intrathecal dosages and concentrations

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daphilster78

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For those of you who do intrathecal trials with the patient hospitalized (usually under 24 hours observation), what mixtures of opioids do you use for your intrathecal infusion?

a. Morphine–PF: 0.01 mg/ml OR _____ mg/ml plus Bupivacaine-MPF 0.03125% OR _____%
b. HYDROmorphone-PF: 0.0025 mg/ml OR _____ mg/ml plus Bupivacaine-MPF 0.03125% OR _____%
c. FENTanyl-PF: 0.05 mcg/ml OR _____ mcg/ml plus Bupivacaine-MPF 0.03125% OR _____%
d. Infusion Rate: ________ ml/hr
e. Patient Controlled Bolus: none OR 3 ml q 15 minutes


These are some pre-printed sheets at a local hospital. While the morphine values are correct and in line with what I typically use in a pump starting out if run at 3-4 ml/hr, I don't have a good idea on whether this is realistic for fentanyl or hydromorphone. Also, I don't usually use bupivicaine in my intrathecal trial infusions, are these realistic numbers?

Thanks!
 
daphilster78 said:
For those of you who do intrathecal trials with the patient hospitalized (usually under 24 hours observation), what mixtures of opioids do you use for your intrathecal infusion?

a. Morphine–PF: 0.01 mg/ml OR _____ mg/ml plus Bupivacaine-MPF 0.03125% OR _____%
b. HYDROmorphone-PF: 0.0025 mg/ml OR _____ mg/ml plus Bupivacaine-MPF 0.03125% OR _____%
c. FENTanyl-PF: 0.05 mcg/ml OR _____ mcg/ml plus Bupivacaine-MPF 0.03125% OR _____%
d. Infusion Rate: ________ ml/hr
e. Patient Controlled Bolus: none OR 3 ml q 15 minutes


These are some pre-printed sheets at a local hospital. While the morphine values are correct and in line with what I typically use in a pump starting out if run at 3-4 ml/hr, I don't have a good idea on whether this is realistic for fentanyl or hydromorphone. Also, I don't usually use bupivicaine in my intrathecal trial infusions, are these realistic numbers?

Thanks!
Click to expand...

I do epidural trials. Just easier.
 
Just do a single shot bolus trial. No need for extended hospital stay and continous trial -- just a waste of time, resources, and more potential complications...IMHO
 
NOSfan said:
Just do a single shot bolus trial. No need for extended hospital stay and continous trial -- just a waste of time, resources, and more potential complications...IMHO
Click to expand...

I think this is debatable.

Some would argue in hospital trial is better since it's longer lived and somewhat more realistic.

Typically with a single shot intrathecal trial: 1)you are using a 'higher' dose than what would be infused over a period of time w/ a ITP 2) patients get a transient, 'high' if you will and will feel good, but then the benefit sort of weans 3) respiratory depression may occur hours after the single shot, when the patient is at home. In fact a Pain Medicine article I think by coffey,et demonstrated a higher incidence of mortality and morbidity from single shot trials.
 
The last article in Pain Physician i believe showed that there is little to no predictive value for single shot epidurals, multishot epidurals, or continuous epidural infusions. The consensus agreement sounded like it was much more up to the physician, and to even consider if a trial is necessary...

section 9.1 of this pdf: http://www.painphysicianjournal.com/2011/may/2011;14;E283-E312.pdf

(ps remember that hydromorphone is technically not FDA approved for intrathecal use...)
 
PinchandBurn said:
I think this is debatable.

Some would argue in hospital trial is better since it's longer lived and somewhat more realistic.

Typically with a single shot intrathecal trial: 1)you are using a 'higher' dose than what would be infused over a period of time w/ a ITP 2) patients get a transient, 'high' if you will and will feel good, but then the benefit sort of weans 3) respiratory depression may occur hours after the single shot, when the patient is at home. In fact a Pain Medicine article I think by coffey,et demonstrated a higher incidence of mortality and morbidity from single shot trials.
Click to expand...

