scholarly journals Respiratory Failure Following Delayed Intrathecal Morphine Pump Refill: A Valuable, but Costly Lesson

2010 ◽  
Vol 4;13 (4;7) ◽  
pp. 337-341
Author(s):  
Xiulu Ruan
Keyword(s):  
Drug Delivery ◽  
Respiratory Failure ◽  
Side Effects ◽  
Respiratory Depression ◽  
Intrathecal Morphine ◽  
Infusion Pump ◽  
Opioid Tolerance ◽  
Intrathecal Catheter ◽  
Patient Reported ◽  
Preservative Free

Background: Spinal analgesia, mediated by opioid receptors, requires only a fraction of the opioid dose that is needed systemically. By infusing a small amount of opioid into the cerebrospinal fluid in close proximity to the receptor sites in the spinal cord, profound analgesia may be achieved while sparing some of the side effects due to systemic opioids. Intraspinal drug delivery (IDD) has been increasingly used in patients with intractable chronic pain, when these patients have developed untoward side effects with systemic opioid usage. The introduction of intrathecal opioids has been considered one of the most important breakthroughs in pain management in the past three decades. A variety of side effects associated with the long-term usage of IDD have been recognized. Among them, respiratory depression is the most feared. Objective: To describe a severe adverse event, i.e., respiratory failure, following delayed intrathecal morphine pump refill. Case Report: A 65-year-old woman with intractable chronic low back pain, due to degenerative disc disease, and was referred to our clinic for an intraspinal drug delivery evaluation, after failing to respond to multidisciplinary pain treatment. Following a psychological evaluation confirming her candidacy, she underwent an outpatient patient-controlled continuous epidural morphine infusion trial. The infusion trial lasted 12 days and was beneficial in controlling her pain. The patient reported more than 90% pain reduction with improved distance for ambulation. She subsequently consented and was scheduled for permanent intrathecal morphine pump implantation. The intrathecal catheter was inserted at right paramedian L3-L4, with catheter tip advanced to L1, confirmed under fluoroscopy. Intrathecal catheter placement was confirmed by positive CSF flow and by myelogram. A non-programmable Codman 3000 constant-flow rate infusion pump was placed in the right mid quandrant between right rib cage and right iliac crest. The intrathecal infusion consisted of preservative free morphine, delivering 1.0 mg / day. Over the following 6 months, the dosage was gradually titrated up to 4 mg/day with satisfactory pain control without significant side effects. However, the patient was not able to return to the clinic for pump refill until 12 days later than the previously scheduled pump-refill date. Her pump was accessed and was noted to be empty. Her intrathecal pump was refilled with preservative free morphine, delivering 4 mg/day (the same daily dose as her previous refill). However, on the night of pump refill, 10 hours after the pump refill, the patient was found to be unresponsive by her family members. 911 was called. Upon arriving, paramedics found her in respiratory failure, with shallow breathing at a rate of 5/min, pulse oxymetry showing oxygen saturation about 55-58%. She was emergently intubated on site and rushed to local hospital ER. The on call physician for our clinic was immediately contacted, and advised the administration of intravenous Naloxone. Her respiratory effort improved dramatically after receiving a total of 0.6 mg IV Naloxone IV over 25 minutes. Her intrathecal pump was immediately accessed by clinic on call physician and the remainder of the medication in the catheter space was aspirated. The pump infusate was immediately diluted with preservative free normal saline, to deliver preservative free morphine at 1mg/day. She was transferred to the intensive care unit and extubated the next morning. She recovered fully without any sequelae. Conclusion: Loss of opioid tolerance due to delayed pump refill may subject patients to the development of severe respiratory depression. Meticulous approach should be employed when refilling pumps in these patients when their pumps are completely empty. To our knowledge, this is the first reported case of this type. Key words: intraspinal drug delivery pump, intrathecal morphine, respiratory depression, opioid tolerance

scholarly journals Migrating lumbar intrathecal catheter fragment associated with intracranial subarachnoid hemorrhage

