Fentanyl and pleuritic pain

[DrQuinn]

Heard a rumor from one resident that Fentanyl had more affinity for pleural pain, i.e. pneumothorax, chest tube insertion, empyema, etc...

True?

Heh. I hope they didn't confuse fentanyl's pleural affinity for wooden chest.

Q

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[lobelsteve]

Yup, the patches stick pretty good on the chest. Other than that- I think it would be difficult to predict a particular opioids response based on pain location.

 

[DrQuinn]

Thats what I figgered.
Q

 

[drrinoo]

Thats what I figgered.
Q

It is lipophillic....intrapleural catheter, clamp chest tube...fentanyl admixture with local...diffuses thru the innermost intercostal membrane to the intercostal nerves...pain relief...

 

[lobelsteve]

It is lipophillic....intrapleural catheter, clamp chest tube...fentanyl admixture with local...diffuses thru the innermost intercostal membrane to the intercostal nerves...pain relief...

True. But I am unsure how many of us are placing intrapleural catheters in the outpatient setting. My training shows my thought process- all outpatient, all the time. I recall intrapleural questions on the boards and was at what the heck are they talking about. I think that is more regional than pain as it does not seem feasible to run a catheter to an implantable pump. I do have a few folks with pleuritic pain from thoracotomy who either cannot have a nerv stim put in or have failed nerve stim. It may be interesting if this is done elsewhere. Anybody ever run an IT cath to the intrapleural space and dropped a Medtronic pump in the belly?

 

[drrinoo]

True. But I am unsure how many of us are placing intrapleural catheters in the outpatient setting. My training shows my thought process- all outpatient, all the time. I recall intrapleural questions on the boards and was at what the heck are they talking about. I think that is more regional than pain as it does not seem feasible to run a catheter to an implantable pump. I do have a few folks with pleuritic pain from thoracotomy who either cannot have a nerv stim put in or have failed nerve stim. It may be interesting if this is done elsewhere. Anybody ever run an IT cath to the intrapleural space and dropped a Medtronic pump in the belly?

You are quite right...it is only used for acute post-op pain or rib fractures....it is an extremely gratifying procedure...if you have an opportunity, you should try to do it in the hospital...it works fairly well...but there is probably no role in chronic pain

The intrapleural catheter technique with a connection to an IT pump is intriguing, but the only concern that I have is that the volumes would have to be extremely large with current local anesthetics (e.g 8-12 cc/hour)...and in the intrapleural space, volume is more important than dose...so, a higher concentration LA may not be effective (recall concentrations in IT pumps range forom the 1-3% range)..it there is a malignancy, then perhaps a DuPen catheter might work with an external infusion pump? but if an extremely long acting LA (curiously amitriptyline held promise a couple of years ago, but fell out of favor due to concerns of neurotoxicity)...the IT pump concept may fly.What do you think?

 

[lobelsteve]

You are quite right...it is only used for acute post-op pain or rib fractures....it is an extremely gratifying procedure...if you have an opportunity, you should try to do it in the hospital...it works fairly well...but there is probably no role in chronic pain

The intrapleural catheter technique with a connection to an IT pump is intriguing, but the only concern that I have is that the volumes would have to be extremely large with current local anesthetics (e.g 8-12 cc/hour)...and in the intrapleural space, volume is more important than dose...so, a higher concentration LA may not be effective (recall concentrations in IT pumps range forom the 1-3% range)..it there is a malignancy, then perhaps a DuPen catheter might work with an external infusion pump? but if an extremely long acting LA (curiously amitriptyline held promise a couple of years ago, but fell out of favor due to concerns of neurotoxicity)...the IT pump concept may fly.What do you think?

For some quirky twist of fate reason, I had two patients ask me about this today. Neither were post-thoractomy. One appears like PHN but no rash ever and no response to Lyrica, Lidocaine, Neurontin, Elavil; limited response to qid oxycodone (and he wants off of it). The other patient has what appears to be a healed lung contusion with pleuritic pain.

Both want to try a single peripheral octrode lead before considering surgery. Both failed a fluoro guided intercostal block and TESI.

 

[C Fiber]

At what level would you put the lead? Do you throw the lead a little more to the gutter instead of midline trying to get more peripheral nerve/dorsal root entry zone for chest pain? I have not done one of these, is there literature to support this for PHN, post-thoracotomy pain?
(It's weird to think about the chest tubes that I put in years ago in residency may end up being my patients again in my chronic pain clinic.)

 

[lobelsteve]

Very unreliable trying to catch stim in the epidural space for the T or L spine. I put it in the subQ overlying the region with the most pain and run it as a PNS. Literature is lacking but Alo and Popenoy (spelling) have done some work with peripheral stim.