Unexpected complication of successful nerve block. Morphine induced respiratory depression precipitated by removal of severe pain

Our plain-English summary of Unexpected complication of successful nerve block. Morphine induced respiratory depression precipitated by removal of severe pain, by G.W. Hanks, R.G. Twycross, J.W. Lloyd (Anaesthesia, 1981).

The study

• Authors: G.W. Hanks, R.G. Twycross, J.W. Lloyd
• Journal: Anaesthesia
• Published: 1981;36(1):37-9
• Type of article: Case report
• Cited by: 87 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

A case is reported of a 76-year-old man with a right-sided mesothelioma who required large doses of oral narcotics to control his severe chest pain. After a successful chlorocresol intrathecal nerve block, respiratory failure was induced by doses of oral morphine at the same level as those used before the block, and also by substantially smaller doses. A considerable reduction in analgesic requirements may be possible following non-drug intervention to relieve pain and may be essential in patients with compromised respiratory function. This observation emphasises the importance of pain as a potent stimulator of the respiratory centre in patients with reduced respiratory reserve who are receiving narcotic drugs.

In plain English

This case report described a 76-year-old man with right-sided mesothelioma who needed large doses of oral morphine for severe chest pain. The article does not mention asbestos. Oral morphine 60 mg every four hours failed to relieve his pain adequately; 90 mg considerably relieved it. He then had a chlorocresol nerve block injected into the spinal canal at the T2-3 level, with his morphine dose unchanged. Eighteen hours later he became stuporose and cyanosed, with Cheyne-Stokes breathing. Naloxone reversed this but brought unbearable pain and withdrawal symptoms. On 30 mg every four hours his consciousness again deteriorated, with cyanosis and twitching from lack of oxygen, and naloxone was given again. On 10 mg every four hours he was pain-free; after 2 days this was raised to 15 mg. He died 6 weeks after admission. Postmortem examination found his right pleural cavity completely encased by mesothelioma. The authors concluded that his pain had been acting as a powerful stimulus to breathing. They suggested routinely reducing narcotic doses in advance after non-drug pain relief in patients with impaired respiratory function.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report
• Who was studied: One 76-year-old man who presented in April 1979 with severe right upper chest pain and breathlessness on exertion. Mesothelioma was diagnosed from his history and radiographs, and he was later confirmed at postmortem.
• Exposure: The article does not describe any asbestos exposure. The case concerns oral morphine given before and after an intrathecal chlorocresol nerve block for pain relief.
• Main results:
  • Before admission, oral morphine 60 mg four hourly did not adequately relieve the patient's pain.
  • After admission, oral morphine increased to 90 mg 4 hourly considerably relieved the pain.
  • An intrathecal nerve block was done at the T2-3 interspace, and the oral morphine dose was left unchanged.
  • After the block, the patient became stuporose and cyanosed, with Cheyne-Stokes respiration.
  • After naloxone, the patient had unbearable right chest pain and symptoms of acute narcotic withdrawal.
  • When oral morphine was recommenced at 30 mg four hourly, the patient's level of consciousness deteriorated and he became sleepy and cyanosed, with anoxic twitching of the upper limbs.
  • Naloxone was given again and produced the same reaction as on the previous day.
  • On oral morphine 10 mg four hourly the patient was pain-free, and after 2 days the dose was increased to 15 mg four hourly.
  • The patient died 6 weeks after admission. Postmortem showed the right pleural cavity completely encased by mesothelioma.
  • The authors interpreted the sequence as showing that the pre-existing pain had acted as a powerful respiratory stimulus in a patient with grossly impaired respiratory function.
• The authors' conclusion: The authors suggested that, in patients with impaired respiratory function, the narcotic dose be reduced routinely and in advance following any non-drug intervention to relieve pain.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma.

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