When normal-release epidural or intrathecal morphine is used for the prevention and treatment of postoperative pain, the patients of your institution are usually under monitoring into special units such as PACU (post-anesthesia-care-units) or into the surgical wards under trained nursery vigilance?
In our institution, the patients are monitorized into the PACU for a minimun period of 12 hours. Arterwards, they are translated to the surgical ward when the specific nursery team, located into each surgical setting, begins a vigilance protocol including VAS (visual analogic scale), adequacy of ventilation (e.g., respiratory rate, depth of respiration), oxygenation (e.g., pulse oximetry when appropriate), and level of consciousness each 8 hours.
Moreover, should the nursery team routinely be trained in the managemet of the respiratory depression in this postoperative setting?
In my institution the patients are monitorized into the PACU during 12 h.
I think that this vigilance period of 12 h is enough when normal release neuraxial morphine is used as a bolus. But in my institution when a continuous epidural infusion of LA plus morphine is used whe extend this period to 24 h.
At our institution we usually administer morphine intrathecally along with a local anesthetic for major lower limb surgery (mostly primary and revision arthroplasty) and keep the patients monitored on the ward (pulsoxymetry, ECG, NIBP) until the next morning. Depending on the patient's general physical status and comorbidities/co-medications we administer 100-300mcg and so far had no problems with respiratory failure/desaturation.
Thank you Kresimir for your answer. Our practice is very similar to yours so we usually used intrathecal morphine doses below 300 mcg together with LA as a single bolus before surgery. Patients remain in the PACU until the next morning during 12-24 hours depending to the surgery timing. However the discussion point appears when an epidural catheter is also placed and a epidural infusion (LA plus morphine) is started after surgey. Should these patients be monitorized into the PACU for 48-72 hours or could they be vigilated by the surgical nursery team in the hospitalization wards after 24 hours into the PACU?
I believe that with educated nursing staff you can have the patients on the ward, regardles of a continuous infusion. Sometimes I place a spinal catheter for a continuous LA/morphine infusion in patients in which a triple osteotomy of the pelvis was performed. The nurses are instructed to regularly check on the patients SpO2 and respiratory rate and have written instructions to administer Naloxone and call the anesthesiologist in case of respiratory depression.
This is the latest review on this topic (Anesthesiology 2016; 124:535–52)
Whats your opinion about it?
° This statement presents new findings from the scientific literature since 2008 and from surveys of both expert consultants and randomly selected ASA members.
° These practice guidelines are developed as a collaborative effort between the ASA and the American Society of Regional Anesthesia and Pain Medicine.
° These guidelines include specific recommendations in four areas:
1. Identification of patients at increased risk of respiratory depression, with specific recommendations for focused history and physical examination.
2. Strategies for the prevention of respiratory depression after neuraxial opioid depression, including recommendations for drug selection and dose selection.
3. Detection of respiratory depression through monitoring for adequacy of ventilation, oxygenation, and level of consciousness.
4. Management and treatment of respiratory depression with recommendations regarding the administration of supplemental oxygen, reversal agents, and application of noninvasive positive pressure ventilation.
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