Depo-Dur....

[InGasWeTrust]

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As CA 1.5 thought I would quickly share my first experience with it.

72 y.o male with HTN, DM2, hx. of colon CA, now with renal CA going for L. partial v radical nephrectomy.

Called my attending night before stated I heard and read a little about depo dur, attending replied dittto, I said I wanna try it, attending was like cool.


Tough epidural, tight space, etc......but found the space dropped 15mg of Depo Dur and chased it with 5cc of NS.

Put pt. to sleep w/ 150mcg of fentanly, prop, sux, surgeons check flank, feel kidney is larger than it appears on CT, deceide to make a whopper flank,abdomen incision.

Case goes on uneventful for 4hrs with another 100mcg of fentanyl at the 2hr mark, wake pt up smoothly. BTW it was radical, kidney was the size of a friggin footbal.

30min after case-no pain, 50min after case no pain, 1.5 hrs as Im heading for home no pain, 26hrs postop no pain


And this was all with no additional analgesics


So after this one case Im wowed, no quite a believer, but I am definetly convinced this CAN work. I will check up tommorrow to see where his pain, if any is at


Just thought I would share my experience

 

[Noyac]

If no local is being used whatsoever, then I am also impressed.

However, I am not totally familiar with Depo-dur but 15 mg seems like a "BIG ASS" dose. Better watch that resp. rate if it is as big as I think. Is that the dose that is recommended?

 

[InGasWeTrust]

Noyac,

No local was used. In fact, local cannot be used at all with Depo Dur. I think it intereferes with the release of the Drug.

And the final follow up: Visited pt. this AM, was still at 0/10 pain!

 

[sdn1977]

If you have an opportunity, I'd appreciate more follow up on your experience with this. This is the first of a unique technology - water-filled chambers which contain the active drug which are dispersed thru a lipid matrix (a combination of phospholipids & triglycerides). The morphine is actually designed to provide optimum pain relief through 48 hours so I'm not surprised with your experience, but I'm curious as to how the analgesia reduces after that time....slowly which would allow oral analgesics or rapidly which would require IV?

Also, would you still have to watch for other epidural-type side effects of MS (urinary retention) as agressively since it is still being delivered, altho since no catheter is in place it may not be perceived by nursing as an epidural side effect - did I ask that question clearly enough?

I'm pretty sure the lipids are cleared pretty fast from the epidural space, but if you have an egg allergic pt it could be an issue. The matrix is a suspension & you can't change the pH of the suspension without breaking it (separating the components) so that is probably why locals aren't recommended. Anyway...anymore info you have on using this stuff, I'd appreciate hearing. Pain folks are looking into it too altho its expensive.

 

[jetproppilot]

As CA 1.5 thought I would quickly share my first experience with it.

72 y.o male with HTN, DM2, hx. of colon CA, now with renal CA going for L. partial v radical nephrectomy.

Called my attending night before stated I heard and read a little about depo dur, attending replied dittto, I said I wanna try it, attending was like cool.


Tough epidural, tight space, etc......but found the space dropped 15mg of Depo Dur and chased it with 5cc of NS.

Put pt. to sleep w/ 150mcg of fentanly, prop, sux, surgeons check flank, feel kidney is larger than it appears on CT, deceide to make a whopper flank,abdomen incision.

Case goes on uneventful for 4hrs with another 100mcg of fentanyl at the 2hr mark, wake pt up smoothly. BTW it was radical, kidney was the size of a friggin footbal.

30min after case-no pain, 50min after case no pain, 1.5 hrs as Im heading for home no pain, 26hrs postop no pain


And this was all with no additional analgesics


So after this one case Im wowed, no quite a believer, but I am definetly convinced this CAN work. I will check up tommorrow to see where his pain, if any is at


Just thought I would share my experience

Nice case.

Before the drug came out, I went to one of the sites that the company sets up to ask clinicians their opinion on the drug...they pay you for about 30 minutes.

My opinion was it's use would be limited by the fact that you cant use the epidural for local, and its hard to justify placing an epidural for neuraxial morphine-only.

But if it works as well as described above, I'd be willing to try it.

Would like to hear more cases and how the clinicians rated this new extended release neuraxial opiod.