2015 ◽  
Vol 22 (1) ◽  
pp. 47-51 ◽  
Author(s):  
Luke Hnenny ◽  
Hatem A. Sabry ◽  
Jeffrey S. Raskin ◽  
Jesse J. Liu ◽  
Neil E. Roundy ◽  
...  
Keyword(s):  
Drug Delivery ◽  
Subarachnoid Hemorrhage ◽  
Intrathecal Morphine ◽  
Failed Back Surgery Syndrome ◽  
Intrathecal Catheter ◽  
Head Ct ◽  
Failed Back Surgery ◽  
Back Surgery ◽  
History Of ◽  
Csf Diversion

Intrathecal catheter placement into the lumbar cistern has varied indications, including drug delivery and CSF diversion. These Silastic catheters are elastic and durable; however, catheter-associated malfunctions are well reported in the literature. Fractured catheters are managed with some variability, but entirely intradural retained fragments are often managed conservatively with observation. The authors describe a case of a 70-year-old man with an implanted intrathecal morphine pump for failed back surgery syndrome who presented to an outside hospital with a history of headache, neck pain, nausea, and photophobia of 3 days' duration. He also described mild weakness and intermittent numbness of both legs. Unenhanced head CT demonstrated subarachnoid hemorrhage (SAH). A right C-5 hemilaminectomy was performed. This case is unique in that there was no indication that the lumbar intrathecal catheter had fractured prior to the patient's presentation with SAH. This case demonstrates that intrathecal catheter fragments are mobile and can precipitate intracranial morbidity. Extrication of known fragments is safe and should be attempted to prevent further neurosurgical morbidity.

Postoperative analgesia after radical prostatectomy with high-dose intrathecal morphine and intravenous naloxone: A retrospective review

2018 ◽  
Vol 5 (6) ◽  
pp. 331-339 ◽  
Author(s):  
Annette Rebel, MD ◽  
Paul Sloan, MD ◽  
Michael Andrykowski, PhD
Keyword(s):  
Side Effects ◽  
Postoperative Pain ◽  
Pain Relief ◽  
Radical Prostatectomy ◽  
Respiratory Depression ◽  
Postoperative Analgesia ◽  
Intrathecal Morphine ◽  
Major Surgery ◽  
High Dose ◽  
The Mean

Background and methods: Intrathecal opioids (ITOs) have been used for decades to control postoperative pain. Intrathecal opioid dosing is limited, however, by opioid-related side effects, most importantly respiratory depression. To overcome these limitations, we combined intrathecal morphine with a continuous intravenous (IV) postoperative naloxone infusion to control opioid-related side effects. The purpose of this study is to document the efficacy and safety of high-dose intrathecal morphine combined with postoperative naloxone infusion to provide postoperative analgesia after major surgery. After IRB approval, a retrospective chart analysis was performed on 35 patients who had a radical prostatectomy from 2004 to 2006. All patients received a single injection of ITOs before anesthesia, a typical general anesthestic, followed by naloxone infusion at 5 μg/kg/h started 1 hour post-ITOs and continued for 22 hours postoperatively. The following information was collected: patient age, height, weight, anesthesia technique/time, and dose of ITOs given. Postoperative pain relief was assessed for 48 hours using the Visual Analog Score (VAS) for pain (0, no pain; 10, worst pain), perioperative opioid use, NSAID consumption, and ability of patient to ambulate. The safety of this novel treatment was assessed with opioid-related side effects and vital signs. All data are reported as mean (SD).Results: Mean ITOs given were morphine 1.3 (0.3) mg combined with fentanyl 56 (9) μg. The intrathecal morphine dose ranged from 0.8 to 1.7 mg. The mean worst pain VAS in the first 12 hours postoperatively was only 1.0 (1.7). The first NSAID dose was given 6.6 (3.1) hours post-ITOs. The first opioid on the floor was given an average of 22.6 (14.5) hours post-ITOs. A mean of only 5.7 (12.3) morphine equivalents were required on postoperative day 1 (POD 1). On POD 2, the mean worst pain VAS was only 2.6 (2.2) with only 5.7 (6.2) morphine equivalents needed to provide pain relief. On POD 1, 25 patients required no additional opioids for their entire hospital stay. Overall, 11 of 35 patients did not require any additional postoperative opioids. Thirtyfour patients (97 percent) were able to ambulate in the first 12 hours postoperatively. No opioid-induced respiratory depression was observed. Opioid-related side effects (pruritus, nausea) were infrequent and minor.Conclusions: High-dose ITOs combined with postoperative IV naloxone infusion provided excellent analgesia for radical prostate surgery. IV naloxone infusion appeared to control opioid side effects without diminishing the analgesia. No serious adverse effects were noted.

