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12 Sir Charles Gairdner Hospital Acute Pain Service Guidelines Intrathecal morphine Single dose intrathecal morphine (eg in doses of 100 to 300 micrograms) can provide effective post operative analgesia for up to 24 hours. Intra operative use. Use preservative free morphine sulphate. Write dose and time administered on the Anaesthesia Record. To ensure that all non theatre staff are aware of administration, complete a yellow Intrathecal Morphine “sticker” and place it on the patients Drug chart and the Intravenous Opioid Analgesia chart (if PCIA is in use). If large doses are given and/or the patient has significant co-morbidities, consider arranging admission to a high dependency area for closer observation for the first 24 hours. Side effects Nausea and vomiting PONV is common (approximately 30%) after intrathecal morphine (2). Order anti emetic as per APS protocol. Pruritus Pruritus results from stimulation of spinal and supraspinal opioid receptors and may be difficult to treat. (1) Order naloxone 100 micrograms SCI hourly prn. Delayed respiratory depression Respiratory depression which is late in onset, is a potentially dangerous complication as it may occur unexpectedly hours after the injection of the opioid. It is believed to result from the rostral spread of opioids in the CSF. It is more likely to occur with: Higher doses Concomitant use of parenteral opioids Elderly patients Opioid naïve patients (2) The timing of respiratory depression in opioid naive patients is 3.5 to 7.5 hours following intrathecal injection. (1). 12 Sir Charles Gairdner Hospital Acute Pain Service Guidelines Monitoring should include hourly sedation score and respiratory rate for 24 hours post dose. The patient should have oxygen administered (2L/min via nasal prongs or 5L/min via mask), for 24 hours. Urinary retention Interaction with opioid receptors in the spinal cord causes detrusor muscle relaxation leading to an increase in maximal bladder capacity and urinary retention. (2). This effect may last for up to 16 hours. Insertion of an indwelling urinary catheter in theatre should be considered for this fact alone. If an indwelling catheter is not insitu, an initial bladder scan should be performed four hours after return to the ward. If an IDC is not inserted, the scan should be repeated six hourly until 16 hours post operatively. 1. Australian and New Zealand College of Anaesthetists. Acute pain management: scientific evidence. Australian Government;2005. Available at www.anzca.edu.au. 2. Rawal N. Intraspinal opioids. In: Rowbotham DJ, Macintyre PE, editors. Clinical pain management: acute pain. London, England. Arnold. 2003. Date issued: Date revised: November 2005 Developed by: Reviewed by: Lyn Hellier, APS CNC Drs L Roberts, J Graham.