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Biomedical subjects

I Curelaru

Publications and source records attributed to I Curelaru.

At least 19 recordsLinked to original sources
PubMed1999

Clinical experience using intrathecal (IT) bupivacaine infusion in three patients with complex regional pain syndrome type I (CRPS-I).

BACKGROUND AND AIM: To date, there is no reliable method for treating the severe pain and for modifying the natural evolution of CRPS-I. Therefore, we explored the effect of long-term IT bupivacaine infusion (with or without buprenorphine) on this syndrome. PATIENTS AND METHODS: (a) PATIENTS: two women and one man, 25, 31 and 42 years old, with CRPS-I of the lower (n=2) or upper (n=1) extremity lasting for 4 and 5 months, and 14 years. (b) INTERVENTIONS: insertion of externalized IT catheters; IT infusion of buprenorphine 0.015 mg/ml and bupivacaine 4.75 mg/ml (n=1), or only bupivacaine 5 mg/ml (n=2) from external electronic pumps. RESULTS: The IT treatment lasted for 172, 282 and 668 days. The mean/maximal daily doses of the IT bupivacaine were 39/66, 55/80 and 69/125 mg, respectively. The pain intensity decreased from VASmean =7+/-1 to VASmean =2+/-2. None of the patients had regression of allodynia, edema, and trophic disturbances in the affected extremities. In 2 patients, the IT treatment did not prevent spread of the disease to the opposite extremity or the occurrence of phantom pain and stump allodynia after amputation. The IT catheters were withdrawn as being no longer needed: in 2 patients 56 and 458 days after amputation of the involved extremity, and in another one before replacement of the IT bupivacaine infusion with epidural dorsal column stimulation (EDCS). After termination of the IT treatment, the patients were observed for 1437, 1575, and 2689 days (until September 1, 1998). At that date, all the patients were alive, and still affected by their CRPS-I, either in the amputation stump (n=2), and/or in the opposite or remote extremities (n=2); further, two were unemployed and one worked for 75% of the time. One of them was taking up to 1500 mg of slow-release morphine to cope with pain. CONCLUSION: The IT pain treatment with bupivacaine (with or without buprenorphine) alleviated the "refractory" pain, but affected neither the associated symptoms and signs of the CRPS-I, nor its natural evolution. Thus, the IT treatment cannot be recommended in preference to other pain treatment regimens for CRPS-I.

Adult↗
PubMed1998

[Severe pain relief with intrathecal infusion. The patient controls, treatment can be provided at home].

Intrathecal administration of an opioid such as morphine in combination with a local anaesthetic such as bupivacaine is an effective treatment for severe cancer pain. The treatment, which can often be made available in the patient's home, provides relief from pain without unwanted sedation, when high-dose oral or parenteral morphine no longer has any effect. The patient controls the treatment, and can achieve a balance between pain relief and side-effects. The article outlines the routines established at the pain unit at Sahlgrenska Hospital in Gothenburg.

Analgesia, Patient-Controlled↗
PubMed1998

Long-term intrathecal (i.t.) infusion of bupivacaine relieved intractable pain and spasticity in a patient with multiple sclerosis.

There is no reliable method to relieve both 'refractory' pain and spasticity in patients with multiple sclerosis (MS). This paper reports on the long-term use of continuous intrathecal bupivacaine infusion in such a patient. The patient under study was a 56-year-old woman affected for 18 years by MS, unsuccessfully treated with analgesics, baclofen, opioids, peripheral neurolysis (obturator nerves, lumbar plexus) and six intrathecal neurolyses of the L4-S3 nerve roots, each time with 1.5 ml of 50% phenol in glycerol. Intrathecal baclofen was not considered (MS with bulbar location and neurogenic pains). An intrathecal catheter was inserted via the L3-L4 interspace and its tip was placed at the height of the T12-L1 intervertebral disc. An intrathecal infusion of 0.5% bupivacaine at a rate of 3 ml (=15 mg)/day was started. The infusion rate was gradually increased from 20 mg on the first day to 95 mg/day after 68 days. The pain intensity decreased from a mean visual analogue score (VAS(mean)) of 7 before treatment to 1 (on a 0-10 scale) during the intrathecal treatment. The patient became free from pain and spasticity. No side-effects or complications were recorded. The treatment was given for 712 days, at which point the patient died (unrelated to the treatment). Intrathecal infusion of bupivacaine relieved 'refractory' spasticity and pain in a MS patient in whom administration of intrathecal baclofen was contraindicated and neurodestructive procedures had been inefficient. Copyright 1998 European Federation of Chapters of the International Association for the Study of Pain.

