Anesthesia and analgesia in pregnancy
Hung N. Winn, Frank A. Chervenak, Roberto Romero in Clinical Maternal-Fetal Medicine Online, 2021
A modification of conventional epidural analgesia, the combined spinal–epidural (CSE) technique, has also been gaining usage at major centers over the past decade. Following placement of the epidural needle in the epidural space, a small-gauge pencil-point spinal needle is passed through the epidural needle and the dura is punctured. A small dose of preservative-free opioid or opioid local anesthetic combination is injected intrathecally. The epidural catheter is then passed through the epidural needle and tested. Analgesia is achieved rapidly and there is no need for a bolus loading dose of local anesthetic via the epidural catheter (76,77). Following placement and testing of the epidural catheter, a maintenance infusion is begun. By the time the intrathecal dose has dissipated, the epidural infusion has reached a sufficient level to maintain satisfactory analgesia.
The development and practice of palliative care
John Lombard in Law, Palliative Care and Dying, 2018
Palliative medication may be administered in a number of different ways including injection, oral, suppository or through intrathecal pump. The intrathecal pump functions by delivering ‘small doses of medication directly to the spinal fluid’.192 This has the effect of increasing the ‘relative strength of the drug compared to its oral or intravenous equivalent’.193 This approach can minimise potential side effects of sedative drugs. The control exercised over the administration of sedative drugs is important due to the harmful consequences associated with an excessive dose. Naturally, it follows that sedation should be the ‘lowest necessary to provide adequate relief of suffering’.194 In the context of morphine it appears that when it is administered at such a level there is ‘little data to support the belief that appropriate use of opioids hastens death in patients dying from cancer and other chronic diseases’.195 The challenge which this presents is the identification of what constitutes an appropriate level of sedative. This level will vary over the course of a patient’s care, for example, after the initial sedation the risk of hastening death decreases. This is based on the fact that the ‘risk of respiratory depression is greatest when opioids are first begun’.196 As treatment progresses, the ability of a patient to cope with respiratory side effects increases,197 but over time toxicity may occur.
Amikacin
M. Lindsay Grayson, Sara E. Cosgrove, Suzanne M. Crowe, M. Lindsay Grayson, William Hope, James S. McCarthy, John Mills, Johan W. Mouton, David L. Paterson in Kucers’ The Use of Antibiotics, 2017
The dosage of amikacin usually recommended is 15–20 mg/kg i.m. or i.v. per day administered as a single dose or in two divided doses. Intravenously, the dose is dissolved in 30–50 ml of i.v. fluid and then infused over 30 min. In several adults, the drug has been administered intrathecally as an adjunct to systemic therapy for meningitis caused by gentamicin-resistant Gram-negative bacteria. In one patient the daily intrathecal dose was 4 mg (Hamory et al., 1976), and in two others it was 20 mg (Block et al., 1977, Corpus et al., 2004). Intrathecal therapy was well tolerated and appeared to contribute to the recovery of both patients. As with gentamicin (see Chapter 52, Gentamicin), the intrathecally administered drug is unlikely to reach the cerebral ventricles.
