Intrathecal Infusion Complications Are a Rare Life-Threatening Occurrence That If Not in the Differential of the Provider Can Have Devastating Consequences

Abstract

SESSION TITLE: Poisoning and Drug Overdose 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Intrathecal analgesia (IA) has allowed for overall decreased side effects in patients requiring long-term, high dose opoids. Though rare, there is at least one life-threatening complication unique to IA. CASE PRESENTATION: 55-year-old female with metastatic rectal carcinoma arrived at pain clinic for routine refill of intrathecal hydromorphone pump. Due to extensive metastatic lesions with bone involvement, the patient has been receiving intrathecal hydromorphone for the past year after failing other pain relief modalities. The patient was given her usual doses of intrathecal medications (hydromorphone 1mg, bupivacaine 40mg/ml, clonidine 50 mcg/ml). After the procedure, the patient became lethargic and encephalopathic in recovery. On vitals, blood pressure was found to be 210/120, much higher than the pre-procedure 130/80. The rest of the vitals were normal, and the patient had a benign physical exam with no focal neurological deficits. The patient was taking immediately to brain computer tomography scan that was negative for acute hemorrhagic stroke. Electrocardiography and bedside echocardiogram did not show any cardiac abnormalities. The patient was transferred to the intensive care unit and started on nicardipine intravenously. A pharmacy error was suspected and the intrathecal pump was reduced to one tenth its previous dose. Blood pressure was slowly corrected to 180/100 in the first hour. The patient’s mental status improved within the first two hours and was able to be discharged the next day. Blood pressure was back to baseline on discharge. DISCUSSION: Intrathecal opoids and alpha 2 agonists have been associated with several potential complications including intracranial hemorrhage, seizure, hypotension, and altered mental status (1,2). Case reports of intrathecal morphine overdoses have described hypertensive emergency as a manifestation of intrathecal opioid overdose (3). In this case, we report a rare scenario where a combination of intrathecal hydromorphone, clonidine, and bupivacaine lead to hypertensive encephalopathy. CONCLUSIONS: This rare cause of paradoxical hypertensive emergency should be considered after patient has had intrathecal medications. Patients may benefit from extended post-procedure monitoring following device manipulation. Reference #1: Sauter, K., Kaufman, H. H., Bloomfield, S. M., Cline, S., & Banks, D. (1994). Treatment of high-dose intrathecal morphine overdose: Case report. Journal of neurosurgery, 81(1), 143-146. Reference #2: Mironer YE, Haasis JC, Chapple I, Brown C, Satterthwaite JR. Efficacy and safety of intrathecal opioid/bupivacaine mixture in chronic nonmalignant pain: A double blind, randomized, crossover, multicenter study by the National Forum of Independent Pain Clinicians (NFIPC). Neuromodulation. 2002;5:208-13. Reference #3: Groudine, S. B., Cresanti-Daknis, C., & Lumb, P. D. (1995). Successful treatment of a massive intrathecal morphine overdose. The Journal of the American Society of Anesthesiologists, 82(1), 292-295. DISCLOSURE: The following authors have nothing to disclose: Pranay Parikh, John Kern, Rajkumar Dasgupta No Product/Research Disclosure Information