Journal Article↗
PubMed1998

Efficacy and technical complications of long-term continuous intraspinal infusions of opioid and/or bupivacaine in refractory nonmalignant pain: a comparison between the epidural and the intrathecal approach with externalized or implanted catheters and infusion pumps.

OBJECTIVE: To compare efficacies, failure rates, and technical complication rates of intraspinal treatments in patients with "refractory" nonmalignant pain conditions in relation to the approach (epidural/intrathecal), the drug (opioid/opioid-bupivacaine or bupivacaine), and the type of system used (externalized/internalized). In these comparisons, recent data from a companion paper (Nitescu et al., Clin J Pain 1998;14:17-28) were used as a reference to be compared with data from a literature review of different intraspinal treatment modalities in nonmalignant pain. DESIGN: Prospective, cohort, nonrandomized, consecutive trial. SETTING: Tertiary care center, institutional practice, hospitalized, and ambulatory care. PATIENTS: Five groups according to treatment modality: (a) externalized, long-term intrathecal nylon catheters, connected to external, electronic infusion pumps (companion paper), n = 90; (b) internalized, long-term intrathecal catheters (Silastic) connected to implanted SynchroMed pumps, n = 330 (literature review); (c) externalized, "short-term" epidural catheters for "temporary" infusions, n = 565 (literature review); (d) externalized, long-term epidural catheters, n = 50 (literature review); (e) internalized, long-term epidural catheters, n = 111, connected to implanted systems: Port-A-Cath injection ports, n = 58; Infusaid pumps, n = 46; and SynchroMed pumps, n = 7 (literature review). INTERVENTIONS: In reviewing the literature, we found 21 studies that reported on the intraspinal (epidural or intrathecal) administration of opioids with or without local anesthetics (usually bupivacaine). These studies were analyzed with respect to the rates of the variables satisfactory pain relief (efficacy), failures, and technical complications. A rate is the number of observations of a variable divided by the number of patients or the number of catheters or infusion systems, as logically indicated (e.g., the numbers of complications, such as epidural abscess and meningitis, were related to the number of patients and those of catheter occlusion or leakage to the number of the catheters). The variables were expressed as the means of the rates of a variable from studies belonging to various treatment modalities: approach (epidural vs. intrathecal), duration (short vs. long term), drugs administered intraspinally (opioid vs. opioid and/or local anesthetic), and type of infusion system (externalized vs. internalized). Further, the sums of all observations of one variable in different studies with various treatment modalities were related to the corresponding sums of the patients (alternatively, catheters or implanted devices). The proportions of these sums were tested for significance in relation to treatment modality. MAIN OUTCOME MEASURES: Comparative rates of successful intraspinal treatment and its failures and complications. RESULTS: (a) The intrathecal approach, compared with the epidural approach, was associated with higher rates of satisfactory pain relief for both externalized (86/90, 95% vs. 17/40, 42.5%, p < .0001) and internalized (295/336, 89% vs. 33/56, 59%, p < .0001) catheters; higher rates of treatment failures with externalized epidural catheters than with internalized intrathecal catheters (24/47, 51%, vs. 36/338, 11%, p < .0001); lower rates of treatment failures with internalized intrathecal catheters than with internalized epidural catheters (36/338, 11% vs. 29/76, 38%, p < .0001); higher rates of system replacement with internalized epidural catheters than with internalized intrathecal catheters (23/32, 72% vs. 6/49, 12%, p < .0001; higher rates of system removal with internalized epidural catheters than with internalized intrathecal catheters (22/49, 45% vs. 5/49, 10%, p < .001); higher rates of catheter-related complications with epidural than with intrathecal catheters (dislodgement 13/126, approximately 10% vs. 6/150, 4%, p < .05; leakage 5/51, approximately 10% vs. 1/116, 0.9%, p < .05; obstruction 2

Anesthetics, Local↗
PubMed1998

Continuous infusion of opioid and bupivacaine by externalized intrathecal catheters in long-term treatment of "refractory" nonmalignant pain.

