Hypothermia associated with intrathecal morphine

Key words  intrathecal morphine - hypothermia - spinal anesthesia     

Loss of intrathecal morphine analgesia in terminal cancer patients is associated with high levels of excitatory amino acids in the CSF

PURPOSE: To examine excitatory amino acid (EAA) levels in the cerebrospinal fluid (CSF) of patients on long-term morphine treatment for terminal cancer pain relief and to correlate these with morphine's analgesic effect. METHODS: Fourteen terminal cancer patients suffering severe pain and requiring long-term opioid treatment for pain relief were included. An intrathecal (IT) catheter was implanted at the L(3-4)/L(4-5) level and advanced 10 cm in a cephalad direction. IT morphine injection was started at 100 microgram q 12 hr with a daily incremental dose of 50 microgram until the effective dose was reached. The CSF was sampled (2 mL) as follows: 1) before the first IT morphine injection, 2) when the effective dose of morphine was reached, 3) when loss of morphine's analgesic effect at the effective dose (pain visual analogue scale > 5), and 4) after consecutive increases of the morphine dose (50 microgram, IT, daily) for satisfactory pain relief and up to double the effective dose. The concentrations of glutamate and aspartate in the CSF were determined. RESULTS: CSF levels of glutamate and aspartate at the effective dose of morphine were lower than the baseline levels and increased when pain intensity increased and when morphine's analgesic effect was lost. CONCLUSION: Long-term IT morphine administration was accompanied by an increase of EAA level in the CSF that was associated with a loss of morphine's analgesic effect.     

Persistent vesicovaginal fistula associated with endometriosis

Vesicovaginal fistula with endometriosis is an extremely rare scenario. A case of a 50-year-old woman with persistent vesicovaginal fistula associated with endometriosis is described.     

Arterial and ventricular CSF pharmacokinetics after intrathecal meperidine in humans

In order to investigate the mechanisms leading to respiratory depression after lumbar administration of opioids, plasma and ventricular CSF pharmacokinetics of intrathecal meperidine (1 mg.kg-1) were studied in five head-injured patients undergoing surgery for lower limb fracture. Meperidine was detected both in the plasma (arterial catheter) and in the ventricular CSF (intracranial catheter) soon after intrathecal administration: 45 +/- 17 min and 100 +/- 14 min, respectively. The maximal plasma concentration was 341 +/- 133 ng.ml-1, whereas, in ventricular CSF, it was 64.5 +/- 14.9 ng.ml-1. The ventricular CSF-plasma ratio increased with time (r = 0.82) from 0.18 +/- 0.04 at the first hour to 0.38 +/- 0.1 at 16th hour. It is concluded that the putative risk of respiratory depression appears to be mainly related to the absorption into the systemic circulation and to redistribution back into CSF.     

鞘内置管脑脊液置换与反复腰穿放脑脊液分别鞘内注药治疗结核性脑膜炎的疗效比较

目的探讨鞘内置管脑脊液置换与反复腰穿放脑脊液分别鞘内注药治疗结核性脑膜炎的疗效。方法在常规综合治疗的基础上,对照组采用反复腰穿放脑脊液并鞘内注药,观察组采用鞘内置管脑脊液置换加鞘内注药。结果观察组总有效率（93.1%）明显高于对照组（73.0%）（P〈0.01）;观察组脑脊液压力恢复正常和住院时间均明显短于对照组（P〈0.01）;对照组不良反应（5例）明显多于观察组（0例）（P〈0.05）。结论相比反复腰穿放脑脊液,鞘内置管脑脊液置换疗效高,疗程短,不良反应少,值得临床推广应用。     

Persistent subcutaneous CSF leak after removal of epidural catheter

We report the case of an 11‐month‐old boy with Wilm's tumor, who underwent nephrectomy. Postoperative pain was managed with a lumbar epidural for 3 days, with the formation of a persistent cerebral spinal fluid cutaneous fistula.     

The CSF and plasma pharmacokinetics of sufentanil after intrathecal administration.

