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Macorigh C, Guibbert V, Casanova M, Haenni C. Stability study of hydromorphone and bupivacaine mixture by HPLC-UV. Eur J Hosp Pharm 2020; 27:95-99. [PMID: 32133135 DOI: 10.1136/ejhpharm-2018-001553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/03/2018] [Accepted: 09/06/2018] [Indexed: 11/04/2022] Open
Abstract
Objectives The objective of this study was to evaluate the physical and chemical stability of hydromorphone hydrochloride and bupivacaine hydrochloride in concentrations of 15 mg.ml-1 and 10 mg.mL-1 in 0.9% sodium chloride injection. Test samples of hydromorphone/bupivacaine mixtures were stored at 37°C, body temperature encounterd during continuous intrathecal infusion, for 90 days. The solutions were packaged in 20 ml plastic syringes. Evaluations for physical and chemical stability were performed initially and throughout the storage periods. Physical stability was assessed by visual observation. The chemical stability of the drug was evaluated by means of a stability-indicating high-performance liquid chromatographic (HPLC) analytical technique. In addition, pH and osmolarity were measured electronically. Methods This study determines the stability and compatibility of hydromorphone (15 mg.ml-1) and bupivacaine (10 mg.ml-1) mixture after 3 months at 37°C using a validated method by HPLC-UV. A simple, precise, specific and accurate reversed phase high performance liquid chromatographic (RP-HPLC) method was developed and validated. The different analytical performance parameters such as linearity, accuracy, specificity, precision and sensitivity (limit of detection and limit of quantitation) were determined according to International Conference on Harmonisation ICH Q2 (R1) guidelines. RP-HPLC was conducted on a nucleoshell RP18plus (C18 150×4.6 mm with 2.7 µm particle size) column. The mobile phase consisted of buffer A (phosphate buffer (0.05M) pH 4.5) and acetonitrile B. The gradient used for the elution is the following one: time (min)/% of B: 0 min/20%; 1.9 min/50%; 2.5 min /40%; 4.5 min/40%; 5.5 min/20%; and 8 min /20%, and the flow rate was maintained at 1.0ml.min-1 and performed at 35°C. The molecules were monitored using Dionex ultimate 3000, equipped with photo diode array detector (λ=210 nm). Linearity was observed in concentration range of 9-21 mg.l-1 for hydromorphone and 6-14 mg.l-1 for bupivacaine. All the system suitability parameters were found within the range. Results The degradation study shows a photolytic degradation compound for hydromorphone and an oxidative degradation compound found for bupivacaine. The stability study shows no visible haze or particulate formation or gas evolution. pH and osmolarity were stable during the 3 months. Colour changed after 2 months, although this colouring is due to hydromorphone, proportional to hydromorphone concentrations and increases with time but it is a well known modification. The quantitative study by HPLC method revealed no significant change in hydromorphone and bupivacaine concentration. There is less than 5% of variability during the 3-month period. Conclusions Hydromorphone (15 mg.ml-1) and bupivacaine (10 mg.ml-1) were physically and chemically compatible and analysed with HPLC, which revealed no significant change in hydromorphone and bupivacaine concentration in this simulated compatibility study.