Adjust opioid regime prior to trial, give a single bolus, usually around 0.5 mg of IT morphine, 24-hour hospital stay to assess efficacy, tolerability, monitor ASE, and obtain functional measures assessed during stay.

Continuous multi-day infusion does not predict outcome in regard to long-term efficacy.

Coffey's latest article refers to priming boluses as a source of mortality, not single shot trials.

Medical Practice Perspective: Identification and Mitigation of Risk Factors for Mortality Associated with Intrathecal Opioids for Non-Cancer Pain Pain Physician Vol 11, Issue 7; 1001-1009, July 2010

 
Ok, not exactly the response I was hoping for. Debating aside, among those who do intrathecal trials (continuous in the hospital), any advice? Or are too few pain docs doing those? I know its off label, but a lot of what we put in pumps are and i was hoping to pick the brain of someone with more experience.

In my limited experience, I feel a 2 day trial gives so much more information than a single shot (which is complicated sometimes pts have trouble distinguishing the injection pain from the needle or if mac is used, they get iv fentanyl which complicates the pain picture too). I've had patients say they feel awesome the first night, and then realize it was more from the iv sedation and opioids they got before they realize functionally they are not much better off in day 2.
 
daphilster78 said:
Ok, not exactly the response I was hoping for. Debating aside, among those who do intrathecal trials (continuous in the hospital), any advice? Or are too few pain docs doing those? I know its off label, but a lot of what we put in pumps are and i was hoping to pick the brain of someone with more experience.

In my limited experience, I feel a 2 day trial gives so much more information than a single shot (which is complicated sometimes pts have trouble distinguishing the injection pain from the needle or if mac is used, they get iv fentanyl which complicates the pain picture too). I've had patients say they feel awesome the first night, and then realize it was more from the iv sedation and opioids they got before they realize functionally they are not much better off in day 2.
Click to expand...

Not trying to be smug, but why would you use sedation, iv fentanyl, or even MAC for a single shot trail anyway? You only need some local and a 22-gauge spinal needle.

Anyway, if you are determined to do a catheter trial then PF Morphine 0.1 mg/mL at 0.5 mls per hour or bolus 0.25-0.5 mg with infusion started at 1 mg/day. Adjust as you desire from there. I wouldn't use combination mixtures for the trial unless you are going to use them at the onset of implantation. Ultimately, the patient may require a mixture, but just start off with the simple solution 🙂
 
how do i put this without sounding smug...

maybe the reason you are not getting the response that you desire is because there is no good response to your question. The multiple different answers you have recieved point to the fact that there has not been shown to be a "right" way or "wrong" way to proceed, and that, regardless of how they are done, trials may not have enough prognostic value. thats why there are multiple different answers...

ultimately, someone will post that they also do 2 day trials and they work great, maybe making you feel justified in what they do, but it appears that the literature is not there to say that a trial HAS to be done one way or another to be predictive of long term success....
 
Ducttape said:
how do i put this without sounding smug...

maybe the reason you are not getting the response that you desire is because there is no good response to your question. The multiple different answers you have recieved point to the fact that there has not been shown to be a "right" way or "wrong" way to proceed, and that, regardless of how they are done, trials may not have enough prognostic value. thats why there are multiple different answers...

ultimately, someone will post that they also do 2 day trials and they work great, maybe making you feel justified in what they do, but it appears that the literature is not there to say that a trial HAS to be done one way or another to be predictive of long term success....
Click to expand...

I do a single shot trial every few years. I pray that it never works. 😀

Would be happy to place it for malignant pain, but the folks I see do well on fentanyl and actiq/fentora and pass on without terrible pain.
 
Single shot IT. If I use fentanyl or Dilaudid I send them home same day when pain returns. Morphine stays overnight.
 
DocShark said:
I do epidural trials. Just easier.
Click to expand...