Eight patients (7 men and 1 woman, 45-68 yr old) scheduled to undergo thoracotomy were given, preoperatively, 15 micrograms sufentanil in the lumbar intrathecal space for a study of cerebrospinal fluid (CSF) and plasma kinetics of sufentanil. Multiple samples of plasma and CSF from the lumbar region were obtained through indwelling catheters for 12 h and analyzed for sufentanil by radioimmunoassay. Pharmacokinetic parameters were derived by noncompartmental analysis. In plasma, the maximal concentration of sufentanil appeared after 0.65 +/- 0.17 h (mean +/- SEM). No equilibrium was reached between the sufentanil concentration in CSF and plasma, but the CSF/plasma concentration ratio declined from approximately 140 at 2 h to about 15 at 10 h. Extrapolation indicates that another 10 h would be required before the concentration in CSF would equal that in plasma. The mean residence time (MRT) of sufentanil in CSF was 0.92 +/- 0.08 h and in plasma was 6.8 +/- 0.6 h. The volume of distribution at steady state (Vss) in the subarachnoid compartment was 1.54 +/- 0.39 ml/kg, and the clearance from the CSF was 27 +/- 5 microliters.kg-1.min-1. The intrathecal administration of 15 micrograms sufentanil at the beginning of the operation did not produce analgesia that lasted into the postoperative period. Most patients had urinary retention, but none experienced any serious complications. This study demonstrates that the lipophilic opioid sufentanil undergoes rapid clearance from CSF and absorption to plasma after intrathecal administration. These pharmacokinetic characteristics are slower for the less lipophilic opioids meperidine and morphine. The rapid pharmacokinetics of sufentanil explain its rapid onset of action and short-lasting effects.     

Persistent trigeminal artery associated with intracranial arterial aneurysm

Two patients with persistent trigeminal artery associated with a ruptured arterial intracranial aneurysm arising from the ipsilateral internal carotid artery at the level of the posterior communicating artery are presented. One patient underwent successful clipping of the aneurysm. The other patient died on the x-ray table shortly after admission during the performance of emergency carotid angiography. In each patient, the anomalous vessel was considered to be incidental.     

Persistent hypothermia after intrathecal morphine: case report and literature review

Purpose

To describe a case of persistent hypothermia following spinal anesthesia with intrathecal morphine.

Clinical features

Following elective right total knee arthroplasty under spinal anesthesia with isobaric 0.5% bupivacaine 11?mg, fentanyl 15???g, and preservative-free morphine 150???g, a 57-yr-old female (93.5?kg, 151?cm) developed postoperative hypothermia with a nadir rectal temperature of 33.6°C four hours after surgery. At times, her temperature could not be measured by tympanic, temporal arterial, oral, axillary, or rectal routes. In spite of the low temperature, the patient complained of feeling hot and was diaphoretic without shivering. With the exception of her temperature, her vital signs were normal postoperatively, and aside from hyperglycemia, complete blood count, electrolytes, thyroid-stimulating hormone, serum cortisol, troponin, and twelve-lead electrocardiogram were normal. Her temperature did not respond to warming efforts with a forced-air warming blanket, infusion of warmed intravenous crystalloid, and hourly bladder irrigation with warm saline through an indwelling urinary catheter. Normothermia returned after she received a small dose of sublingual lorazepam eight hours after surgery. The remainder of her postoperative stay was uneventful.

Conclusion

Patients undergoing spinal anesthesia with intrathecal morphine may develop postoperative hypothermia that is resistant to warming measures. This complication may be treated successfully with lorazepam.     

Transverse myelitis associated with Acinetobacter baumanii intrathecal pump catheter-related infection

OBJECTIVE: To describe a late neurologic complication of intrathecal pump implantation and show the methods used for the diagnosis and successful treatment of transverse myelitis in this setting. CASE REPORT: A 32-year-old man with a chronic abdominal pain syndrome presented with right lower-extremity numbness 2 months after the placement of an intrathecal morphine pump. This progressed to bilateral lower extremity and ascending sensory loss to T12-L1 dermatome, significant lower-extremity weakness, constipation with overflow incontinence, and detrusor instability causing urinary incontinence in discrete episodes over the following 2 months consistent with a myelopathy. Magnetic resonance imaging (MRI) of the thoracic spine and cerebrospinal fluid (CSF) analysis were consistent with transverse myelitis. The intrathecal pump was removed and an Acinetobacter baumanii catheter-tip infection was diagnosed. Clinical course improved with the co-administration of intravenous corticosteroids and antibiotics, with significant clinical improvement within 30 days. CONCLUSIONS: Clinicians should recognize transverse myelitis as a possible late complication of intrathecal pump placement. Early medical intervention and removal of the intrathecal pump may be necessary to prevent irreversible spinal cord damage and may support good recovery.     

