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211: Are you where you think you are? A complication following aspiration and refilling of an intrathecal morphine pump
Posters
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Chronic Pain Management
61
211. Are you where you think you are? A complication following aspiration and refilling of an intrathecal morphine pump
224. Lumbar ganglion chemical sympathectomy in phantom limb pain— case report
R. Siegmeth, D.M. Bailey The Pain Management Unit, Ipswich Hospital, Ipswich, UK
J. Grzesiak1, J. Les1, M. Baranski2, W. Gdowski2, R. Bak2, M. Labus1 1Department of Anaesthesiology and Intensive Therapy, Military Institute of The Health Services, Central Clinical Hospital of The Department of National Defence, Warsaw, Poland, 2Department of Septic and Post-Traumatic Infection Therapy, Military Institute of The Health Services, Central Clinical Hospital of The Department of National Defence, Warsaw, Poland
Introduction: We report a complication following the refilling of a neuraxial medication delivery system. Case: A patient presented for refilling of his intrathecal morphine pump one month following its insertion. The injection port was located using the manufacturer’s template. After entering the skin a distinct pop was felt which was assumed to be the drug reservoir membrane. 15mls of fluid was aspirated which was the expected residual drug volume. The pump was easily refilled with 525mg morphine. Ten minutes later erythematous wheals developed around the pump site. Suspecting a seroma, 25mls of drug was re-aspirated leaving 150mg morphine extravasated in subcutaneous tissue. The true drug reservoir was then located, aspirated and refilled with 35mls of 1.5% morphine. The patient was closely monitored but after suffering no sedation or respiratory depression was discharged home without further complications. The original cavity aspirate contained 33g/l of protein confirming a seroma. Discussion: Massive morphine overdose has occurred during incorrect refilling of intrathecal pumps1,2. The delivery of large dose morphine into a seroma represents another potential danger. Seroma formation following pump insertion occurs in 1 in 13 to 1 in 30 cases and can persist for several months3,4,5. Care is required when refilling a new pump as the sensation of entering a seroma can mimic that of puncturing the drug reservoir diaphragm placing patients at risk of massive opioid overdose. Our patient, who had a long history opioid use, appeared tolerant to its effects. Conclusion: Vigilance must be maintained to the significant morbidity that can be associated with the refilling of these devices.
References 1. 2. 3. 4. 5.
Yilmaz et al. Neurol India 2003:51(3);410-1. Sauter et al. J Neurosurg 1994:81(1);143-6 Ethans et al. Spinal Cord 2005:43;214-18 Likar et al. Arzeneimittelforschung 1999:49(6);489-93 Levin AB, Sperling KB. Stereotact Funct Neurosurg. 1995;65:147-51
A 20-year-old male after the right lower limb amputation suffered extreme phantom pain. A right-sided lumbar ganglion chemical sympathectomy on the L3 and L5 level, using of 75% ethanol, was executed and almost total reduction of the pain was achieved. In our opinion it is necessary to use medicines (analgesics, anticonvulsants, antidepressants) together with invasive methods such as sympathetic blocks in phantom pain therapy.
•
Chronic Pain Management
61
211. Are you where you think you are? A complication following aspiration and refilling of an intrathecal morphine pump
224. Lumbar ganglion chemical sympathectomy in phantom limb pain— case report
R. Siegmeth, D.M. Bailey The Pain Management Unit, Ipswich Hospital, Ipswich, UK
J. Grzesiak1, J. Les1, M. Baranski2, W. Gdowski2, R. Bak2, M. Labus1 1Department of Anaesthesiology and Intensive Therapy, Military Institute of The Health Services, Central Clinical Hospital of The Department of National Defence, Warsaw, Poland, 2Department of Septic and Post-Traumatic Infection Therapy, Military Institute of The Health Services, Central Clinical Hospital of The Department of National Defence, Warsaw, Poland
Introduction: We report a complication following the refilling of a neuraxial medication delivery system. Case: A patient presented for refilling of his intrathecal morphine pump one month following its insertion. The injection port was located using the manufacturer’s template. After entering the skin a distinct pop was felt which was assumed to be the drug reservoir membrane. 15mls of fluid was aspirated which was the expected residual drug volume. The pump was easily refilled with 525mg morphine. Ten minutes later erythematous wheals developed around the pump site. Suspecting a seroma, 25mls of drug was re-aspirated leaving 150mg morphine extravasated in subcutaneous tissue. The true drug reservoir was then located, aspirated and refilled with 35mls of 1.5% morphine. The patient was closely monitored but after suffering no sedation or respiratory depression was discharged home without further complications. The original cavity aspirate contained 33g/l of protein confirming a seroma. Discussion: Massive morphine overdose has occurred during incorrect refilling of intrathecal pumps1,2. The delivery of large dose morphine into a seroma represents another potential danger. Seroma formation following pump insertion occurs in 1 in 13 to 1 in 30 cases and can persist for several months3,4,5. Care is required when refilling a new pump as the sensation of entering a seroma can mimic that of puncturing the drug reservoir diaphragm placing patients at risk of massive opioid overdose. Our patient, who had a long history opioid use, appeared tolerant to its effects. Conclusion: Vigilance must be maintained to the significant morbidity that can be associated with the refilling of these devices.
References 1. 2. 3. 4. 5.
Yilmaz et al. Neurol India 2003:51(3);410-1. Sauter et al. J Neurosurg 1994:81(1);143-6 Ethans et al. Spinal Cord 2005:43;214-18 Likar et al. Arzeneimittelforschung 1999:49(6);489-93 Levin AB, Sperling KB. Stereotact Funct Neurosurg. 1995;65:147-51
A 20-year-old male after the right lower limb amputation suffered extreme phantom pain. A right-sided lumbar ganglion chemical sympathectomy on the L3 and L5 level, using of 75% ethanol, was executed and almost total reduction of the pain was achieved. In our opinion it is necessary to use medicines (analgesics, anticonvulsants, antidepressants) together with invasive methods such as sympathetic blocks in phantom pain therapy.