Spinal opioids

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Please note this guidance is for use in in-patients and is not designed for managing patients with chronic pain

General Guidelines
  • Spinal opioids may only be administered by an Anaesthetist within the theatre suite.
  • The surgical medical staff or clinical nurse practitioner should be called for all routine surgical problems.
  • In addition the following should be dealt with in the first instance by the ward staff according to current guidelines:
    - Hypotension
    - Nausea and vomiting
    - Inadequate analgesia
    - Sedation and respiratory problems
    - Urine retention
    - Itching
  • If further advice is required please contact the Acute Pain Nurse (bleep 1003) and if not available, the ITU anaesthetist
General Management
  • Routine post-op care should be given unless instructed to do otherwise by an anaesthetist.
  • Administer oxygen (2 to 4 litres/minute via nasal cannual) only if O2 saturations ≤ 94% Ensure that there is a patent IV cannula for 24 hours after the spinal opioid has been administered.

Naloxone (400microgram injection) must be immediately available on the ward.

Nursing Management

All observations must be recorded on the NEWs chart if this is in use.

Spinal Morphine

Spinal Diamorphine

Spinal Fentanyl

Hourly respiratory rate and sedation score for 24 hours but do not wake the patient up if their respiratory rate is normal.

Standard post-operative observations or PCA/opioid algorithm observations if in use.

Standard post-operative observations or PCA/opioid algorithm observations if in use. 

Complications of spinal opioids are related to opioid side-effects. Potentially, patients are at risk of respiratory depression for a much longer period after a spinal dose of opioid compared to patients who have received oral, subcutaneous or intravenous opioids.

Moderate respiratory depression (respiratory rate < 9 breaths/minute + sedation score 1 or 2)

• Withhold all other forms of opioids (PCA, S/C or oral opioids).
• Administer Oxygen at 10 litres/min via a face mask and ensure a clear airway
• Monitor the respiratory rate, sedation score and oxygen saturations every 15 minutes until the respiratory rate is greater than 10 per minute.
• Consider why this has occurred. Review the analgesia and exclude other causes.
• Contact the Acute Pain Service or ITU Anaesthetist for further advice.

Severe respiratory depression (respiratory rate < 7 breaths/ minute or unrousable - sedation score 3)
  • Administer oxygen at 10 litres/min via a face mask and ensure a clear airway.
  • Give naloxone 100 micrograms intravenously*. Repeat every 1 minute until there is an adequate response to a maximum of 400 micrograms.
  • Contact the ward house officer, the CNP or surgical registrar and stay with the patient.
  • Monitor the respiratory rate, sedation score and oxygen saturations every 15 minutes for 1 hour and hourly for 4 hours thereafter, to ensure that respiratory depression does not return. A Naloxone infusion may be required. Contact the ITU Anaesthetist for advice.
  • Stop all forms of opioids (PCA, S/C or oral opioids).
  • Consider why this has occurred. Review the analgesia prescribed and administered.
  • Consider hypovolaemia, cardiac problems, anaphylaxis.
  • Contact the ITU Anaesthetist for advice regarding subsequent analgesia, if required.

    *Prepare naloxone in a 5ml syringe using 3mls of 9% sodium chloride and 400 micrograms (1ml) naloxone to give a solution containing naloxone 100microgram/ml, checking expiry date of both drug and diluent.

    Administer the Naloxone intravenously in 100microgram (1ml) increments every minute, until the respiratory rate is greater than 10 and the patient’s sedation score is 0 or 1.

    Maximum dose of Naloxone should be 400 micrograms. If this dose has not given an adequte response then consider other causes of respiratory depression.

Editorial Information

Last reviewed: 30 November 2018

Next review: 30 November 2020

Author(s): Acute Pain Team, Raigmore Hospital

Version: 2

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Acute Pain Nurse Specialists