Expert: Nigel Simmons - 8/28/2007

Question
QUESTION: I'm going to try to make this short, but it is complicated. My 90-yr-old Dad has not been eating well and has lost lots of weight in the last 3-4 mths. After a recent endoscopy by a GI, he was told that, among other problems, he has a hiatal hernia that is the largest one the doctor has ever seen--possibly there and growing since birth--but it has never been diagnosed before (nor has it ever given him any problems), and it has recently caused him lots of problems. Long before this was discovered, it was determined that he has COPD (has never smoked) and Interstitial Lung Disease. He also has a pacemaker and has had an angioplasty.
The GI said there were a couple of things he could try but because of the COPD and the ILD, he didn't think my dad would survive an operation. He finally decided to contact a surgeon and consult with him about it, and the surgeon decided he would try 3 things: 1) pull down the portion (about 25%) of his stomach that was protruding through his diaphragm and stitch it in place closer to where it belongs; 2) insert a J-tube to feed him (an earlier attempt this week at inserting a G-tube was unsuccessful due to the hernia); and 3) try to repair the hernia (this last attempt was ultimately unsuccessful). The first two procedures went well, and he didn't have any distress during the operation. Since the operation (which was completed Friday night around 6:30 p.m.), his vital signs have been amazingly good with BP at 115/58 on Saturday and 135/63 on Sunday, heart rate at 75 to 85, and blood saturation at 97 to 100. They wanted him off the respirator ASAP and were able to take him off of it at 8:30 p.m. Friday night.
After all that background, my question is this: he was given morphine for the operation (which I have read everywhere is not recommended to be used on a patient with COPD), and he has still not woken up since the operation.
I have looked everywhere on the Internet and I have been unable to find anything that says how long it might take for it to wear off for someone with his many complications. I have, however, read many things that said it may even be contraindicated to give morphine to a patient with COPD. While I was really encouraged about how good his vital signs are, I'm very concerned about what I keep reading about COPD and Morphine. Can you give me any guidance in this area? If all goes well, is it out of line to think it might be sometime Monday before he even begins to wake up? As you can imagine, my mother is very anxious at this point. Please help!

ANSWER: Bonnie

Firstly you need to remember that your father has been throgh what for someone with his history and age is very major surgery.

If as you say your father is now off the ventilator and is breathing spontaneously, then it is unlikley that the morphine has depressed the respiratory control area in his brain. This is the reason why morphine is usually avoided in COPD patients.

I'm not experienced enough in intensie care medicine to predict how long it will take for your father to regain consciousness. Reducing the morphine dose may help, but the doctors will want to keep him pain free, because this will only place more strain on his frail system. However there will be other medications that also need to be eliminated from his system, and these may be a factor.

I would expect the doctors and nurses will be carrying out regular neurological examinations - checking reflexes, responses to stimuli etc. This will give them the best indication of whether his consciousness is increasing.

Regrettably, there is also a possibility that your father may not have survived the surgery unharmed and may therefore never fully revcover. Breathing is a very reflex process and so while part of the brain may be damaged, other parts can continue to function. You may need to prepare yourself for this and discuss it with the doctors before speaking to your mother.

I hope this helps.

---------- FOLLOW-UP ----------

QUESTION: I just wanted to say thanks for trying to give me some kind of answer.

They did indeed take him off of morphine Saturday night at around 6:00 p.m. And he is, in fact, off the ventilator (and has been since 2 hours after the operation on Friday), as I mentioned. He is now reacting somewhat to having his feet poked, has been trying to open his eyes a little, has made attempts to turn his head a little, and there is slow dilation of the eyes when they shine the light in them--all encouraging things but still a long way to go. They did a CT scan on him today, and we'll know results of that tomorrow.

Now, it's just a waiting game, but at least there's a little tiny bit of positive. The surgeon said not to 'write him off' just yet and to keep talking to him and playing his favorite music, which I did and, amazingly, he seems to react to a couple of songs on the CD.

His vital signs continue to be good. He is on the j-tube feedings and getting liquid vitamins as well. When you mention "other medicines that may need to be eliminated from his system"--he has a slight infection in his lungs and is on antibiotics for this. Surely, he is also on something for pain (just not morphine), but I don't know what. Are these the types of medicines to which you are referring--antibiotics and other pain killers, both of which, obviously, he has to be given? What other types of meds might he be given?

Thanks again for your help.

Answer
Bonnie

It does sound as though your father is making slow, but steady progress and is getting out of the woods. He is clearly responding to stimuli and everything you can do to encourage this will help.

When talking about other drugs remaining in his system, I was particularly referring to the other anaesthetic agents that are likely to have been used while he was on the ventilator - drugs like short acting benzodiazepines. Antibiotics would not be a problem.

With regard to analgesia, your father may be given an alternative to morphine, but until he is able to swallow, choices are limited. The observations will show if your father is in pain, and treatment will be given appropriately. If possible they would want to avoid prolonged use of Morphine, because of its depressant effects.

Fingers crossed the news today will be better.