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Affiliation(s)
| | - Vincent Guibbert
- Department of Pharmacy, Fribourg Hospital (HFR), Fribourg, Switzerland
| | - Marine Casanova
- Department of Pharmacy, Fribourg Hospital (HFR), Fribourg, Switzerland
| | - Catherine Haenni
- Department of Pharmacy, Fribourg Hospital (HFR), Fribourg, Switzerland
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Hansson E, Skiöldebrand E. Anti-inflammatory effects induced by ultralow concentrations of bupivacaine in combination with ultralow concentrations of sildenafil (Viagra) and vitamin D3 on inflammatory reactive brain astrocytes. PLoS One 2019; 14:e0223648. [PMID: 31596904 PMCID: PMC6785114 DOI: 10.1371/journal.pone.0223648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/25/2019] [Indexed: 11/29/2022] Open
Abstract
Network coupled cells, such as astrocytes, regulate their cellular homeostasis via Ca2+ signals spread between the cells through gap junctions. Intracellular Ca2+ release is controlled by different signaling pathways that can be stimulated by ATP, glutamate and serotonin (5-HT). Based on our findings, all these pathways are influenced by inflammatory agents and must be restored to fully recover the Ca2+ signaling network. An ultralow concentration of the local anesthetic agent bupivacaine reduced 5-HT-evoked intracellular Ca2+ release, and an ultralow concentration of the phosphodiesterase-5 inhibitor sildenafil in combination with vitamin D3 reduced ATP-evoked intracellular Ca2+ release. Combinations of these three substances downregulated 5-HT-, glutamate- and ATP-evoked intracellular Ca2+ release to a more normal Ca2+ signaling state. Furthermore, inflammatory Toll-like receptor 4 expression decreased with a combination of these three substances. Substance P receptor neurokinin (NK)-1 expression was reduced by ultralow concentrations of bupivacaine. Here, bupivacaine and sildenafil (at extremely low concentrations) combined with vitamin D3 have potential anti-inflammatory properties. According to the present study, drug combinations at the right concentrations, especially extremely low concentrations of bupivacaine and sildenafil, affect different cellular biochemical mechanisms and represent a potential solution for downregulating inflammatory parameters, thereby restoring cells or networks to normal physiological homeostasis.
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Affiliation(s)
- Elisabeth Hansson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Skiöldebrand
- Department of Pathology, Institute of Biomedical Sciences and Veterinary Public Health, Swedish University of Agricultural Sciences, Uppsala, Sweden.,Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska University Hospital, Gothenburg University, Gothenburg, Sweden
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Huang M, Dalm B, Simpson RK. Toxic Myelitis and Arachnoiditis After Intrathecal Delivery of Bupivacaine via an Implanted Drug Delivery System: Case Report and Review of the Literature. Cureus 2018; 10:e2240. [PMID: 29719742 PMCID: PMC5922505 DOI: 10.7759/cureus.2240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The off-label usage of amino-amide anesthetics in intrathecal drug delivery systems (IDDS) for the treatment of chronic non-malignant and malignant pain is supported in the polyanalgesic consensus guidelines as a second-line adjunctive therapy. Although strong evidence for its clinical efficacy is lacking, its clinical safety profile has been well established within established dosing parameters. Despite the rarity of neurological adverse reactions to intrathecal bupivacaine, whether given as regional anesthesia or intrathecal therapy, neurologic morbidity associated with its administration is well documented. The etiology of adverse reactions is often difficult to definitively identify, especially given the variabilities associated with compounding errors in the formulation, solvent contamination, and mechanical factors. We present a rare case of toxic myelitis and arachnoiditis resulting in paraplegia two months after the addition of bupivacaine to the intrathecal analgesic regimen and discuss possible etiological factors with a review of the literature.