scholarly journals The Use of Intrathecal Morphine for Acute Postoparative Pain in Lower Limb Arthroplasty Surgery: A Survey of Practice at an Academic Hospital.

2021 ◽  
Author(s):  
Mpumelelo Sibanyoni ◽  
Ntombiyethu Biyase ◽  
Palesa Motshabi Chakane
Keyword(s):  
Side Effects ◽  
Respiratory Depression ◽  
Spinal Anaesthesia ◽  
Side Effect ◽  
Intrathecal Morphine ◽  
Side Effect Profile ◽  
Academic Hospital ◽  
Rescue Analgesia ◽  
Vas Score ◽  
Total Knee

Abstract Background and purpose of the study: Intrathecal morphine (ITM) provides optimal postoperative analgesia in patients who are scheduled for total knee and hip operation with spinal anaesthesia. However, the ideal dose at which maximal analgesic effect occurs with minimal side effects is not known. This study aimed to describe the use of two doses of ITM, and side effect profile in patients undergoing elective hip and knee arthroplasty.Methods: This was a prospective, descriptive, and contextual study conducted on patients who had total hip and knee replacement at Chris Hani Baragwanath Academic Hospital from 1 September to 30 November 2020. The sample size consisted of 66 patients who were 18 years and older, American Society of Anaesthesiology (ASA) classification 1-3, patients who had received either 100 mcg or 150 mcg ITM dose under spinal anaesthesia and sent to the ward postoperatively. Visual Analogue Scale (VAS) score was used to assess pain in the first 24 hours, consumption of rescue analgesia and reported side effects were documented.Results: There was no relationship between age, weight, ASA classification or type of surgery and VAS score classification groups. Patients who received 100 mcg ITM had a higher median VAS pain score 2 (1-5) compared to those who received 150 mcg ITM 1 (0-2), p = 0.01. The need for rescue analgesia between the two groups was marginally less in the 150mcg ITM group (p =0.098). There was no difference in the rate of side effects between the 100 mcg ITM group [12 (41%)] and the 150 mcg ITM group [17 (59%)], p = 0.92. Rescue analgesia was marginally different between groups, p = 0.09. There were no real differences in the VAS pain scores between the total knee and total hip surgeries. None of the patients experienced clinically significant respiratory depression. Conclusion: The 150mcg ITM dose provided good analgesic effects with longer duration of action and comparable side effect profile to the 100mcg ITM dose. This dose was not associated with development of respiratory depression can therefore be administered safely to patients who are discharged to the ward postoperatively in a resource constraint environment.