I have found epidural trials overnight in the hospital Are a good indicator, despite the literature. I usually use morphine 40mcg/cc and start at 6 cc/hr after an epidural bonus of 3-5 mg of duramorph. I do maybe 5-6 a year and 4-5 get pumps and all pass away within 1year, usually...

By no means I am an expert, but hospital staff are not good with intrathecal trials but are very comfortable with epidural trials. Plus less chance of headache, less chance of delayed respiratory depression. All in all, easier and I believe them to Be predictive in most cases. Fwiw
 
I do about 2 per month. All are admitted for 2-3 days (some longer). most are intrathecal trals and the medication I use depends on the patients. I try to implant prior to discharge (medicare patients).

Hydromorphone 1mg/ml and start at 0.1ml/hr. +/- Bupivacaine
Prialt trials are longer-- I start low and go up every 2 or 3 days. Have been very successful with this approach

I will try to wean patients off their narcotic meds to lowest dose possible pre trial and then I will hold their home pain medication after admision and will start a PCA and decrease its dose daily as i increase the IT med.
 
DocShark said:
I have found epidural trials overnight in the hospital Are a good indicator, despite the literature. I usually use morphine 40mcg/cc and start at 6 cc/hr after an epidural bonus of 3-5 mg of duramorph. I do maybe 5-6 a year and 4-5 get pumps and all pass away within 1year, usually...

By no means I am an expert, but hospital staff are not good with intrathecal trials but are very comfortable with epidural trials. Plus less chance of headache, less chance of delayed respiratory depression. All in all, easier and I believe them to Be predictive in most cases. Fwiw
Click to expand...

Interesting starting point, so basically the amount of IT morphine is .040mg/cc *6cc/hr *24hr = 5.76mg/day. That's a lot more than the starting dose I do which is usually 1-2 mg/day. It depends on the dose of opiate they are on chronically, but I usually still stick to those lower numbers even when they are on mega doses.

Also sounds like there's a lot of variation as to how much to decrease the home opioid med by in house, I usu reduce by 50%.
 
daphilster78 said:
Interesting starting point, so basically the amount of IT morphine is .040mg/cc *6cc/hr *24hr = 5.76mg/day. That's a lot more than the starting dose I do which is usually 1-2 mg/day. It depends on the dose of opiate they are on chronically, but I usually still stick to those lower numbers even when they are on mega doses.

Also sounds like there's a lot of variation as to how much to decrease the home opioid med by in house, I usu reduce by 50%.
Click to expand...

5.6 mg of EPIDURAL morphine. Which is 0.5 mg of intrathecal equivalent. I usually start most pump patients at 0.5 to 0.75 mg per day in the actual pump, again depending on their situation.


But not 5.6 mg of IT morphine for the trial...
 
Jcm800 said:
I have found epidural trials overnight in the hospital Are a good indicator, despite the literature. I usually use morphine 40mcg/cc and start at 6 cc/hr after an epidural bonus of 3-5 mg of duramorph. I do maybe 5-6 a year and 4-5 get pumps and all pass away within 1year, usually...

By no means I am an expert, but hospital staff are not good with intrathecal trials but are very comfortable with epidural trials. Plus less chance of headache, less chance of delayed respiratory depression. All in all, easier and I believe them to Be predictive in most cases. Fwiw
Click to expand...
i needed to remind myself about this. And found my own post on it. how fortuitous
 
Jcm800 said:
i needed to remind myself about this. And found my own post on it. how fortuitous
Click to expand...

Are you still doing the epidural trialing? Have you adjusted to microdosing?
 
Lol I guess. Honestly I never found there to be that much money in it especially to put up with the hassles especially with it being the one thing that was going to get you called in at night and on the weekends or holidays.
 
Laryngospasm said:
Lol I guess. Honestly I never found there to be that much money in it especially to put up with the hassles especially with it being the one thing that was going to get you called in at night and on the weekends or holidays.
Click to expand...