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Affiliation(s)
- Meng Huang
- Department of Neurosurgery, Houston Methodist Neurological Institute
| | - Brian Dalm
- Department of Neurosurgery, Houston Methodist Neurological Institute
| | - Richard K Simpson
- Department of Neurosurgery, Houston Methodist Neurological Institute
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Pharmacology of Intrathecal Therapy. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00066-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Deer TR, Pope JE, Hayek SM, Lamer TJ, Veizi IE, Erdek M, Wallace MS, Grider JS, Levy RM, Prager J, Rosen SM, Saulino M, Yaksh TL, De Andrés JA, Abejon Gonzalez D, Vesper J, Schu S, Simpson B, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks. Neuromodulation 2017; 20:155-176. [DOI: 10.1111/ner.12579] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/22/2016] [Accepted: 12/07/2016] [Indexed: 01/12/2023]
Affiliation(s)
| | | | - Salim M. Hayek
- University Hospitals Cleveland Medical Center, Case Western Reserve University; Cleveland OH USA
| | | | - Ilir Elias Veizi
- Veterans Administration Medical Center, Case Western Reserve University; Cleveland OH USA
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- UK HealthCare Pain Services, University of Kentucky College of Medicine; Lexington KY USA
| | | | - Joshua Prager
- Center for the Rehabilitation of Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology, University of California; San Diego CA USA
| | - Jose A. De Andrés
- Valencia School of Medicine, Hospital General Universitario; Valencia Spain
| | | | - Jan Vesper
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf; Germany
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
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Adler DMT, Cornett C, Damborg P, Verwilghen DR. The stability and microbial contamination of bupivacaine, lidocaine and mepivacaine used for lameness diagnostics in horses. Vet J 2016; 218:7-12. [PMID: 27938712 DOI: 10.1016/j.tvjl.2016.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 10/14/2016] [Accepted: 10/21/2016] [Indexed: 11/30/2022]
Abstract
Local anaesthetics (LAs) are frequently used for diagnostic procedures in equine veterinary practice. The objective of this study was to investigate the physico-chemical stability and bacterial contamination of bupivacaine, lidocaine and mepivacaine used for lameness examinations in horses. The LAs were stored in 12 different groups at different temperatures (-18 °C to 70 °C), light intensities and in common veterinary field conditions for up to 16 months. The pH, presence of bacterial contamination and concentrations of LAs and methylparaben (a preservative present in lidocaine) were determined serially in both new and repeatedly punctured (RP) vials. Mepivacaine remained chemically stable. A 1.9% increase in bupivacaine concentration was evident in one group, whereas a 1.9-3.7% decrease was noted in six groups. Risk factors associated with a change in concentration were light and RP vials. Lidocaine concentration decreased 6.3% in one group and increased 5.3-7.2% in two groups. Risk factors for degradation were heat and RP vials whereas storage in practice vehicles was a risk factor for increased concentrations. Methylparaben decreased 8.3-75.0% in seven groups, and RP vials, heat and storage in practice vehicles were risk factors for degradation. No contamination was present in any of the LAs and pH remained stable. Commercially available solutions of lidocaine, mepivacaine and bupivacaine stored under common veterinary field conditions are extremely stable and sterile for extended periods. The minor changes in concentration documented in this study are unlikely to affect anaesthetic efficacy during equine lameness examinations. When using products containing methylparaben, degradation of the preservative over time is to be expected.
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Affiliation(s)
- D M T Adler
- Department of Large Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Hoejbakkegaard Allé 5, Taastrup, Copenhagen DK-2630, Denmark.
| | - C Cornett
- Department of Analytical Biosciences, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, Copenhagen DK-2100, Denmark
| | - P Damborg
- Department of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Stigbøjlen 4, Frederiksberg DK-1870, Denmark
| | - D R Verwilghen
- Department of Large Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Hoejbakkegaard Allé 5, Taastrup, Copenhagen DK-2630, Denmark
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Intrathecal drug delivery for chronic pain management-scope, limitations and future. J Clin Monit Comput 2014; 29:241-9. [DOI: 10.1007/s10877-014-9607-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 08/13/2014] [Indexed: 10/24/2022]
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Ver Donck A, Vranken JH, Puylaert M, Hayek S, Mekhail N, Van Zundert J. Intrathecal drug administration in chronic pain syndromes. Pain Pract 2013; 14:461-76. [PMID: 24118774 DOI: 10.1111/papr.12111] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 07/29/2013] [Indexed: 01/01/2023]
Abstract
Chronic pain may recur after initial response to strong opioids in both patients with cancer and patients without cancer or therapy may be complicated by intolerable side effects. When minimally invasive interventional pain management techniques also fail to provide satisfactory pain relief, continuous intrathecal analgesic administration may be considered. Only 3 products have been officially approved for long-term intrathecal administration: morphine, baclofen, and ziconotide. The efficacy of intrathecal ziconotide for the management of patients with severe chronic refractory noncancer pain was illustrated in 3 placebo-controlled trials. A randomized study showed this treatment option to be effective over a short follow-up period for patients with pain due to cancer or AIDS. The efficacy of intrathecal opioid administration for the management of chronic noncancer pain is mainly derived from prospective and retrospective noncontrolled trials. The effect of intrathecal morphine administration in patients with pain due to cancer was compared with oral or transdermal treatment in a randomized controlled trial, which found better pain control and fewer side effects with intrathecal opioids. Other evidence is derived from cohort studies. Side effects of chronic intrathecal therapy may either be technical (catheter or pump malfunction) or biological (infection). The most troublesome complication is, however, the possibility of granuloma formation at the catheter tip that may induce neurological damage. Given limited studies, the evidence for intrathecal drug administration in patients suffering from cancer-related pain is more compelling than that of chronic noncancer pain.