 

[hokie]

Nice case.

Before the drug came out, I went to one of the sites that the company sets up to ask clinicians their opinion on the drug...they pay you for about 30 minutes.

My opinion was it's use would be limited by the fact that you cant use the epidural for local, and its hard to justify placing an epidural for neuraxial morphine-only.

But if it works as well as described above, I'd be willing to try it.

Would like to hear more cases and how the clinicians rated this new extended release neuraxial opiod.

We use this for most of our total hips and for some gyn procedures. For the hips we use a CSE (bupi or tetracaine in the spinal, depending on surgeon), depodur in epidural space, no catheter threaded. I have also done cases where I have placed a catheter because I was unsure of the length of the procedure (re-do's, etc.). Then you can either give the depodur at the end (ONLY if you have not needed to use the catheter) or if the case runs longer than the spinal, dose catheter with local and forget about depodur.
Two major complications so far: one intractable nausea and one resp. depression requiring naloxone infusion for 24 hours. We have decreased our dosing and almost never use more than 10 mg.

 

[sdn1977]

Nice case.

Before the drug came out, I went to one of the sites that the company sets up to ask clinicians their opinion on the drug...they pay you for about 30 minutes.

My opinion was it's use would be limited by the fact that you cant use the epidural for local, and its hard to justify placing an epidural for neuraxial morphine-only.

But if it works as well as described above, I'd be willing to try it.

Would like to hear more cases and how the clinicians rated this new extended release neuraxial opiod.

Do any of your pain colleagues use it for extended analgesia to facilitate PT? The manufacturer suggests it can be titrated to provide analgesia from 1-30 days, but I've never actually known it to be done. 30 days seems like a long time. Have you heard any experience with this use? I'm really curious how you would titrate it since once the matrix is dissolved, the kinetics should be like any MS in the epidural space.

 

[Noyac]

SDN1977, why is it not approved for intrathecal use? Is it b/c of the lipid matrix?

 

[InGasWeTrust]

sdn1977,

Unfortunately I dont have additional followup on the patient. I was sent to neurorads and just didnt have the time/energy to do the follow up. Tommorrow, I will find out where the pt is and swing by and review the chart to find out the quantity of narcs he has recieved thus far.

Hokie,
Thanks for the CSE info, as my attending did not know the answer to that question.


Could the respiratory depression have been a cause of an accidental intrathecal injection?

Good info and questions peeps!

 

[sdn1977]

SDN1977, why is it not approved for intrathecal use? Is it b/c of the lipid matrix?

Noyac...actually I believe in the original studies it was used in every route except intraarticular & intravenous. But, either the company did not seek approval or the FDA did not give approval for intrathecal use due to "profound & prolonged respiratory depression" - so it was only approved for epidural @ the lumbar & lower levels only. Not sure this is an actual concern for those of you using it and perhaps as you all become familiar, it will be used off label intrathecally (not advocating this mind you...).

Generally, intrathecal medications cannot have preservatives (parabens particularly) due to toxicity (& not an issue since this is not a preserved product) and I'm not really certain about the size of the molecules - this one ranges from 17-23 um. That may be a limiting issue - worth looking into the research.

I did find out - work has been done w/ lidocaine administered 5min before the matrix....the lidocaine increases the peak serum level of the MS. Not sure about the other parameters...area under curve, duration, etc.. - but they haven't sorted out the actual chemistry yet. No other work was done w/ other anesthetics, but you can assume all amides would do the same. Will be an interesting drug to follow......it may find a home...it may be a bust...but for sure...it will change delivery technology! I'm still interested in actual experience..

 

[lvspro]

sdn1977,

Unfortunately I dont have additional followup on the patient. I was sent to neurorads and just didnt have the time/energy to do the follow up. Tommorrow, I will find out where the pt is and swing by and review the chart to find out the quantity of narcs he has recieved thus far.

Hokie,
Thanks for the CSE info, as my attending did not know the answer to that question.


Could the respiratory depression have been a cause of an accidental intrathecal injection?

Good info and questions peeps!

Interesting case. I'm curious to see how things turn out. Thanks for posting... it's a nice break from the match related drivel thats dominating the forum.