It’s a patient who comes into ur office for the rest of their life. Sounds like $$ to me.
 
drusso said:
My SCI patients would disagree. Why should they be punished?
Click to expand...
who is being punished? I didn't tell you to stop treating your SCI patients.

unless you are doing Prialt or baclofen, "new" chronic nonmalignant patients should not be introduced to this therapy, as it is an opioid by a different direction.

if you have a pump and have been using it for years, then you are a Legacy patient, and you just have to hope that your treating doctor doesn't retire or change his mind about filling them...
 
Ducttape said:
who is being punished? I didn't tell you to stop treating your SCI patients.

unless you are doing Prialt or baclofen, "new" chronic nonmalignant patients should not be introduced to this therapy, as it is an opioid by a different direction.

if you have a pump and have been using it for years, then you are a Legacy patient, and you just have to hope that your treating doctor doesn't retire or change his mind about filling them...
Click to expand...

When a therapy is devalued it effects everyone, but not everyone equitably.
 
when a treatment has been shown to have an untoward high risk to benefit ratio, routine use of this therapy should be appropriately adjusted downwards. unfortunately, financial reimbursement factors inappropriately in this paradigm, and generally not favorably.
 
I still do baclofen pump on appropriate patients . However these have become less frequent sense I refuse to be a monkey for some unscrupulous neurologist who insists on determining who is a candidate or not.

And I still put opiate intrathecal pump’s in patients with end-of-life malignancies. But both have become infrequent.

I have never put one in for back pain.

as far as money, you stil see the patients multiple times a year, it’s not bad from a financial perspective. The actual payment for the pump stuff isn’t great anymore, but what is?
 
I'm not sure the Albany Medical Center neurosurgery team is as financially focused. I guess they could've implanted another IPG/paddle rather than a pump.
 
I had a patient how many stimulator leads can u implant in ur spine? She had neck pain, low back pain and pelvic pain. She asked me why we couldn’t implant them for everything. I didn’t have a good answer other than $$ . Other docs may just have done it bc why not ($$$ ). Wats a good way to answer her ?
 
Orin said:
I'm not sure the Albany Medical Center neurosurgery team is as financially focused. I guess they could've implanted another IPG/paddle rather than a pump.
Click to expand...
They still got the RVUs...
But fine, this then:
1596921153602.jpeg
 
There is a female pain doctor in NorCal who pumps ppl ALL THE TIME. She does really well financially.
 
So intrathecal single shot trials... how much you guys do in cancer patients? 0.5mg?

did an epidural trial on a poor young patient with metastatic breast ca. Results were not overwhelming. Maybe there is some overlying psych issues also, has young children, not dealing with her diagnosis well, etc.

But now, wants the pump. Thinking about re-trialing with IT single shot first. She is still undergoing treatment, but I don’t think she will last a few years...keeps coming back to the hospital. I have low expectations for the trial, but do feel somewhat ethically obligated to make sure I do investigate further before putting a pump in that may not be of benefit. And potentially give me lots of headaches when the miracle isn’t as sublime as they wished...
 
Jcm800 said:
So intrathecal single shot trials... how much you guys do in cancer patients? 0.5mg?

did an epidural trial on a poor young patient with metastatic breast ca. Results were not overwhelming. Maybe there is some overlying psych issues also, has young children, not dealing with her diagnosis well, etc.

But now, wants the pump. Thinking about re-trialing with IT single shot first. She is still undergoing treatment, but I don’t think she will last a few years...keeps coming back to the hospital. I have low expectations for the trial, but do feel somewhat ethically obligated to make sure I do investigate further before putting a pump in that may not be of benefit. And potentially give me lots of headaches when the miracle isn’t as sublime as they wished...
Click to expand...

Just put pump in and use dilaudid.
 
Where's the pain pattern? I would agree the best thing is to put the device in and titrate. You can get a psychological evaluation like you would for an SCS. You can explain the limitations. You can't fix the dying, young kids, etc. You just got to struggle with that.

If you're going to do another trial, put a IT catheter in and run it off an external pump too see what you get.
 
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