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Block L, Jörneberg P, Björklund U, Westerlund A, Biber B, Hansson E. Ultralow concentrations of bupivacaine exert anti-inflammatory effects on inflammation-reactive astrocytes. Eur J Neurosci 2013; 38:3669-78. [PMID: 24083665 PMCID: PMC4211363 DOI: 10.1111/ejn.12364] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 08/07/2013] [Accepted: 08/25/2013] [Indexed: 12/11/2022]
Abstract
Bupivacaine is a widely used, local anesthetic agent that blocks voltage-gated Na(+) channels when used for neuro-axial blockades. Much lower concentrations of bupivacaine than in normal clinical use, < 10(-8) m, evoked Ca(2+) transients in astrocytes from rat cerebral cortex, that were inositol trisphosphate receptor-dependent. We investigated whether bupivacaine exerts an influence on the Ca(2+) signaling and interleukin-1β (IL-1β) secretion in inflammation-reactive astrocytes when used at ultralow concentrations, < 10(-8) m. Furthermore, we wanted to determine if bupivacaine interacts with the opioid-, 5-hydroxytryptamine- (5-HT) and glutamate-receptor systems. With respect to the μ-opioid- and 5-HT-receptor systems, bupivacaine restored the inflammation-reactive astrocytes to their normal non-inflammatory levels. With respect to the glutamate-receptor system, bupivacaine, in combination with an ultralow concentration of the μ-opioid receptor antagonist naloxone and μ-opioid receptor agonists, restored the inflammation-reactive astrocytes to their normal non-inflammatory levels. Ultralow concentrations of bupivacaine attenuated the inflammation-induced upregulation of IL-1β secretion. The results indicate that bupivacaine interacts with the opioid-, 5-HT- and glutamate-receptor systems by affecting Ca(2+) signaling and IL-1β release in inflammation-reactive astrocytes. These results suggest that bupivacaine may be used at ultralow concentrations as an anti-inflammatory drug, either alone or in combination with opioid agonists and ultralow concentrations of an opioid antagonist.
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Affiliation(s)
- Linda Block
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Balga I, Gerber H, Schorno X, Aebersold Keller F, Oehen HP. Bupivacaine crystal deposits after long-term epidural infusion. Anaesthesist 2013; 62:543-8. [DOI: 10.1007/s00101-013-2179-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 03/19/2013] [Accepted: 04/18/2013] [Indexed: 11/28/2022]
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Spinal analgesia for advanced cancer patients: An update. Crit Rev Oncol Hematol 2012; 82:227-32. [DOI: 10.1016/j.critrevonc.2011.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 04/21/2011] [Accepted: 05/19/2011] [Indexed: 11/15/2022] Open
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Upadhyay SP, Mallick PN. Intrathecal drug delivery system (IDDS) for cancer pain management: a review and updates. Am J Hosp Palliat Care 2011; 29:388-98. [PMID: 22089523 DOI: 10.1177/1049909111426134] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cancer pain remains undertreated and a significant number of patients with cancer pain die from severe untreated pain. With increasing survival rate in cancer, the prevalence of cancer pain is also increasing in number. Though majority of patients with cancer pain can be effectively treated with conventional medical management, still a significant portion of patients required some form of interventional pain management techniques. Among the interventional techniques, intrathecal drug delivery is increasingly used in cancer pain management. Our objective of this article is to review literatures and clinical studies on intrathecal drug delivery system (IDDS) in cancer pain management and to provide updates on its use, precautions, contraindications, side effects and its management, socioeconomic consideration, and management of IDDS in difficult or uncommon situations.