OBJECTIVE: To explore the possibility of obtaining pain relief by continuous intrathecal infusion of bupivacaine and opioid in patients with intractable nonmalignant pain. DESIGN: Prospective, cohort, nonrandomized, consecutive trial. SETTING: Tertiary care center, institutional practice, hospitalized, and ambulatory care. PATIENTS: A total of 90 patients, 40 men and 50 women, 20 to 96 years old (median, 70 years), with various nonmalignant "refractory" pain conditions lasting for 0.3 to 50 years (median, 3 years) with nociceptive (n = 9), neurogenic/neuropathic (n = 17), and mixed pain (n = 64) were consecutively included in the study when (a) the pain dominated their lives totally, (b) other methods failed to provide acceptable pain relief, and (c) unacceptable side effects from opioids had occurred. Moribund patients and those with overt psychoses at the time of the assessment were excluded from the study. INTERVENTIONS: (a) Insertion of externalized, tunnelled intrathecal catheters (101 in 90 patients). (b) Intrathecal infusion of opioid (morphine 0.5 mg/ml, or buprenorphine 0.015 mg/ml, and/or bupivacaine 4.75-5.0 mg/ml) from external electronic pumps was started in the operating room at a basic rate of 0.2 ml/hour, with optional bolus doses (0.1 ml 1-4 times/hour) by patient-controlled analgesia (PCA). Thereafter, the daily volumes were tailored to give the patients satisfactory to excellent (60-100%) pain relief, with acceptable side effects from the infused drugs, by increase or decrease of the basic rates and/or of the bolus doses, and their timing. (c) Supervision of the patients for 24 hours after catheterization in the postoperative ward. (d) Daily phone contact with the patients, their families, or the nurses in charge. (e) The patients had ad libitum access to nonopioid analgesics/sedatives and to opioids administered by various routes, until they obtained satisfactory pain and anxiolytic relief. MAIN OUTCOME MEASURES: (a) Pain intensity (visual analog scores 0-10) and pain relief (0-100%). (b) Daily dosages (opioid administered by intrathecal and other routes, and intrathecal bupivacaine). (c) Scores (0-5) of nonopioid analgesics, gait and ambulation, duration of nocturnal sleep, and (d) rates of adverse effects. RESULTS: During the intrathecal period [range, 3-1,706 days; median, 60 days; totaling 14,686 days, 7,460 (50% of which were spent at home)], 86 patients (approximately 95%) obtained acceptable (60-100%) pain relief. The nocturnal sleep duration increased from <4 to 7 hours (median values), nonopioid analgesic and sedative daily consumption became approximately two times lower, whereas the gait ability and ambulation patterns remained practically unchanged. Five patients still had ongoing treatment after durations of 30 to 1,707 (median, 206) days at the close of the study. In the remaining 85 patients, the intrathecal treatment was terminated because of patients' death (n = 23), replacement of the intrathecal treatment by dorsal column stimulation (n = 1), pain resolution (n = 32), refusal to continue the intrathecal treatment (n = 19), lack of cooperation due to delirium or to manipulation of the pump (n = 8), and loss of efficacy of the intrathecal treatment (n = 2). Thus, in the long run, the intrathecal treatment failed in 29 of the 85 patients with terminated treatment (34%). The principal side-effects and complications, except those attributed to the dural puncture, the equipment, and the long-term catheterization of the subarachnoid space, which are presented separately, were severe bradypnea (n = 1), transient paresthesiae (n = 26), short-lasting pareses (n = 16), temporary urine retention (n = 34), episodic orthostatic arterial hypotension (n = 11), and attempted suicide (n = 5, 3 of which were successful). No neurologic sequelae or death could be attributed to the intrathecal procedure. (ABSTRACT TRUNCATED)

Activities of Daily Living↗
PubMed1998

High thoracic/low cervical, long-term intrathecal (i.t.) infusion of bupivacaine alleviates "refractory" pain in patients with unstable angina pectoris. Report of 2 cases.

BACKGROUND: There is no reliable treatment for "refractory" pain from unstable angina pectoris (UAP) when epidural infusion of bupivacaine has failed to relieve it. In two such cases we explored the potential of intrathecal (i.t.) bupivacaine infusion to provide pain relief. PATIENTS AND METHODS: Two female patients, 70 and 67 years. An 18-G nylon catheter was inserted intrathecally through a 17-G Tuohy needle via the T2-T3 interspace and its tip located at the height of C6-C7 vertebrae. The catheter was connected to a portable, programmable electronic pump filled with bupivacaine 5 mg/ml. The infusion started at rates of 0.1-0.2 ml/h, with optional bolus doses of 0.1-0.2 ml, 4-2 times/h, respectively, by PCA (Patients-Controlled Analgesia), and then adjusted to give the patients satisfactory (80%-100%) pain relief. RESULTS: Pain relief was obtained with doses of i.t.-bupivacaine ranging from 17 to 45 (mean = 25) mg/d. The pain intensity decreased from VAS (Visual Analogue Score) 9-10 to 0-2 out of 10. The nocturnal sleep improved from 2-4 to 6-7 h. The patients could now ambulate, walking or in a wheel-chair. The i.t.-treatment lasted 700 and 437 d, of which 540 and 343 d (respectively) were spent at home, and was terminated by: (a) the patient's death due to intracranial bleeding (1st case); (b) progressive aggravation of the unstable angina that could not be fully countered by increasing the bupivacaine dose above 1.0 mg/h due to occurrence of cerebral transient ischemic attacks, usually not correlated with orthostatic arterial hypotension but apparently facilitated by microembolization of the cerebral arteries (2nd case). CONCLUSION: I.t.-bupivacaine infusion may alleviate "refractory" pain in patients with unstable angina pectoris when epidural bupivacaine failed to do so. Its use is apparently limited by the IT-bupivacaine critical dosage (in these patients = 1.0-1.5 mg/h).