Novel Strategy Involving High-Dose Chemotherapy with Stem Cell Rescue Followed by Intrathecal Topotecan Maintenance Therapy without Whole-Brain Irradiation for Atypical Teratoid/Rhabdoid Tumors
Published in Pediatric Hematology and Oncology, 2023
Ai Yamada, Mariko Kinoshita, Sachiyo Kamimura, Takashi Jinnouchi, Minako Azuma, Shinji Yamashita, Kiyotaka Yokogami, Hideo Takeshima, Hiroshi Moritake
Radiotherapy, especially for patients younger than three years old, has been reported to induce late CNS toxicities, such as intellectual impairment, endocrine dysfunction, growth disturbances, and an increased risk of secondary malignancy.24,25 It remains unclear whether intrathecal therapy or high-dose chemotherapy with autoPBSCT (HDCT/autoPBSCT) can be substituted for radiotherapy. Athale et al. described patients who received intrathecal therapy as having a survival advantage, with a 2-year OS of 64% versus 17.3% for those who did not receive this therapy according to a meta-analysis.26 Reddy et al. suggested the benefits of HDCT/autoPBSCT and local radiotherapy for children under 3 years old with AT/RT according to a large-scale prospective study.27 The administration of thiotepa, melphalan, and topotecan as a conditioning regimen is known to be effective against a number of brain tumors while also demonstrating excellent CNS penetration; however, a considerable number of regimen-related toxicities have been observed.28–30 It is therefore important to consider ways to reduce treatment-related mortalities when administering HDCT/autoPBSCT.31 Topotecan-melphalan-cyclophosphamide (TMC) as a conditioning regimen with autoPBSCT rescue following intrathecal topotecan therapy was reported to be safe and effective for treating an infant with relapsed medulloblastoma.30
Prepontine cisternal routine for intrathecal targeted drug delivery in craniofacial cancer pain treatment: technical note
Published in Drug Delivery, 2022
Haocheng Zhou, Dong Huang, Dingquan Zou, Junjiao Hu, Xinning Li, Yaping Wang
In the end stage of tumor, one hallmark feature of cancer-related pain is the excruciating pain, that is insufficiently treated by oral analgesic medications. Likely, both cases presented with severe pain (8/10 VAS) at resting state and the worst suffering during breakthrough pain episodes, with considerable amounts of opioids consuming up to 380 and 790 mg equivalent morphine in 24 hours. Despite unsatisfactory control of pain, multiple side effects of analgesic effect are frequently reported, including dizziness, nausea, vomiting, constipation and physical dependence (Benyamin et al., 2008). One advantage of intrathecal therapy is the significant reduction of opioids intake, which may attenuate the side reaction. Oral opioids were totally replaced one week after implantation procedure in the first patient, and the intrathecal titration was completed one month after discharge for the other case. The daily cisternal amount of morphine ranged between 1.9 and 3.0 mg, accounting for about 0.05% of oral dosage. This data is consistent with the conventional 300:1 ratio (Sylvester et al., 2004). In addition to conversion ratio, one key parameter of intrathecal therapy is the pharmacratic formation. Combination of local anesthetics (bupivacaine) with morphine may contribute to provide supplementary pain control for the intractable cases (van Dongen et al., 1999). In this study, both cases achieved sufficient relief with prepontine cisternal morphine delivery.
A safety review of approved intrathecal analgesics for chronic pain management
Published in Expert Opinion on Drug Safety, 2021
Alan Chalil, Michael D. Staudt, Tessa A. Harland, Elizabeth M. Leimer, Ravneet Bhullar, Charles E. Argoff
Intrathecal (IT) drug delivery is an effective treatment modality with a different risk-benefit profile compared to conventional oral or parenteral pain medications. IT analgesia was first described around the turn of the 20th century [5]. The discovery of opioid receptors in the spinal cord was instrumental in advancing the field [6,7], leading to a report by Wang et al. describing the use of IT morphine in the treatment of intractable cancer pain in 1979 [8]. Soon after, Onofrio et al. reported on the first implantable IT drug delivery system in 1981 [9]. The study of IT pain therapy has subsequently flourished, with multiple studies describing efficacy in chronic malignant and nonmalignant pain. In 2000, the Polyanalgesic Consensus Conference (PACC) was founded to develop evidence-based guidelines in order to improve the safety and efficacy of IT therapies, with the most recent guidelines published in 2017 [10–12].
Related Knowledge Centers
- Cerebrospinal Fluid
- Meninges
- Pain Management
- Chemotherapy
- Route of Administration
- Injection
- Spinal Canal
- Spinal Anaesthesia
- Blood–Brain Barrier
- Anatomic Space