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Affiliation(s)
- Surjya Prasad Upadhyay
- Department of Anaesthesiology, Critical care and Pain management, Al Jahra Hospital, Ministry of Health, State of Kuwait, Kuwait.
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Veizi IE, Hayek SM, Narouze S, Pope JE, Mekhail N. Combination of Intrathecal Opioids with Bupivacaine Attenuates Opioid Dose Escalation in Chronic Noncancer Pain Patients. PAIN MEDICINE 2011; 12:1481-9. [DOI: 10.1111/j.1526-4637.2011.01232.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Measured Density and Calculated Baricity of Custom-Compounded Drugs for Chronic Intrathecal Infusion. Reg Anesth Pain Med 2011; 36:7-11. [DOI: 10.1097/aap.0b013e3181fe7f29] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goucke CR, Dusci LJ, Van Leeuwen S, Fairclough D, Ilett KF. Stability and Tolerability of High Concentrations of Intrathecal Bupivacaine and Opioid Mixtures in Chronic Noncancer Pain: An Open-Label Pilot Study. PAIN MEDICINE 2010; 11:1612-8. [DOI: 10.1111/j.1526-4637.2010.00958.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Medel R, Pouratian N, Elias WJ. Catheter-tip mass mimicking a spinal epidural hematoma. J Neurosurg Spine 2010; 12:66-71. [DOI: 10.3171/2009.7.spine08888] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As > 95,000 spinal drug-delivery devices have been implanted since their inception in the 1980s, the recognition of associated adverse effects is essential. Since 1985, numerous reports have described the presence of catheter-tip granulomas. In the current case, the authors describe a less frequent complication of epidural bupivacaine precipitation. Regardless of origin, these unusual lesions have been increasingly recognized as a rare but potentially devastating complication of intrathecal infusions.
A 34-year-old woman with an intrathecal pain-pump delivering fentanyl, bupivacaine, and clonidine for thoracic outlet syndrome presented with rapidly progressive neurological deficits and increasing neck and upper-extremity pain. Neuroimaging disclosed a C7–T1 mass that was thought to be a hematoma that occurred after a recent epidural steroid injection. On emergency surgical decompression by laminectomy, a chalky mass containing viscous fluid was identified surrounding an epidurally located catheter. Histopathological examination revealed a proteinaceous mass consistent with drug precipitate enveloped by fibrosis and mild inflammation. Postoperatively, the patient recovered with minimal neurological deficit. The presentation and clinical relevance are discussed in conjunction with a review of the pertinent literature.
Catheter-tip masses are a rare complication of implantable drug-delivery devices occurring in < 3% of all patients with intrathecal catheters. Regardless of the anatomical site, the most common presenting features are neurological deficits, worsening pain, and increasing requirements for pain medication. Expedient diagnosis and management are essential for physicians treating patients with spinal infusion devices to prevent significant neurological sequelae. Further investigation is warranted regarding the use of bupivacaine as an adjunct in permanent spinal infusion systems.