Aged↗
PubMed1997

Spinal epidural metastasis: implications for spinal analgesia to treat "refractory" cancer pain.

Two hundred one consecutive patients with cancer pain who received intrathecal pain treatment between 1985 and 1993 were included in this retrospective study undertaken to test the hypothesis that epidural metastasis is a common cause of "refractory" cancer pain and that its presence may affect the efficacy and the complication rates of intraspinal pain treatment. Fifty-seven (approximately 28%) patients were investigated by metrizamide myelography, computerized tomography (CT), magnetic resonance imaging (MRI), laminectomy, or neurohistopathology. Epidural metastases were found in 40 (70%) and spinal stenosis in 33 (approximately 58%); 7 patients with total and 26 with partial occlusion of the spinal canal. Presence of epidural metastasis affected catheter insertion complications, daily dosages, and complications of the intrathecal pain treatment only when it was associated with spinal canal stenosis (partial or total). During the period of the intrathecal treatment, the patients with confirmed epidural metastasis and total spinal canal stenosis needed significantly (P < 0.05) higher daily doses of opioid (means = 77 +/- 103 versus 22 +/- 29 mg) and intrathecal bupivacaine (means = 65 +/- 44 versus 33 +/- 20 mg) and had significantly (P < 0.05) higher rates (14% versus 0%) of radicular pain at injection and poor distribution of analgesia than those without epidural metastasis and spinal canal stenosis. In contrast, the rate of occurrence of post-dural puncture headache was significantly (P < 0.05) lower in patients with partial (4%) and total (14%) spinal stenosis than in those without (29%). Unexpected paraplegia occurred in four patients and was due to accidental injury during attempted dural puncture (N = 1) and collapse (due to cerebrospinal fluid leakage leading to "medullary coning" of an unknown epidural metastasis (N = 3).

Adolescent↗
PubMed1996

Continuous intracisternal and high cervical intrathecal bupivacaine analgesia in refractory head and neck pain.

BACKGROUND: The upper cervical component of the spinomesencephalic tract and cranial nerves V, VII (nervus intermedius), IX, and X are involved in mechanisms of acute and chronic pain from head and neck structures. To date there is no reliable method for relief of refractory pain (i.e., pain that cannot be relieved by conventional pharmacologic therapies) from these structures. Therefore, we explored continuous intracisternal infusion of bupivacaine for the treatment of refractory pain of the head and neck. METHODS: Intracisternal catheters were inserted in 13 adults with refractory nonmalignant (n = 4) and malignant (n = 9) pain from the head, face, mouth, neck, and upper extremities; 0.5% plain bupivacaine was infused continuously at rates of 1-7 (median 1.5) mg/h with optional bolus doses of 0.5-2.0 mg 4-2 times/h. The efficacy was assessed from pain relief (daily VAS(max), VAS(min), and VAS(mean) scores 0-10), daily doses of intracisternal bupivacaine and total opioid (expressed as mg parenteral morphine-eq), amount of nocturnal sleep, and rates of adverse effects. RESULTS: The 13 patients were treated for 3-182 days (median 37, total 712 days), 3 patients being treated at home for 10-112 days (median 88, total 210 days). In one patient, the efficacy of the treatment could not be estimated because of advanced senility. Eleven of the remaining 12 patients obtained acceptable pain relief with daily doses of intracisternal bupivacaine ranging from 20 to 118 mg (median 37 mg): VAS(mean) scores decreased from 7 to 2, mean pain relief increased for 30% to 80%, total opioid daily dose decreased from 53 to 36 mg parenteral morphine-eq, and nocturnal sleep increased from 2 to >6h (all figures are median values). Speech, eating, walking, and natural functions were generally not affected. Side effects such as tiredness and malaise, somnolence and sleep, feeling of coldness in the neck and skull base, transient post-spinal puncture headache, paresthesias, hoarseness, dysphagia, transient paresis of the upper/lower extremities, episodic miosis and conjunctival hyperemia, and transient orthostatic arterial hypotension were each observed in one or two patients. No patient presented clinical evidence of phrenic nerve paralysis. There was no nausea or vomiting. No persistent neurologic deficit or death could be attributed to the intracisternal pain treatment. CONCLUSIONS: Continuous intracisternal infusion of bupivacaine may be a useful method in exceptional, well selected patients with refractory pain from the head and neck structures. Further studies are necessary to establish the indications and the safety of the method.