Intrathecal Morphine for Postoperative Analgesia in Children after Selective Dorsal Root Rhizotomy

Neurosurgery ◽  
1991 ◽  
Vol 28 (4) ◽  
pp. 519-522 ◽  
Author(s):  
Mark M. Harris ◽  
Madelyn D. Kahana ◽  
T. S. Park
Keyword(s):  
Single Dose ◽  
Side Effects ◽  
Postoperative Analgesia ◽  
Dorsal Root ◽  
Intrathecal Morphine ◽  
Low Doses ◽  
Selective Dorsal Rhizotomy ◽  
Dorsal Rhizotomy ◽  
High Doses ◽  
Preservative Free

Abstract The authors report their experience with low doses (0.007-0.015 mg/kg);, moderate doses (0.016-0.025 mg/kg);, and high doses (0.026-0.035 mg/kg); of intrathecal morphine for postoperative analgesia after selective dorsal root rhizotomy surgery in 50 children, aged 3 to 12 years. After closure of the dura, a single dose of preservative-free morphine was injected into the subarachnoid space, and patients were assessed for 48 hours for level of comfort and side effects. The three doses of morphine provided equivalent analgesia and similar side effects. The duration of postoperative analgesia ranged from 3 to 48 hours (mean, 12.2 ± 9.5 h);. Common side effects were limited to nausea and vomiting (42%); and mild facial pruritus. No patient experienced late respiratory depression or generalized pruritus. The authors conclude that low doses of intrathecal morphine is as effective as moderate or high doses of morphine for reducing pain in the immediate postoperative period. Intrathecal morphine provides excellent analgesia after selective dorsal rhizotomy.

scholarly journals Thoracic Nerve Root Entrapment by Intrathecal Catheter Coiling: Case Report and Review of the Literature

2016 ◽  
Vol 3;19 (3;3) ◽  
pp. E499-E504 ◽  
Author(s):  
Jing L. Han
Keyword(s):  
Drug Delivery ◽  
Case Report ◽  
Operating Room ◽  
Nerve Root ◽  
Fluoroscopic Guidance ◽  
Intrathecal Catheter ◽  
Catheter Migration ◽  
Thoracic Nerve ◽  
Patient Reported ◽  
Nerve Root Entrapment

Background: Intrathecal catheter placement has long-term therapeutic benefits in the management of chronic, intractable pain. Despite the diverse clinical applicability and rising prevalence of implantable drug delivery systems in pain medicine, the spectrum of complications associated with intrathecal catheterization remains largely understudied and underreported in the literature. Objective: To report a case of thoracic nerve root entrapment resulting from intrathecal catheter migration. Study Design: Case report. Setting: Inpatient hospital service. Results/Case Report: A 60-year-old man status post implanted intrathecal (IT) catheter for intractable low back pain secondary to failed back surgery syndrome returned to the operating room for removal of IT pump trial catheter after experiencing relapse of preoperative pain and pump occlusion. Initial attempt at ambulatory removal of the catheter was aborted after the patient reported acute onset of lower extremity radiculopathic pain during the extraction. Noncontrast computed tomography (CT) subsequently revealed that the catheter had ascended and coiled around the T10 nerve root. The patient was taken back to the operating room for removal of the catheter under fluoroscopic guidance, with possible laminectomy for direct visualization. Removal was ultimately achieved with slow continuous tension, with complete resolution of the patient’s new radicular symptoms. Limitations: This report describes a single case report. Conclusion: This case demonstrates that any existing loops in the intrathecal catheter during initial implantation should be immediately re-addressed, as they can precipitate nerve root entrapment and irritation. Reduction of the loop or extrication of the catheter should be attempted under continuous fluoroscopic guidance to prevent further neurosurgical morbidity. Key words: Implantable drug delivery system, intrathecal, catheter migration, postoperative complications, looping, fluoroscopy

scholarly journals Drug-Related Side Effects of Long-term Intrathecal Morphine Therapy

2007 ◽  
Vol 2;10 (3;2) ◽  
pp. 357-365
Author(s):  
Xiulu Ruan
Keyword(s):  
Pain Management ◽  
Side Effects ◽  
Opioid Receptors ◽  
Intrathecal Morphine ◽  
Infusion Pump ◽  
Pump Therapy ◽  
Morphine Administration ◽  
Opioid Administration ◽  
Morphine Therapy

