Patient-Controlled Spinal Analgesia for Postoperative Pain Control Marc Domsky,
DO,
and David Tarantino,
MD
Department of Anesthesiology, Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland
W
ith continuous spinal anesthesia, maintaining the catheter for postoperative analgesia can be a natural extension of its intraoperative use. The use of a continuous intrathecal catheter for patient-controlled analgesia (PCA) has not been reported. We report a case of patient-controlled spinal analgesia with fentanyl.
Case Report A 70-yr-old woman (111kg, 157 cm) presented with a comminuted subtrochanteric fracture of the right hip. Her medical history included chronic obstructive pulmonary disease, deep venous thrombosis of both lower extremities, and peripheral vascular disease; medications included lorazepam and furosemide. The scheduled procedure was a right femoral intramedullary nailing with a Russell-Taylor Recon nail and cerclage wiring. With the patient in the left lateral decubitus position, a 17-gauge Tuohy needle was placed at the L2-3 interspace, and a 18-gauge catheter (Perifix, Burron, Bethlehem, Pa.) was inserted 3 cm into the subarachnoid space; no paresthesias were elicited during placement. A millipore filter was connected to the catheter. The patient was turned to the supine position, and a total of 50 mg of 5% lidocaine with 7.5% glucose was injected incrementally over 15 min, resulting in a sensory blockade to T-10. The patient was then repositioned supine on a fracture table by the surgeons. Another 50 mg of lidocaine and 12.5 pg of preservative-free fentanyl was injected incrementally through the intrathecal catheter 1 h later, just before making the surgical incision. During the 4.5-h procedure, an additional 150 mg of lidocaine in divided doses was administered through the catheter to maintain a sensory blockade to T-10. The patient was maintained in the horizontal position throughout all Accepted for publication April 17, 1992. Address correspondence to Dr. Domsky, Wayne State University, Department of Anesthesiology, Detroit Receiving Hospital, 4201 St. Antoine, Detroit, MI 48201. 01992 by the International Anesthesia Research Society 0003-2999/92/$5.00
injections and for the duration of the procedure. A total of 6 mg of midazolam and 150 pg of fentanyl was administered intravenously throughout the procedure for sedation in support of the spinal anesthetic. The patient was moving her legs on arrival in the recovery room and complained of pain within 10 min. Her level of sensory blockade was to L-3. Analgesia was evaluated by a visual analogue scale (VAS) in which 10 cm indicated maximal pain and 0 cm complete pain relief. This patient’s pain score was 10. After injection of 12.5 pg of fentanyl through the catheter, her score decreased to 5 within 15 min. A PCA pump (Pancretec, Provider 5500, San Diego, Calif .) with a reservoir of fentanyl in preservative-free normal saline solution (2 pg/mL [250 mLJ) was connected to the catheter. Initial settings were for a 3-mL (6 pg) bolus dose with a lockout interval of 1.5 h. After the patient was instructed in the use of PCA, she was discharged to the stepdown unit with a VAS score of 5, feeling comfortable. Vital signs were monitored every 2 h. The VAS score and level of consciousness were documented every 8 h. Over the next 12 h, 24 mL (48 pg) of fentanyl was used. The patient made a total of 33 requests, 8 of which were delivered. Her VAS score remained 5. The lockout interval was decreased to 1 h. During the next 24 h, 21 rnL (42 pg) of fentanyl was used in seven doses (the patient made nine requests). Her VAS score ranged from 3 to 5. In the final 24-h period of catheter use, the patient’s activity was increased, and she was moved to a chair twice during the day. Fentanyl (33 mL [66 pg]) was administered on 11 occasions (in response to 21 requests). Her VAS score ranged from 1 to 3. Indomethacin and oxycodone with acetaminophen were administered orally. The catheter was removed without difficulty; the tip was sent for culture, and results were negative. The patient never experienced any signs of postdural puncture headache, nausea, pruritus, respiratory depression, or somnolence. She was discharged on the seventh postoperative day, pleased with her treatment. Anesth Analg 1992;75:45>5
453
454
CASE REPORTS
ANESTH ANALG 1992;7545>5