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Kumar K, Bodani V, Bishop S, Tracey S. Use of Intrathecal Bupivacaine in Refractory Chronic Nonmalignant Pain. PAIN MEDICINE 2009; 10:819-28. [DOI: 10.1111/j.1526-4637.2009.00640.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Compatibility and stability of binary mixtures of acetaminophen, nefopam, ketoprofen and ketamine in infusion solutions. Eur J Anaesthesiol 2009; 26:23-7. [DOI: 10.1097/eja.0b013e328319c04b] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bianchi F, Ginggen A, Tardy Y. Stability and compatibility of drug mixtures in an implantable infusion system. Anaesthesia 2008; 63:972-8. [DOI: 10.1111/j.1365-2044.2008.05516.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ghafoor VL, Epshteyn M, Carlson GH, Terhaar DM, Charry O, Phelps PK. Intrathecal drug therapy for long-term pain management. Am J Health Syst Pharm 2008; 64:2447-61. [PMID: 18029950 DOI: 10.2146/ajhp060204] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The use, safety, and efficacy of intrathecal medication administration with implantable pumps for cancer and chronic pain management are reviewed. SUMMARY Implanted intrathecal drug-delivery systems (IDDSs) are used for long-term management of persistent, severe pain despite a multimodal approach with conventional pain treatment options. Currently, consensus papers published in the literature are used as guidelines for determining patient selection and medication administration, because there is a lack of supporting evidence from randomized, controlled, clinical trials. Pharmacists have a critical role in the safe use of intrathecal medication. Most of the medication concentrations and combinations administered through IDDSs are not commercially available and therefore must be compounded in a pharmacy. Medications commonly administered through IDDSs include opioids, local anesthetics, clonidine, baclofen, and ziconotide. It is important for pharmacists who prepare products for IDDSs to understand the pharmacology, adverse effects, and concentration limitations of each medication in order to prevent adverse events related to postoperative subarachnoid hemorrhage, infection, catheter-tip inflammatory masses, withdrawal, and overdose. Pharmacists play an important role in maintaining quality assurance of intrathecal drug use, including the use of standard procedures for ordering and compounding medications, documentation of patient education, and monitoring of patient outcomes. CONCLUSION The use of long-term intrathecal drug delivery for the treatment of intractable pain or intolerable medication adverse effects has expanded to include the treatment of patients with chronic or cancer-related pain. Important considerations for the use of intrathecal drug therapy include the appropriate selection of patients, delivery systems, and medications, as well as potential complications of therapy and quality-assurance measures necessary to ensure patient safety.
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Affiliation(s)
- Virginia L Ghafoor
- Pain Management, Pharmacy Department, University of Minnesota Medical Center (UMMC), Minneapolis 55454, USA.
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Shields D, Montenegro R, Aclan J. Chemical Stability of an Admixture Combining Ziconotide and Bupivacaine During Simulated Intrathecal Administration. Neuromodulation 2007; 10 Suppl 1:1-5. [DOI: 10.1111/j.1525-1403.2007.00131.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Deer T, Krames ES, Hassenbusch SJ, Burton A, Caraway D, Dupen S, Eisenach J, Erdek M, Grigsby E, Kim P, Levy R, McDowell G, Mekhail N, Panchal S, Prager J, Rauck R, Saulino M, Sitzman T, Staats P, Stanton-Hicks M, Stearns L, Willis KD, Witt W, Follett K, Huntoon M, Liem L, Rathmell J, Wallace M, Buchser E, Cousins M, Ver Donck A. Polyanalgesic Consensus Conference 2007: Recommendations for the Management of Pain by Intrathecal (Intraspinal) Drug Delivery: Report of an Interdisciplinary Expert Panel. Neuromodulation 2007; 10:300-28. [DOI: 10.1111/j.1525-1403.2007.00128.x] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Turner JA, Sears JM, Loeser JD. Programmable intrathecal opioid delivery systems for chronic noncancer pain: a systematic review of effectiveness and complications. Clin J Pain 2007; 23:180-95. [PMID: 17237668 DOI: 10.1097/01.ajp.0000210955.93878.44] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We