Using Intrathecal Patient-Controlled Analgesia in the Postop Setting: Case Report

Interview with Alec Peniche, MD, Lawrence Poree, MD, PhD, Xiaobing Yu, MD

Patient-controlled anesthesia (PCA) is not new to pain management, but using intrathecal patient-controlled anesthesia (IT-PCA) does remain a controversial topic amidst concerns over patient safety.

However, a team of researchers at the University of California San Francisco recently reported their first successful case using IT-PCA as part of an acute postoperative multimodal regimen.¹According to the team, IT-PCA could be a beneficial form of treatment for patients with prior exposure to intrathecal pump treatment.

“At this time, we do not feel that patients without implanted intrathecal pumps [ITP] would be good candidates for IT-PCA given their ‘naïve’ status to intrathecal opioids. In obstetric [OB] patients with spinal catheters, IT-PCA is also rarely used in part due to similar safety concerns,” the doctors explained.

“Our patient had prior experience with her ITP activator and we did not make any changes to her intrathecal pump settings during the perioperative period. It seems that patients with prior experience would do better with this therapy as cessation of their IT-PCA may result in a loss of a significant portion of their baseline opioid requirement in addition to poor postoperative pain control,” the doctors told Practical Pain Management.

The Case Study

In the case study, a 70-year-old woman with chronic obstructive pulmonary disease (COPD) and scoliosis was set to receive a T10 to pelvis posterior spinal fusion. With a history of multiple spinal surgeries, including implantation of an intrathecal pump and a spinal cord stimulator, the patient was experienced with intrathecal drug delivery.

Indeed, ITP interrogation on the day of the surgery showed the patient receiving an infusate mixture of hydromorphone, ketamine, bupivacaine, and clonidine “with greater than one-third of the daily dose delivered via the IT-PCA with the catheter located at the T4 level,” the doctors wrote.

Following the procedure, the patient was put on mechanical ventilation and continued IT infusion with additional intravenous (IV) infusions of propofol, fentanyl, and ketamine. Despite continued IV ketamine and transition to high-dose IV hydromorphone PCA, the patient was experiencing poor pain control.

After serious multidisciplinary discussion among the patient’s care team, the patient was allowed use of her IT-PCA, which appeared to provide improved analgesia. The patient was discharged to an acute rehabilitative facility on day 7 after surgery with no changes to her ITP settings.

Maintaining IT-PCA: Effective Post-Op Analgesia for the Right Patient?

According to the doctors, limiting in-patient IT-PCA could lead to escalating opioid doses administered IV, potentially leading to patient complications and increased length of stay. However, while this case illustrates a successful integration of IT-PCA, doctors should be aware of the safety concerns involved with IT-PCA during postoperative care.

“The potential serious adverse events (i.e., respiratory depression and hemodynamic change) from IT-PCA use during perioperative period, particularly postoperatively, are the major concerns of the anesthesia providers. Many providers are comfortable managing systemic opioid therapies and providing spinal anesthesia, however the lack of knowledge and experience with the use of IT-PCA via intrathecal pump prompts their safety concerns,” the doctors said.

“In addition, the widespread addition of potent medications such as ketamine, clonidine, and baclofen into intrathecal infusion solutions and high-dose settings further discourage the providers from considering use of IT-PCA for acute postoperative pain control,” the doctors said.

Because of this, close communication among providers is “vital,” for ensuring patient safety with IT-PCA, the doctors pointed out.

The doctors are currently developing a hospital policy for this form of analgesia. “This is the first in-hospital policy for patient activated implanted pump protocol that we are aware of.” However, while another patient recently received IT-PCA for their postoperative pain control, the doctors do not expect this to become a standard of care in postoperative treatment.

Rather, IT-PCA should be considered on a case-by-case basis with specific safety measures in place, including close monitoring with telemetry and continuous pulse oximetry. “The inpatient pain service should be designated to manage the intrathecal pump. Hospital pharmacists need to be aware of the medications that are being infused and nursing must document the frequency of daily IT-PCA use in addition to all other opioid medications given throughout the postoperative period,” the doctors noted.

Reference

1. Peniche A, Higgins E, Lieberman J, et al. Integrating intrathecal patient-controlled analgesia into postoperative pain management. Poster presented at: Regional Anesthesiology and Acute Pain Medicine Meeting. April 6-8, 2017; San Francisco, CA. Poster 3356.