Persistent trigeminal artery associated with brainstem infarct--case report.

A 47-year-old male presented with a sudden onset of right hemiparesis and numbness of the left face. Magnetic resonance imaging demonstrated a lacunar infarct in the ventral pons. Cerebral angiography demonstrated a persistent trigeminal artery (PTA) anastomosing the left internal carotid artery to the distal basilar artery. Bilateral vertebral arteries and the basilar artery below the PTA junction were extremely hypoplastic. The bilateral posterior communicating arteries were embryonic. The posterior fossa circulation was almost independent from the circle of Willis. The poor vascular supply to the posterior fossa probably caused the brainstem infarct.     

Temporary motor and sensory paralysis associated with intrathecal administration of morphine

We are reporting a temporary, totally reversed motor and sensory paralysis subsequent to the intrathecal administration of 1.6 mg of morphine sulfate. This may represent an event which is not based on medication-induced myelopathy but on cardiovascular changes occurring as a result of pain relief.     

腰大池置管间断引流鞘内注射抗生素治疗胸腰椎术后脑脊液漏伴颅内感染

<正>硬膜损伤致脑脊液漏是胸腰椎手术最常见的并发症之一,发生率为2.31%~9.37%~([1~3])。但硬膜损伤后脑脊液漏继发颅内感染的报道尚不多见,一旦发生,常规静脉应用抗生素治疗效果差,死亡率高。我院自2009年2月~2014年3月在静脉应用抗生素的基础上,采用腰大池置管间断引流联合鞘内注射抗生素治疗胸腰椎术后脑脊液漏伴颅内感染患者共6例,疗效满意,总结如下。临床资料6例患者中男2例,女4例;年龄61.5±11.5(51~72岁)。腰椎间盘突出症术后4例,胸椎间盘突出     

Difficulties in treatment of CSF leakage associated with a temporal meningocele

Summary Temporal meningocele is a rarely encountered pathology. It is caused by communication between the subarachnoid space of the middle fossa and lateral extension of the sphenoid sinus. Cerebrospinal fluid (CSF) pressures and the hydrostatic pulsatile forces may lead to the development of pitholes on the middle fossa at the sites of arachnoid villi with herniation of dura/arachnoid or brain tissue into the sinus. We describe an adult patient who presented with spontaneous CSF rhinorrhea due to a temporal meningocele. She was first operated on transsphenoidally, but the CSF rhinorrea did not cessate, therefore she was operated transcranially five days after the first operation. There has been no CSF rhinorrhea for three and a half years. Transcranial temporal encephalocele repairment is more effective than transsphenoidal surgery. Recurrent CSF leaks can occur due to both the increased CSF pressure and the insufficient operation technique.     

Persistent primitive hypoglossal artery associated with arteriovenous malformation--case report.

A case of persistent primitive hypoglossal artery (PPHA) associated with arteriovenous malformation (AVM) is reported. A 46-year-old male suddenly developed severe headache followed by transient unconsciousness and was admitted to our hospital 2 hours later. A computed tomographic scan showed subarachnoid hemorrhage. Angiograms revealed an AVM in the left cerebellar hemisphere and an ipsilateral PPHA. The AVM was completely removed and he was discharged 1 month after surgery without neurological deficit. Only three cases of PPHA associated with intracranial AVM have been reported in the literature. One patient died of rebleeding from the AVM before surgery, and another was conservatively treated because the AVM was too large for resection. The remaining one was surgically treated only by ligation of the feeding arteries. Ours is the first case treated by total removal of the AVM. Since these four cases, including ours, account for 3.0% of 134 cases of PPHA reported, PPHA associated with AVM is considered rare.     

Persistent primitive hypoglossal artery associated with Arnold-Chiari type I malformation

The case of a 49-year-old woman with persistent primitive hypoglossal artery associated with Arnold-Chiari type I malformation is reported. The hypoglossal artery was located on the left side. The left vertebral artery was hypoplastic, the right vertebral artery could not be visualized angiographically. The clinical significance of a persistent primitive hypoglossal artery is discussed.