Adult↗
PubMed1995

Complications of intrathecal opioids and bupivacaine in the treatment of "refractory" cancer pain.

OBJECTIVE: To test the concept that externalized tunneled intrathecal catheters lead to a high risk of complications, such as meningitis and epidural abscess, and therefore should not be used for durations of intrathecal pain treatment of > 1 week. DESIGN: Prospective, cohort, nonrandomized, consecutive, historical control trial. SETTING: Tertiary care center, institutional practice, hospitalized and ambulatory care. PATIENTS: Two hundred adults (107 women, 93 men) with refractory cancer pain treated for 1-575 (median, 33; total, 14,485) days; 79 patients were treated at home for 2-226 (median, 36; total, 4,711) days. All patients had died by the close of the study. INTERVENTIONS: Insertion of intrathecal tunneled nylon (Portex) catheters (223 in 200 patients) with Millipore filters. The catheter hubs were securely fixed to the skin with steel sutures. Standardized care after insertion: (a) daily phone contact with the patients, their families, or the nurses in charge; (b) weekly dressing change at the tunnel outlet by the nurses; (c) refilling of the infusion containers by the nurses; (d) exchange of the infusion systems when empty (within 1 month) and of the antibacterial filter once a month by specially instructed Pain Department nurses. All contact between the connections of the syringes, cassettes, and needles with the operator's hands was carefully avoided during filling and refilling of the infusion containers and exchange of the antibacterial filters; no other aseptic precautions were taken. MAIN OUTCOME MEASURES: We recorded the rates of perfect function and complications of the systems. The rates of complications recorded in this study with externalized tunneled intrathecal catheters are discussed and compared with the rates reported in the literature with externalized (tunneled and non-tunneled) epidural and intrathecal catheters, as well as with internalized (both epidural and intrathecal) catheters connected to subcutaneous ports, reservoirs, and pumps. RESULTS: The following rates (as a percentage of number of patients) of perfect function and complications of the systems were recorded (the ranges of rates reported in the literature are given in parentheses): perfect function of the system, 93% (31-90%); accidental injury of an unknown epidural tumor followed by an epidural hematoma, 0.5% (0-6%); skin breakdown at the insertion site, 2% (2-50%); postdural puncture headache, 15.5% (10%); external leakage of CSF, 3.5% (4-27%); CSF hygroma ("pseudomeningocele"), 1.5% (4-6.25%); hearing loss and Ménière-like syndrome, 0% (12%); pain on injection, 0% with continuous infusion and 4.5% with intermittent injections (3-36% with intermittent injections); catheter tip dislodgement, 1.5% (6-33%); catheter (system) occlusion, 1% (3-12%); accidental catheter withdrawal, 4% (3-22%); catheter (system) leakage, 1.5% (2.1-26.6%); all mechanical complications, 8.5% (10-44%); local (catheter entry site) infection, 0.5% (2-33%); catheter track infection, 0% (6-25%); epidural abscess, 0% (0.6-25%); meningitis, 0.5% (1-25%); systemic infection, 0% (3%); incidence of all infections (n/treatment days), 1/7,242 (1/168-1/2,446). CONCLUSIONS: In our population and with the technique of insertion and care reported here, the use of externalized tunneled intrathecal catheters has not been associated with higher rates of complications when compared with earlier reported rates of externalized epidural catheters and internalized (both epidural and intrathecal) catheters connected to subcutaneously implanted ports, reservoirs, and pumps. The opinion that the use of externalized tunneled intrathecal catheters should be restricted only to patients who need pain treatment for < 1 week (because of the potential risk of infection, particularly meningitis and epidural abscess) is unfounded.

Adolescent↗
PubMed1994

Long-term intrathecal morphine and bupivacaine in patients with refractory cancer pain. Results from a morphine:bupivacaine dose regimen of 0.5:4.75 mg/ml.