conducted a systematic review of the literature on the effectiveness and complications of programmable intrathecal opioid and ziconotide drug delivery systems (IDDS) for patients with chronic noncancer pain. METHODS We searched MEDLINE, Cochrane, and other bibliographic databases to identify English-language journal articles reporting programmable IDDS complications or effects on pain or functioning. Additional study methodology criteria were applied for the effectiveness review. Two authors independently abstracted data from each included article. RESULTS Six articles met the inclusion criteria for the effectiveness and complications reviews, and 4 others met the criteria only for the complications review; none were randomized trials or of ziconotide. All 6 articles reviewed for effectiveness reported improvement in pain and functioning on average among patients who received a permanent IDDS. Two articles reported the proportion of patients with > or =50% improvement in pain at 6 months (38%, 56%) and 2 at longer follow-ups (30%, 44%). Intrathecal morphine-equivalent doses increased over time. The most commonly reported permanent IDDS drug side effects were nausea/vomiting (mean rate weighted by sample size=33%), urinary retention (24%), and pruritus (26%). Catheter problems were also reported commonly. Rare but serious complications included intrathecal catheter tip granulomas. CONCLUSIONS The studies reviewed found improvement in pain and functioning on average among patients with chronic noncancer pain who received permanent IDDS. However, their methodologic limitations preclude conclusions concerning the effectiveness of this technology long-term and as compared with other treatments. Drug side effects and hardware complications were common. Suggestions are made for methodologic improvements in future studies.
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Affiliation(s)
- Judith A Turner
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA.
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Likar R, Ilias W, Kloimstein H, Kofler A, Kress HG, Neuhold J, Pinter MM, Spendel MC. Stellenwert der intrathekalen Schmerztherapie. Schmerz 2007; 21:15-8, 20-4, 26-7. [PMID: 17109113 DOI: 10.1007/s00482-006-0515-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intraspinal drug infusion using implantable pumps and catheter systems is a safe and effective therapy for selected pain patients with severe chronic pain. It improves pain relief, reduces drug-related side effects, decreases the need for oral analgesia and enhances quality of life in a segment of chronic pain patients whose pain has not been controlled with more conservative therapies. Intrathecal drug therapy has therefore established its role in the treatment of malignant pain, benign pain and severe spasticity.Careful patient selection and management as well as a multidisciplinary approach are determinants of successful treatment. Current practices for patient selection and management, screening, drug selection, dosing and implantation for intrathecal drug delivery systems are discussed.
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Affiliation(s)
- R Likar
- Landeskrankenhaus, Klagenfurt.
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Wadhwa RK, Shaya MR, Nanda A. Spinal Cord Compression in a Patient with a Pain Pump for Failed Back Syndrome: A Chalk-Like Precipitate Mimicking a Spinal Cord Neoplasm: Case Report. Neurosurgery 2006; 58:E387; discussion E387. [PMID: 16462469 DOI: 10.1227/01.neu.0000195070.41751.62] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE The use of intrathecal morphine has been effective with few complications for chronic intractable pain of both benign and malignant origins. A rare but serious problem that exists is the formation of an inflammatory mass at the catheter tip of the pain pump. CLINICAL PRESENTATION We report the case of a 67-year-old female patient with failed back syndrome who presented with sensory complaints and back pain. INTERVENTION Magnetic resonance imaging revealed impingement on the thoracic cord by a mass. The mass was originally thought to be a spinal cord tumor; however, operation and chemical analysis of the mass showed that it was a bupivacaine precipitate at the tip of the catheter of the pain pump. CONCLUSION This is the first such case, to our knowledge, of a bupivacaine precipitate mimicking a spinal cord tumor.