Background: The introduction of intrathecal opioid administration for intractable chronic non-malignant pain and cancer pain is considered as one of the most important breakthroughs in pain management. Morphine, the only opioid approved by FDA for intrathecal administration, has been increasingly utilized for this purpose. For over 3 decades, there have been numerous reports on the non-nociceptive side effects associated with ever increasing long-term intrathecal morphine usage. Objectives: To review the literature on side effects due to long-term intrathecal morphine therapy with discussions of alternate treatment options. Design: English-language publications were identified through MEDLINE search and the bibliographies of identified articles were reviewed. Results: Most side effects of intrathecal morphine therapy are dose dependent and mediated by opioid receptors. Common ones include nausea, vomiting, pruritus, urinary retention, constipation, sexual dysfunction, and edema. Less common ones include respiratory depression, and hyperalgesia. Catheter tip inflammatory mass formation is a less common complication that may not be mediated by opioid receptors. Conclusion: The utilization of intrathecal morphine administration for cancer and intractable non-malignant chronic pain represents an important leap forward in pain management. Yet, a wide variety of non-nociceptive side effects may also occur in susceptible patients. The side effects due to intrathecal morphine administration are mostly mediated by opioid receptors. Treatment usually involves the utilization of opioid receptor antagonist, such as naloxone. Patients considering intrathecal opioid pump therapy should be informed and advised about the possible side effects associated with longterm intrathecal morphine administration prior to placement of a permanent morphine infusion pump. Key words: side effects, intrathecal morphine, opioid receptors

Respiratory Depression following Administration of Intrathecal Bupivacaine to an Opioid-Dependent Patient

1998 ◽  
Vol 32 (6) ◽  
pp. 653-655 ◽  
Author(s):  
Catherine Y Piquet ◽  
Michel P Mallaret ◽  
Aude H Lemoigne ◽  
Claude E Barjhoux ◽  
Vincent C Danel ◽  
...  
Keyword(s):  
Respiratory Depression ◽  
Extended Release ◽  
Intrathecal Morphine ◽  
Oral Morphine ◽  
Opioid Analgesics ◽  
Leg Pain ◽  
Spontaneous Respiration ◽  
Intrathecal Catheter ◽  
Cancer Of The Bladder ◽  
Dependent Patient

OBJECTIVE: To document two cases of respiratory depression in patients receiving morphine once the stimulating effect of pain on respiration was removed by bupivacaine. CASE SUMMARIES: Case 1: A 72-year-old 84-kg white man with cancer of the bladder and bone metastases had intense back and leg pain that was treated with intrathecal morphine for 6 months at an increasing dosage up to 10 mg twice daily. The intrathecal route was avoided for 4 days because of a suspected local infection at the site of the intrathecal catheter. During this 4-day period the patient received extended-release morphine and subcutaneous morphine daily. When the intrathecal route was used again, he received an identical dose of morphine plus bupivacaine and epinephrine. Ten minutes after the injection, fatal respiratory distress occurred. Case 2: A 92-year-old white woman was admitted for revascularization of arteritis on her left leg. To treat a painful sacrum and heel bedsores, she received extended-release oral morphine for 8 days. Induction of the intrathecal anesthesia was performed with bupivacaine. After 10 minutes, the patient became subcomatose, with miosis and apnea. Intravenous naloxone restored spontaneous respiration and normal consciousness. CONCLUSIONS: Pain is a physiologic antagonist of the respiratory depressant effects of opioid analgesics. By reducing pain stimulation, bupivacaine may make patients more susceptible to opioid respiratory depression. Such situations require titration of bupivacaine and other analgesics as well as increased monitoring of the patient.

scholarly journals Intrathecal Morphine Following Lumbar Fusion: A Randomized, Placebo-Controlled Trial