BACKGROUND: There are no clinical data regarding the ratios and concentrations in which morphine and bupivacaine should be combined, when given intrathecally, to improve analgesia while decreasing adverse effects. This study was undertaken to test the clinical efficacy of a constant infusion of 0.5 mg/ml morphine plus 4.75 mg/ml bupivacaine (morphine: bupivacaine approximately 1:10), given through open intrathecal catheters. METHODS: In 53 patients, the clinical efficacy was estimated from: pain relief (visual analog scale scores 0-10); daily dosages (intrathecal and total opioid and intrathecal bupivacaine); scores (0-5) of nonopioid analgesic and sedative consumption, gait and daily activity, and amount of sleep; and rates of adverse effects. RESULTS: During the intrathecal period (7-334, median 29 days), all 53 patients obtained acceptable pain relief (visual analog scale scores 0-2 vs. 6-10 in the pre-intrathecal stage). The total opioid daily consumption decreased (median 10 vs. 120 mg), the sleep was about two times longer, the nonopioid analgesic and sedative consumption about two times lower, and the gait ability pattern was unchanged. The daily dose of intrathecal morphine (median 6 mg) and the daily intrathecal volumes (median 10 ml) were low, whereas the daily dose of intrathecal bupivacaine was relatively high (median 50 mg). Side effects potentially related to intrathecal morphine (seizures, cerebral, and spinal clonus) were not recorded. Side effects attributable to intrathecal bupivacaine (in patients not having these complications before the intrathecal treatment) occurred in the forms of late urinary retention (9 of 27), paresthesias (11 of 27), paresis/gait impairment (9 of 27), and occasional episodes of orthostatic arterial hypotension (1 of 53 patients). CONCLUSIONS: A constant intrathecal infusion with a morphine:bupivacaine ratio of approximately 1:10 and concentrations of morphine of 0.5 mg/ml and bupivacaine of 4.75 mg/ml may significantly improve the relief of refractory cancer pain with a certain risk of adverse effects (which should be balanced against pain by the patient) from the relatively high intrathecal bupivacaine doses and concentration.

Adult↗
PubMed1992

Neuropathologic findings after long-term intrathecal infusion of morphine and bupivacaine for pain treatment in cancer patients.

Epidural or intrathecal infusions of morphine and bupivacaine mixtures are presently used for the treatment of "refractory" cancer pain even though the neurotoxic potential of such mixtures is unknown. The pathologic findings of the spinal column, the meninges, the nerve roots, and the spinal cord, and the clinical neurologic deficits were recorded in 15 patients (5 men and 10 women), aged 26-83 (median 68) yr, treated for 4-274 (median 81) days with intrathecal infusions of morphine (with preservatives [sodium metabisulfite and sodium edetate]) and bupivacaine mixtures, given through open, subcutaneously tunneled nylon catheters. Six patients had been subjected to radiation therapy (20-96 Gy), applied over the spinal column, and four had been treated with antineoplastics believed to be neurotoxic. Ten patients had various neurologic deficits before the intrathecal treatment. The cumulative doses (ranges) given intrathecally were: morphine 33-11,900 mg, sodium metabisulfite 3.3-1,050 mg, sodium edetate 0.33-105 mg, and bupivacaine 10-41,400 mg; cumulative volumes were 16-9,400 ml. The concentrations of the drugs in the mixtures were: morphine 0.25-4.0 mg/ml, sodium metabisulfite 0.025-0.40 mg/ml, sodium edetate 0.0025-0.04 mg/ml, and bupivacaine 3.0-4.75 mg/ml. The osmolality of the mixtures in vitro ranged from 282 to 286 mOsm/kg and the pH from 4.1 to 4.6. The pathologic findings consisted of vertebral metastases (n = 6), epidural and/or intrathecal tumor masses (n = 8), focal subdural fibrosis (n = 6), infiltration of mononuclear cells in the subarachnoid space (n = 10), and discrete injuries (nerve fiber degeneration or fibrosis) to the anterior (five patients) and posterior (seven) nerve roots, and spinal cord (tumor compression [one], slight thickening of the leptomeninges [one], and thrombosis of a spinal artery and medullary infarction [one]). In none of the cases was any reaction against the nylon catheter within its subarachnoid course recorded. The neuropathologic findings were not related to the duration or cumulative doses of the intrathecal treatment. No new neurologic deficits that could be attributed to the intrathecal administration of the opiate-bupivacaine mixtures were recorded. The neuropathologic and clinical neurologic findings in cancer patients treated with intrathecal morphine-bupivacaine mixtures appeared similar to those in animals and humans reported with either intrathecal morphine or bupivacaine alone.

Adult↗
PubMed1992

Bacteriology, drug stability and exchange of percutaneous delivery systems and antibacterial filters in long-term intrathecal infusion of opioid drugs and bupivacaine in "refractory" pain.

