which is basically manipulate the respiratory drive in a manner which makes the brain think it doesn't actually need to breath to the level required to counteract those processes. In other words, we're using the effect of respiratory depression as a therapeutic effect to be achieved, not an adverse effect to be avoided.

akulahawkRN, ADN, RN, EMT-P · Dec 29, 2014

Morphine is a great drug... administered right, you can easily use it's respiratory depression side effect to bring the hyperventilating "air hunger" patient down into a more normal realm and make their body "think" that all is good. It's easily titratable for that. I would think that it would be easier to appropriately titrate morphine than it would be to give a whole bunch of the stuff and hope that you can appropriately titrate naloxone to achieve a certain desired effect without removing pain control either...

I have some experience titrating naloxone in the Heroin OD patient to get them breathing again without completely wrecking their high and making them very combative... It's not exactly easy. Based on that experience, I'd much rather go with the morphine and save the naloxone for rescue purposes.

Back to the original question, the onset of morphine/opiates and some of the Benzos when given IV can be very fast.

Gooselady, BSN, RN · Dec 29, 2014

Also what would you do in the case of palliative patients who's resps decrease as it does seem naloxone or the reverse of benzoa isn't used? Would we skip next doses

Not necessarily. You should have parameters indicated by the doc to guide you. If a patient is comatose and expected to pass within days or hours, you can 'take note' that the resps dipped quite low and adjust your next dose, but I would RARELY hold it. Almost never.

We had comatose pts on terminal sedation quite often on my previous floor. Every now and then a nurse would panic about RR of 6 and decrease the opioid/benzo sedation. This never went down well. The palliative care team of docs and NRPs cautioned us against doing this, as we don't know what that comatose patient is experiencing, so err on the side of caution.

Being inside a dying body, as the organ systems shut down, toxins build, hypoxia causing tissue infarcts and the pain from that -- I want to err on the side of patient comfort.

It's hard when you personally are afraid you'll accidentally 'give too much' and 'be responsible' for the patient's death a few hours before God would have taken them. So your questions are good, and it sounds like you should sit down with one of the palliative care team and have them explain it to you :) Maybe the whole staff could use an inservice?

These are tough questions for nurses, we're the one's delivering these meds, so it only follows we be educated to the point we see the big picture of the dying process.

Kissy1818 · Dec 29, 2014

Thankyou for all you advice has helped alot. I think I started tqi questions here. I work on a respiratory ward so get both palliative and non and uae opiates in both but tend to only use the benzos in palliative (only seen it given iv few times) both can cause resp depression abd together I presume that will increase. Juat wondered if there were other signs than resp and o2 sats should look for and should I worry about acidosis after their breathing is back to normal?

SierraBravo · Dec 29, 2014

Let me just say, and this may already be understood, but palliative care is not the same as hospice. You can have a patient that is full code but has pain management issues being followed by palliative care. You need to be clear about what the goals of care are for the patient, not just that they are "palliative care". You're not going to know for sure that the patient is experiencing some type of acidosis or alkalosis unless you do a VBG or ABG. Again, the important point to take away is goals of care. If the patient is a hospice patient then you're not expecting to start a bicarb drip if the patient is acidotic.

Kissy1818 · Dec 29, 2014

Yeah I understand that not all palliative patients are end of life, therefore wouldn't be treated the same. As we get such a variety of patients copd ling cancer and chest infection's was more wondering if acidosis chnaged vital signs or caused any changes in actions of patients that may trigger me to aak for an abg. I think it is so important to be aqare of goal of care. Being new its so much to take in just trying to get all the tasks done with such little staff.