From: Insidious Intoxication After Morphine Treatment in Renal Failure: Delayed Onset of Morphine-6-glucuronide Action Anesthes. 2000;92(5):1473. Figure.

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From: Insidious Intoxication After Morphine Treatment in Renal Failure: Delayed Onset of Morphine-6-glucuronide Action Anesthes. 2000;92(5):1473. Figure Legend: Fig. 1. For bilateral nephrectomy a total amount of 110 mg of intravenous morphine had been administered to a young man with chronic severe renal failure. Unconsciousness started at a time when morphine was no longer detectable in plasma, and morphine-6-glucuronide (M6G) concentrations had been high for more than a day. Hemodialysis starting 45 h after surgery almost completely cleared morphine-6-glucuronide from plasma. However, the patient remained unconscious for another 34 h. The slow equilibration of M6G between plasma and the brain seems to explain the long delay between reaching high plasma concentrations of M6G and the onset of unconsciousness, as well as the slow recovery from unconsciousness after clearing most M6G from plasma with hemodialysis. The time course of morphine dosage, the plasma concentrations of morphine, morphine-6-glucuronide, and morphine-3-glucuronide, and of the three parameters assessing the patient’s vigilance (Galveston orientation and amnesia test [GOAT], digital span test, and reaction time to visual stimuli) are displayed. Date of download: 10/10/2017 Copyright © 2017 American Society of Anesthesiologists. All rights reserved.

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