OBJECTIVE: To provide a basis for recommendations on the exchange of containers (syringes and cassettes) and antibacterial filters, and for choice of administration device in patients with "refractory" pain treated with long-term percutaneous intrathecal (IT) infusions of opioid (morphine or buprenorphine) and bupivacaine mixtures. DESIGN: Prospective, cohort, nonrandomized control trial-case series, with consecutive sample, no standard criterion, and cost-benefit analysis. SETTING: Tertiary care center, institutional practice as well as hospitalized and ambulatory care. PATIENTS: Eighty-nine (51 women and 38 men); 81 with malignant pain and 8 with benign "refractory" pain. INTERVENTIONS: (a) The chemical stability of the drugs in the containers during 30 days. (b) The results of bacteriologic culture of the residual volumes of the analgesic mixtures from used and reused (1-16 times) syringes (n = 135) and cassettes (n = 258), and of 5 ml of sterile isotonic saline filtered through the used Millipore filters (n = 149). The bacteriologic samples from the 89 patients were taken after 1-40 (median = 7), 1-86 (median = 20), and 5-78 (median = 31) days of IT treatment, respectively. MAIN OUTCOME MEASURES: Chemical stability: buprenorphine and bupivacaine concentrations-liquid chromatography; morphine concentrations--gas chromatography. Bacteriologic cultures: standard laboratory procedures. The hypothesis (repeated use of the infusion systems and their exchange once a month does not significantly affect drug concentrations or increase the infection risk) was elaborated before data collection began. RESULTS: The bupivacaine-opioid mixtures were found to be chemically stable within 3-10% of the original doses up to 30 days. Seventeen cultures (from five syringes, six cassettes, and six filters) in 13 patients (having no signs of meningeal infection) were found to be colonized with Staphylococcus aureus (n = 4), coagulase negative staphylococci (n = 7), viridans streptococci (n = 3), Neisseria sp (n = 4), Corynebacterium sp (n = 4), Enterobacter sp (n = 2), Klebsiella sp (n = 3), gram-negative bacilli (n = 1), and yeasts (n = 2). The place of IT treatment, its duration, and patient-related infection risk factors (age; malignancy; diabetes; presence of a colostomy, pyelostomy, or indwelling urinary catheter; and the presence and location of infection foci) were not related to the results of the cultures. However, 9 of the 17 positive cultures came from patients with skin ulcers, a notable incidence. The positive cultures had no connection with the cultured item, its in-use duration, the number of times of reuse, the analgesic drugs used, their concentrations or the presence of preservatives (sodium metabisulfite and sodium edetate), or the antiseptic agent (70% ethanol or 0.5% chlorhexidine gluconate) used during bacteriologic sampling. The bacterial growth was sparse in 14 and massive in 3 of the 17 positive cultures. One item (filter) from one patient with meningitis was sterile. CONCLUSIONS: In our population, exchange of the infusion systems when they are empty (within 1 month) and of the antibacterial filters once a month does not appear to affect the concentrations of, or increase the infection risk from, the opioid-bupivacaine mixtures. The risk of bacterial contamination/colonization of the syringes from syringe drivers does not seem to be higher than that of cassettes from external portable pumps.

Adolescent↗
PubMed1991

Long-term, open catheterization of the spinal subarachnoid space for continuous infusion of narcotic and bupivacaine in patients with "refractory" cancer pain. A technique of catheterization and its problems and complications.

The technique of long-term, open catheterization of the spinal subarachnoid space for infusion of analgesics in patients with refractory cancer pain is sparsely reported in the literature. We report on a technique using 18G Portex nylon catheters and 16G-17G Tuohy needles, and its problems and complications. One hundred fifty-seven catheters were inserted in 142 patients, in most of them (79%) under deep sedation and local anesthesia. Attempts were made to place the catheter tip as close to the painful segments as possible. The catheters were tunneled subcutaneously (87% of them paravertebrally, over the shoulder, and further parasternally to the third chondrocostal cartilage). The Luer connections of the catheters were fixed to the patients' skin with monofilament steel sutures of dimension 0 and connected to a bacterial filter. At the end of the procedure, 10 ml isotonic saline was injected intrathecally to prevent postspinal puncture headache. Absorbent and impermeable dressings were applied over the tunnel exit, catheter Luer connection and bacterial filter. Antibiotics were given on the day of insertion and 2 days thereafter. During the insertion procedure, the following problems and complications were encountered; two or more attempts before successful spinal-dural puncture (32%), accidental puncture of an extradural vessel (10%), difficult dural puncture (18%), absence of free dripping of cerebrospinal fluid (CSF) in spite of successful dural puncture (4%), blood-stained CSF (9%), radicular pain and paresthesiae (4%), difficult advancement of the catheter (6%), difficult tunneling (11%), and bleeding in the tunnel (0.7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

Long-term intrathecal morphine and bupivacaine in "refractory" cancer pain. I. Results from the first series of 52 patients.

