IM Narcotics - Patient Recovery Starts in the OR

by Scott Sturman MD

Scott Sturman received a degree in aeronautical engineering  from the United State Air Force Academy.  He flew five years in the Air Force as a rescue and instructor pilot before beginning his medical education.  He completed his anesthesiology residency at the University of Arizona under Dr. Burnell Brown, before entering private practice in 1984 in Fresno, California.

Holy Lake Kong Tsho, Tibet - photo by JoAnn Sturman

You know it’s coming.  Your patient is cruising under general anesthesia, but there are bound to be problems ahead in the recovery room.

IM narcotics are useful when administered in the OR for anticipated post pain or agitation, where a slower onset and prolonged duration of action is preferred to intravenous treatment.  This method of delivery provides a baseline narcotic level which mitigates some of the unpleasant side effects when awakening from general anesthesia, particularly if supplementary regional anesthesia for post operative pain relief is unsatisfactory. 

For example, children awakening from strabismus surgery are frequently agitated and difficult to control.  These antics require more intensive nursing care and are unsettling to parents.  To avoid this predicament, IM meperidine is useful.  Within the last five minutes of surgery and while the patient is breathing spontaneously, I administer meperidine 1mg/kg up to 25 mg maximum IM preferably in the deltoid muscle.  Time of awakening in recovery room may be delayed slightly, but discharge home is hastened.  Ask recovery room nurses familiar with the technique, and they’ll testify to its benefits.

Three other areas where IM narcotics are useful are teenage patients, patients undergoing painful procedures where local anesthetic placement is impractical, such as lumbar spinal fusions, and cesarean sections conducted under general anesthesia.

In the teenage patient population, I often give meperidine 50mg IM within ten minutes from the conclusion of the case.  They awaken in recovery with less shaking and dysphoria.

Spinal surgery patients often take high doses of analgesics chronically, so pain control can be difficult. I routinely give them hydromorphone 2-4 mg IM in the last 30 minutes of the case.  This provides a therapeutic baseline narcotic level when the patient awakens in recovery room, and reduces the number of interventions necessary to provide adequate pain control.

When patients undergo cesarean sections under general anesthesia and are stable, I give meperidine 100mg IM as soon as the umbilical cord is clamped.  By the time surgery is finished, they awaken needing very little additional analgesics.  Along with the IM narcotic, performing a bilateral TAP block at the end of the case helps ease the transition.