intrathecal to IV or PO conversion of morphine?

[myrandom2003]

Little help:

I do not management pumps. But we have a patient in the hospital that has a pump that is going to run out in about 4 days. Being asked to help manage potential withdrawal. I believe this patient has 1-2mg/day. What is the conversion for this?

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[kstarm]

I see a number of pumps every year in the hospital. Is there a chance it can be refilled at the hospital? I assume the 1-2mg a day is morphine or dilaudid? If the pump can not be refilled you can turn the rate down to minimal rate to avoid the pump emptying. If the patient can get a refill soon you could decrease the rate by 20% to give more time to an outpatient refill and have him/her stop any PTM boluses.

For concerns about withdrawal I would just place the patient on oxy 10mg q4 prn and watch COWs. If it goes up you can adjust the dosing. You don't need to try to convert the IT medication 1:1.

 

[Ducttape]

conversion generally is somewhere between 12 to 1 up to 300 to 1 for morphine.

do you have a programmer to turn down the pump to minimal rate?


is he staying in the hospital for longer than 4 more days?


can you reach out to whoever is refilling the pump to try to set up a pump refill - maybe the pump doc can come in to the hospital to do that, or maybe set up a follow up or outpatient appointment...

 

[myrandom2003]

Oh yea guy this is going to be here for a week at least. having cardiac issues from heart failure and A.fib. I will reach out to the Medtronic rep to turn it down. No programmer in the hospital and no one at this hospital manages pumps (including me).

Sorry, yes it is Morphine in the pump.

 

[lobelsteve]

Oh yea guy this is going to be here for a week at least. having cardiac issues from heart failure and A.fib. I will reach out to the Medtronic rep to turn it down. No programmer in the hospital and no one at this hospital manages pumps (including me).

Sorry, yes it is Morphine in the pump.

Not hard to refill the pump in hospital and have rep bring programmer.
Why are you messing with him while in hospital for cardiac disease.
Changing now has risk but no benefit.

100-10-3-1
IT-Epi-IV-PO
This is pretty standard.

 

[Orin]

Bad situation here, but putting this case into opioid withdrawal would be a bad day.

I would call someone like Pentec, AIS, or BHI, to come into the hospital and refill the pump for you. The pump alarm is likely in 4 days, but there is normally a 2 mL early alarm indicator, so you've probably got 4 - 14 days.

The struggle here is that you won't be able to adequately convert for analgesia without significant respiratory depression, secondary right sided heart stress from the elevated pulmonary pressures, and then if you make the patient hurt, that sympathetic surge/stress will be poorly tolerated with their heart.

 

[myrandom2003]

I decreased the dose 15% and bout myself till next week. He is intubated now (prior to decrease) so I will decrease it another 15% and just let it run out if he is here that long. The cardiac and medical team are insistent that he needs to be off opioids.

 

[Orin]

I decreased the dose 15% and bout myself till next week. He is intubated now (prior to decrease) so I will decrease it another 15% and just let it run out if he is here that long. The cardiac and medical team are insistent that he needs to be off opioids.

There's a possibility that what you're seeing is actually intrathecal opioid withdrawal in the case of a fractured catheter in someone with a cardiac history. If he's intubated, then the ICU team can control the sympathetic surge. You can be more aggressive with things in that scenario and cut him 20 - 40% at 24-48h intervals if you need to.

As the last step, I would suggest you refill the pump with saline at the bedside and turning it to minimal rate, as letting it run dry can leave the patient with a non-functional device which may make them upset if they ever recover.

 

[Agast]

I decreased the dose 15% and bout myself till next week. He is intubated now (prior to decrease) so I will decrease it another 15% and just let it run out if he is here that long. The cardiac and medical team are insistent that he needs to be off opioids.

He’s intubated and they want him off opioids? Are they stopping sedating medications because they’re trying to “wake him up?”

Make sure you document in your notes that you are removing the opioids specifically per their request for him to be off all opioids. So whatever happens to his heart with the withdrawals are not something you decided to do on your own.

 

[lobelsteve]

You will be blamed for bad outcomes due to withdrawal. And you are taking orders from ICU docs on how to manage patient. This has bad optics on top of bad care.

 

[myrandom2003]

It does have bad optics, I agree and am not getting him off all opioids.

Patient actually had his pump put in September/October. Came in because of DKA and possibly had a cardiac event while in the hospital and went into cardio genic shock. Having a bedside egd and then a cath later.

I did document that we do not want to precipitate withdrawals.

 

[Ferrismonk]

Little help:

I do not management pumps. But we have a patient in the hospital that has a pump that is going to run out in about 4 days. Being asked to help manage potential withdrawal. I believe this patient has 1-2mg/day. What is the conversion for this?

It does have bad optics, I agree and am not getting him off all opioids.