Neither epidural (EDA) or intrathecal (IT) morphine nor EDA opiate + bupivacaine provides acceptable relief of some types of cancer pain, e.g. pain originating from mucocutaneous ulcers, deafferentation pain, continuous and intermittent visceral and ischaemic pain, and that occurring with body movement as a result of a fracture. To improve pain relief in such conditions, we gave combinations of morphine and bupivacaine through open IT-catheters to 52 patients with "refractory", severe (VAS 7-10 out of 10), complex cancer pain (Edmonton Stage-3), for periods of 1-305 (median = 23) days. The efficacy of the treatment was estimated from: 1) daily dosage (intraspinal and total opiates, and intraspinal bupivacaine), and 2) scores of non-opiate analgesic and sedative consumption, gait and daily activities, and amount and pattern of sleep. Forty-four patients obtained continuous and acceptable pain relief (VAS 0-2), 26 of them with daily doses of IT-bupivacaine of less than or equal to 30 mg/day (less than or equal to 1.5 mg/h). Higher IT-bupivacaine doses (greater than 60-305 mg/day), not always giving acceptable pain relief, were necessary in 13 patients with deafferentation pain from the spinal cord or brachial or lumbosacral plexuses or pain from the coeliac plexus, or from large, ulcerated mucocutaneous tumours. By combining IT-bupivacaine with IT-morphine, it was possible to use relatively low IT-morphine doses (10-25 mg/day during the first 2 months of treatment) in more than half of the patients. The IT-treatment significantly decreased the total (all routes) opiate consumption and significantly improved sleep, gait and daily activities. For the whole period of observation (6 months), the IT-treatment was assessed as adequate in 3.8%, good in 23.1%, very good in 59.6% and excellent in 13.5% of the cases. Adverse effects of the IT-bupivacaine (paraesthesiae, paresis, gait impairment, urinary retention, anal sphincter disturbances and orthostatic hypotension) did not occur with doses of 2.5-3.0 mg/h (approx. 60-70 mg/day).

Adult↗
PubMed1991

Penetration forces in cannulation of the dorsal veins of the hand: I. A comparison between polyurethane (Insyte) and polytetrafluoroethylene (Venflon) cannulae. Results of a study in volunteers compared with those from an in vitro study.

UNLABELLED: The functional tip tapering design of peripheral venous cannulae (introducer steel needle + catheter) made of polyurethane (PUR-Instye) and polytetrafluoroethylene (PTFE-Venflon) was studied with 3 techniques: A) Scanning electron microscopy (SEM). B) Measurement of penetration forces in vitro through latex membranes and lamb skins with a tensile-compression apparatus (Instron-1122) at 1) the introducer steel-needle point, 2) the needle heel (the spot marking the passage from the point of the needle to its shaft). 3) the catheter top (i.e. the beginning of the plastic sheath), 4) the catheter tip, i.e. the beginning of the largest diameter of the plastic sheath, and 5) between the catheter tip and its hub (catheter friction). C) Two cannulae (one of each type for every subject were inserted at random into the dorsal veins of the left and right hand in 37 volunteers, and the penetration forces were measured with a force transducer. RESULTS: A) The PUR-cannulae had a lancet-like appearance and a smoother transition at the catheter top, whilst the PTFE cannulae were arrow-like, cut back and had a less accentuated conical design. B) Penetration forces in vitro through latex membranes were 9-41 times lower (P less than 0.0001) than those through the large skins. The highest forces (mean +/- s.d.) registered in vitro (lamb skins) were 4.1 +/- 0.2 Newtons (N) with PUR-cannulae at the catheter tip, and 3.4 +/- 0.6 with the PTFE-cannulae at the catheter top (P less than 0.05). C).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

Epidural versus intrathecal morphine-bupivacaine: assessment of consecutive treatments in advanced cancer pain.

Twenty-five patients with multifocal and multitype (somatic, visceral, and neurogenic) advanced cancer pain who experienced severe pain despite extradural (ED) morphine and bupivacaine were converted to intrathecal (IT) morphine and bupivacaine. The consecutive ED and IT periods (2-174 days, median = 50 days, and 1-305 days, median = 37 days, respectively) were assessed in clinical terms (daily analgesic dosages giving acceptable pain relief and quality of life expressed as sleeping hours and walking/daily activities). With the IT treatment, the total (all routes) opiate consumption and the daily doses of spinal morphine and spinal bupivacaine decreased significantly at the beginning of the treatment compared to the ED period, and continued to be significantly reduced for up to 1 wk for spinal opiate and bupivacaine and 6 mo for total opiate. The spinal opiate and bupivacaine doses were still lower in 50% of the patients at the end of the IT treatment compared to the end of the ED period. When final ED versus initial (2nd day) IT doses were assessed, the daily median dose ratios were 7.5 for total opiate and 4 for both spinal opiate and bupivacaine. Subsequently, lower daily volumes and higher concentrations were needed for IT administration of the drugs. During the first month of the IT treatment, sleeping and walking scores improved compared to ED treatment. Thus, the IT treatment gave more satisfactory pain relief, and--because of lower daily doses and volume--proved to be more suitable for treatment at home (continuous infusion from external pumps) than the ED treatment.

Adult↗