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Affiliation(s)
- Rishi K Wadhwa
- Department of Neurosurgery, Louisiana State University, Health Sciences Center, Shreveport 71130-3932, USA
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Classen AM, Wimbish GH, Kupiec TC. Stability of admixture containing morphine sulfate, bupivacaine hydrochloride, and clonidine hydrochloride in an implantable infusion system. J Pain Symptom Manage 2004; 28:603-11. [PMID: 15589086 DOI: 10.1016/j.jpainsymman.2004.04.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2004] [Indexed: 11/21/2022]
Abstract
Intrathecal infusion is often performed using drug combinations. This study was conducted to evaluate the stability of the admixture of morphine sulfate, bupivacaine hydrochloride, and clonidine hydrochloride when used in an implantable pump under simulated clinical use conditions. SynchroMed implantable pumps were filled with an admixture and incubated at 37 degrees C for a period of 90 days. Drug admixture stored in glass vials at 4 degrees C and at 37 degrees C served as controls. Samples which included pump reservoir and catheter delivered aliquots were collected every 30 days and analyzed for drug concentrations using a stability-indicating HPLC method. All drugs contained in the admixture were stable and the original concentrations remained greater than 96%. Over 90 days, and with the pump at the simulated body temperature of 37 degrees C, there were no evident heat catalyzed or device catalyzed reactions.
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Hassenbusch SJ, Portenoy RK, Cousins M, Buchser E, Deer TR, Du Pen SL, Eisenach J, Follett KA, Hildebrand KR, Krames ES, Levy RM, Palmer PP, Rathmell JP, Rauck RL, Staats PS, Stearns L, Willis KD. Polyanalgesic Consensus Conference 2003: an update on the management of pain by intraspinal drug delivery-- report of an expert panel. J Pain Symptom Manage 2004; 27:540-63. [PMID: 15165652 DOI: 10.1016/j.jpainsymman.2004.03.001] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2004] [Indexed: 11/19/2022]
Abstract
Intraspinal drug infusion using fully implantable pump and catheter systems is a safe and effective therapy for selected patients with chronic pain. The options for this approach are increasing, as drugs that are commercially available for systemic administration are adapted to this use and other drugs that are in development specifically for intraspinal administration become available. In 2000 a Polyanalgesic Consensus Conference was organized to evaluate the existing literature and develop guidelines for drug selection. The major outcome of this effort, an algorithm for drug selection, was based on the best available evidence at the time. Rapid changes have occurred in the science and practice of intraspinal infusion and a Polyanalgesic Consensus Conference 2003 was organized to pursue the following goals: 1) to review the literature on intraspinal drug infusion since 1999, 2) to revise the 2000 drug-selection algorithm, 3) to develop guidelines for optimizing drug dosage and concentration, 4) to create a process for documenting minimum evidence supporting the use of a drug for intraspinal infusion, and 5) to clarify issues pertaining to compounding of drugs. Based on the best available evidence and expert opinion, consensus recommendations were developed in all these areas. The panel's conclusions may provide a foundation for clinical practice and a rational basis for new research.
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Affiliation(s)
- Samuel J Hassenbusch
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, 77030, USA
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Hayek SM, Joseph PN, Mekhail NA. Pharmacology of intrathecally administered agents for treatment of spasticity and pain. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/j.spmd.2004.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Hildebrand KR, Elsberry DD, Hassenbusch SJ. Stability and compatibility of morphine-clonidine admixtures in an implantable infusion system. J Pain Symptom Manage 2003; 25:464-71. [PMID: 12727045 DOI: 10.1016/s0885-3924(03)00041-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Nonopioid analgesics are often coadministered with intrathecal morphine to increase efficacy. The purpose of this study was to evaluate stability and compatibility of morphine-clonidine admixtures with an implantable infusion system that is commonly used to treat pain patients. Infusion systems were filled with admixture and maintained at 37 degrees C for 90 days. Samples were collected monthly. Drug concentrations were determined using stability-indicating, high-performance liquid chromatography. For compatibility testing, individual materials comprising the fluid pathway of the device were immersed in clonidine solution and stored at 37 degrees C for various periods through 64 weeks and mechanical performance evaluated. After 3 months of containment in the infusion system, morphine and clonidine concentrations remained at > or = 94% of the theoretical starting concentrations. All device materials retained acceptable mechanical performance following clonidine exposure. These results demonstrate that morphine and clonidine are stable when combined in aqueous solution maintained at body temperature in an implantable infusion system for at least 3 months.
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