Neurosurgery ◽  
2018 ◽  
Vol 85 (2) ◽  
pp. 189-198 ◽  
Author(s):  
Perry Dhaliwal ◽  
Daniel Yavin ◽  
Tara Whittaker ◽  
Geoffrey S Hawboldt ◽  
Gordon A E Jewett ◽  
...  
Keyword(s):  
Side Effects ◽  
Postoperative Pain ◽  
Hospital Stay ◽  
Respiratory Depression ◽  
Repeated Measures ◽  
Intrathecal Morphine ◽  
Lumbar Fusion ◽  
Controlled Trial ◽  
Intrathecal Injection ◽  
Lumbar Spine Surgery

Abstract BACKGROUND Despite the potential for faster postoperative recovery and the ease of direct intraoperative injection, intrathecal morphine is rarely provided in lumbar spine surgery. OBJECTIVE To evaluate the safety and efficacy of intrathecal morphine following lumbar fusion. METHODS We randomly assigned 150 patients undergoing elective instrumented lumbar fusion to receive a single intrathecal injection of morphine (0.2 mg) or placebo (normal saline) immediately prior to wound closure. The primary outcome was pain on the visual-analogue scale during the first 24 h after surgery. Secondary outcomes included respiratory depression, treatment-related side effects, postoperative opioid requirements, and length of hospital stay. An intention-to-treat, repeated-measures analysis was used to estimate outcomes according to treatment in the primary analysis. RESULTS The baseline characteristics of the 2 groups were similar. Intrathecal morphine reduced pain both at rest (32% area under the curves [AUCs] difference, P < .01) and with movement (22% AUCs difference, P < .02) during the initial 24 h after surgery. The risk of respiratory depression was not increased by intrathecal morphine (hazard ratio, 0.86; 95% confidence interval, 0.44 to 1.68; P = .66). Although postoperative opioid requirements were reduced with intrathecal morphine (P < .03), lengths of hospital stay were similar (P = .32). Other than a trend towards increased intermittent catheterization among patients assigned to intrathecal morphine (P = .09), treatment-related side effects did not significantly differ. The early benefits of intrathecal morphine on postoperative pain were no longer apparent after 48 h. CONCLUSION A single intrathecal injection of 0.2 mg of morphine safely reduces postoperative pain following lumbar fusion.

Liposomes: Novel Drug Delivery Approach for Targeting Parkinson’s Disease

2020 ◽  
Vol 26 (37) ◽  
pp. 4721-4737 ◽  
Author(s):  
Bhumika Kumar ◽  
Mukesh Pandey ◽  
Faheem H. Pottoo ◽  
Faizana Fayaz ◽  
Anjali Sharma ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Drug Delivery ◽  
Parkinson's Disease ◽  
Side Effects ◽  
Blood Brain Barrier ◽  
Brain Barrier ◽  
Brain Targeting ◽  
Neural Cells ◽  
Blood Brain ◽  
The Brain

Parkinson’s disease is one of the most severe progressive neurodegenerative disorders, having a mortifying effect on the health of millions of people around the globe. The neural cells producing dopamine in the substantia nigra of the brain die out. This leads to symptoms like hypokinesia, rigidity, bradykinesia, and rest tremor. Parkinsonism cannot be cured, but the symptoms can be reduced with the intervention of medicinal drugs, surgical treatments, and physical therapies. Delivering drugs to the brain for treating Parkinson’s disease is very challenging. The blood-brain barrier acts as a highly selective semi-permeable barrier, which refrains the drug from reaching the brain. Conventional drug delivery systems used for Parkinson’s disease do not readily cross the blood barrier and further lead to several side-effects. Recent advancements in drug delivery technologies have facilitated drug delivery to the brain without flooding the bloodstream and by directly targeting the neurons. In the era of Nanotherapeutics, liposomes are an efficient drug delivery option for brain targeting. Liposomes facilitate the passage of drugs across the blood-brain barrier, enhances the efficacy of the drugs, and minimize the side effects related to it. The review aims at providing a broad updated view of the liposomes, which can be used for targeting Parkinson’s disease.

Sign in / Sign up

Export Citation Format

Share Document