Patient actually had his pump put in September/October. Came in because of DKA and possibly had a cardiac event while in the hospital and went into cardio genic shock. Having a bedside egd and then a cath later.

I did document that we do not want to precipitate withdrawals.

Pump was just put in Sept/Oct and he's already on 1-2mg/day?

 

[Baron Samedi]

I would definitely not let the pump go dry. Letting it go dry buys him an unnecessary surgery in the future. Switch it to saline and give him IV or transdermal opioids to avoid withdrawal.

When he has access to expertise would really consider switching from morphine to fentanyl or hydromorphone in his pump. Fluid retention from morphine is not uncommon.

 

[myrandom2003]

Pump was just put in Sept/Oct and he's already on 1-2mg/day?

yes sir. Not my pump and the managing clinic does not have privileges here.

from my limited knowledge, I thought nothing happens if the pump runs dry? Its only if the pump is turned off for extended period of time that it becomes an issue.
I know baclofen and you never want to let that go dry without being in an ICU.

will do transdermal if he is here for that long.

 

[Baron Samedi]

yes sir. Not my pump and the managing clinic does not have privileges here.

from my limited knowledge, I thought nothing happens if the pump runs dry? Its only if the pump is turned off for extended period of time that it becomes an issue.
I know baclofen and you never want to let that go dry without being in an ICU.

will do transdermal if he is here for that long.

Allowing it to go dry can result in pump malfunctioning or losing catheter patentcy. It can be empty for short periods, like for med swaps, but the longer its dry the higher the likelihood of badness.

 

[kstarm]

Agree- don't let it run dry. If you are not comfortable with refilling with saline you can have it turned down to the minimal rate which should provide significant more time to get it refilled. I'm not sure why they need him to be off opioids-that just doesn't make sense to me. If he is intubated in the ICU they could manage withdrawal with precedex, though I would not want a patient with cardiac issues having to go through opioid withdrawal or be on dex. Sounds like a tough case

 

[lobelsteve]

It is an easy case. Refill, continue current rate.
Let each specialist do their job.

 

[Orin]

It is an easy case. Refill, continue current rate.
Let each specialist do their job.

But it's a pump and they're hard...

Lack of comfort/knowledge lead to fear which makes this more complicated from all the teams. The ICU docs are likely concerned about the pump complicating things as they don't control it or understand it. The pain doc doesn't manage these and isn't able to push back from a point of strength.

The optics will look real bad in hindsight if an expert witness takes the stand. As a CYA, I try to document my fears and explicitly state I am doing this at the request of the xxx team, deferring to their knowledge of the patient in this scenario.

Thread jacking a little here, but would you get a consent from the family prior to changing the pump drug dose or refilling the device?

 

[deleted472101]

Don’t fellowships have any experience with conversion of meds and or pumps anymore?

 

[lobelsteve]

But it's a pump and they're hard...

Lack of comfort/knowledge lead to fear which makes this more complicated from all the teams. The ICU docs are likely concerned about the pump complicating things as they don't control it or understand it. The pain doc doesn't manage these and isn't able to push back from a point of strength.

The optics will look real bad in hindsight if an expert witness takes the stand. As a CYA, I try to document my fears and explicitly state I am doing this at the request of the xxx team, deferring to their knowledge of the patient in this scenario.

Thread jacking a little here, but would you get a consent from the family prior to changing the pump drug dose or refilling the device?

Absolutely. Easy enough to present the evidence of pump withdrawal/opiate withdrawal and cardiovascular fragile patients. Hint: It does not improve outcomes.

 

[Ducttape]

if you let the pump continue to run, if it is from one company - it will burn out and have to be replaced. set it at minimal rate, or better yet, keep it running at same rate with same medication. even if the doc does not have privileges, he has some responsibility and maybe he can come in and "assist" you in refilling the pump.

if the pump has been going at the same dose for over a month - he or she is tolerant to the dose.

 

[deleted472101]

I have brought a dry pump to life but I wouldn’t advise

 

[myrandom2003]

The last time I filled a pump was 11 years ago (it was baclofen).
No morphine pumps where i did training.
Regardless, coordinating care with the filling clinic. They advised a 10% decrease every other day. I documented the discussion in the chart. That pump clinic is run by an NP. No doctor there except the Neurosurgeon that puts the pump in and is hands off after.

What is the best way to evaluate for symptoms of opioid withdrawl in an intubed/sedated pump patient?
I know all about COWS but the numbers workout better in an awake patient.

I appreciate all of your opinions and help. much better than any didactic fellowship. nothing beats the collective experience on this thread.

 

[Ferrismonk]

Don’t fellowships have any experience with conversion of meds and or pumps anymore?

I managed several pumps during fellowship. Never did an implant. I still manage some legacy pumps in my current practice, but hate every one. Pump therapy is no longer appropriate for chronic non-cancer pain.

Regarding conversion, I'd be hard pressed to do it without some reading first.