Spinal Anaesthetic and Intrathecal Opioid Information Sheet
Operative information	Patient label
Date ...……..../……..../...……..……… / Operation ..........................………...………............ / Ward ...........................……………….............. / Anaesthetist ..........................………………...............	Name ..................................………………....... / Hospital no ...................................……………..….... / Date of birth …......../..…….../.........……….. / Sex M F
Intrathecal Opioid administered	Period of intensive observation
Fentanyl …………..mcg / Diamorphine …………..mg / Morphine .………….mcg	Record observations for ………...hrs (see below) / 1 hourly for 8 hours, 4 hourly thereafter / Continue until: …..…………….. on ……/………/…..……….
Record observations on Trust Adult Patient Observation Chart and respond to any triggers as directed on that chart / Recommended duration of intensive observation is: Fentanyl 6 hrs; Diamorphine 12 hrs; Morphine 24 hrs
Management of Problem
Blood Pressure Intrathecal Opioids do not usually reduce blood pressure significantly / If systolic BP < 90mmHg  seek medical assistance / exclude haemorrhage, sepsis, acute cardiopulmonary event / If BP < 90 mmHg persists ® call the CNS acute pain or Acute Care Team urgently
Respiration The major risk of Intrathecal Opioids is delayed respiratory depression / If respiratory rate < 8/min ® ensure patient is receiving supplementary oxygen / seek medical assistance urgently / consider opioid toxicity if co-administered / if opioid toxicity suspected, refer to Naloxone algorithm / call the CNS acute pain or Acute Care Team urgently
Sedation If sedation score P or U ® seek medical assistance urgently / consider opioid toxicity if co-administered / if opioid toxicity suspected, refer to Naloxone algorithm / call the CNS acute pain or Acute Care Team urgently
Leg strength If Bromage score is 2 or more ® consider epidural haematoma if > 8 hours after spinal anaesthetic / call the CNS acute pain or Acute Care Team urgently / Backache If the patient complains of new back pain at any time, call the CNS acute pain or Acute Care Team / Infection If there are any signs of infection at the spinal site, call the CNS acute pain or Acute Care Team / If your patient develops headache, photophobia or meningism, call the CNS acute pain or Acute Care Team urgently
Nausea If nausea persists despite giving regular antiemetics ® call CNS acute pain / Pruritus If significant: first bolus 40 mcg naloxone IVI (ie a small dose) / then add 200mcg naloxone to a 1 litre bag of saline 0.9% and infuse over 6 - 8hours
Points of contact
Acute Care Team : Pain: bleep 0195 Deteriorating patient: bleep 89048

Intrathecal Opioids: general principles
Patients should remain on oxygen as prescribed / IV access must be maintained until the stated observation period is complete / Naloxone must be available on the ward at all times / Patients may mobilise with support - there is no need to nurse these patients supine
Intrathecal opioids and analgesia
The subarachnoid space contains the cerebrospinal fluid (CSF) and the spinal cord. Drugs injected into this space are called ‘intrathecal’. Intrathecal opioids are mixed with local anaesthetic and injected into the subarachnoid space of patients having a spinal anaesthetic. Intrathecal opioids act directly on opioid receptors in the spinal cord. A single dose of an intrathecal opioid can provide long lasting pain relief following surgery: / Fentanyl may last up to 6 hours / Diamorphine up to 12 hours / Morphine up to 24 hours.
Intrathecal opioids and respiratory depression
This difference in duration of action is due to differences in the rate of removal of the opioid from the subarachnoid space. Diamorphine and Morphine are cleared slowly and therefore may remain in the CSF for many hours after administration. This is important because the CSF circulates slowly from the brain down the spinal cord before returning back up to the brain again. Diamorphine and morphine may move on these CSF currents from their site of injection low down in the spine up to the respiratory centres of the brain. Here very small amounts of opioid may cause profound respiratory depression. It is therefore essential that regular observations are performed to detect respiratory depression early. / Respiratory depression due to intrathecal opioids is usually preceded by increasing levels of sedation. Both the sedation and the respiratory depression are readily reversed by the administration of Naloxone. For profound respiratory depression an intravenous naloxone infusion may be required - discuss the need with the CNS acute pain or Acute Care Team.
Subsequent opioid analgesia
Eventually the effects of the intrathecal opioid will wear off leading to pain. If your patient is complaining of pain from their surgical wound, then it is reasonable to assume that the amount of opioid remaining in the CSF is very low and that respiratory depression is unlikely. At this point it is acceptable for them to receive opioid analgesia either orally (eg oramorph) or intravenously (eg PCA-morphine). If a PCA is prescribed, then it should be set up and attached in the Theatre Recovery area. However the handset should be given to the patient only when they start to feel pain from their surgical wound. Regular respiratory and sedation monitoring must be continued until the high risk period for respiratory depression has passed (see overpage). / In addition all patients should receive regular paracetamol and a NSAID (unless contraindicated). / Discuss any queries you may have with the CNS acute pain
Confirmation of recovery of spinal cord function
Spinal cord function returns as the local anaesthetic wears off, usually within 8 hours of the spinal anaesthetic. If there is delayed recovery of spinal cord function then spinal cord compression (eg epidural haematoma) should be suspected. It is vital that the nurse looking after the patient confirms spinal cord function has returned 8 hours after the spinal anaesthetic as follows: / Perform the following checks at ……… : ………. on ………. / ………. / …………… / Motor function: the patient has either mobilised or has a Bromage score of 1 / Bladder function: the patient has managed to pass urine voluntarily ie is not just incontinent / Sensation: the patient has normal perineal sensation or can feel the urinary catheter if present / If there is delayed recovery of any of these 3 functions then contact the Acute Care Team urgently / I confirm that I have performed these checks and that spinal cord function as defined above has returned: / Name: ……………………………… Signature: ……………………………… Time: …… : ……. Date: …… / …… / …………

File in the nursing records Issue No. 0426/3