Discussion Renewed interest in continuous spinal anesthesia because of the availability of small-bore spinal catheters has led to a number of reports describing its advantages over both single-dose spinal and continuous epidural anesthesia, but few reports describe the catheter’s use for postoperative analgesia (14).If there are benefits for anesthesia, should there not be benefits for analgesia? Experience with both intrathecal narcotics and PCA led to our combined approach for this patient’s postoperative pain management. A recent study evaluating continuous intrathecal lidocaine infusions for postoperative analgesia found them extremely effective (5); yet other reports suggest that maldistribution and a relatively high dose of local anesthetic may lead to neurotoxicity (6,7). Therefore, we elected to use opioids alone. The high lipid solubility of fentanyl allows for rapid onset of analgesia and limited rostra1 spread. This results in minimal respiratory depression and a short duration of effective analgesia (3-4 h). Patient-controlled analgesia adds a psychologic advantage to postoperative pain management (8). The interval between the onset of pain and delivery of analgesic medication is minimized, and the measure of patients’ control over their own problem undoubtedly plays a significant role in overall comfort and satisfaction. The most serious potential complications associated with this technique include subarachnoid infection, postdural puncture headache, and respiratory depression. Although the incidence of infection should be no different than for a continuous epidural catheter, the sequelae of meningitis may be far greater. Recent studies suggest, however, that colonization and subsequent central nervous system infection should not be a commonly encountered problem (9,lO). Postdural puncture headache remains a controversial issue. Denny et al. (11) recently reported the incidence of postdural puncture headache to be 1.1%among a patient population with a mean age of 63 yr (18-gauge Hustaud needle, 20-gauge catheter). Others have shown a postdural puncture headache rate of 4% and 13% with various sizes of needles and catheters (1,lZ). Of note, the mean age of patients in these studies was significantly less than 63 yr. Suffice it to say that the smallest catheter available should be used in the youngest patients. Respiratory depression should be limited if vigilant patient assessment is performed hourly and optimal therapy is established. The most common problems with PCA therapy are related to operator errors, not the drug or the pump (13). This patient was sent to the stepdown unit postoperatively only because of the duration of her procedure and her overall medical condition. Ready (14) clearly showed that with exten-
sive nursing education, hourly observation for sedation and ventilatory rate, protocols for immediate treatment of complications, and immediate availability of medical personnel, patients can be cared for on conventional hospital wards without special monitors. Recently, Glass et al. (15) used a PCA pump to establish the efficacy of epidural versus intravenous administration of fentanyl. They found that once equieffective analgesia was obtained, both fentanyl utilization and plasma concentrations were similar between the two routes of administration. They suggest that there is little advantage to the epidural administration of fentanyl, because its high lipid solubility leads to rapid systemic absorption. The mean hourly cumulative dose of fentanyl in this 12-h study was 52.1 pg (VAS 2 4 ) . During the first 12 postoperative hours, our patient used a total of 60 pg and thereafter approximately 2 pg/h of fentanyl for the next 24 h (VAS 3-5). Perhaps intrathecal administration of fentanyl will prove to be more efficacious than either epidural or intravenous infusions, because substantially lower dosages of fentanyl may be required to achieve adequate analgesia. Ideal therapy for postoperative analgesia should provide rapid onset of analgesia, easy control, limited tolerance, and few or no side effects. Further investigation of patient-controlled spinal analgesia with fentanyl is necessary to define its role as another modality for postoperative pain management.
References 1. Hurley R], Lambert DH. Continuous spinal anesthesia with a microcatheter technique: preliminary experience. Anesth Analg 1990;70:97-102. 2. Sutter PA, Gamulin Z, Forster A. Comparison of continuous spinal and continuous epidural anaesthesia for lower limb surgery in elderly patients. A retrospective study. Anaesthesia 1989;44:47-50. 3. Shroff PK, Skerman JH, Blass NH. Continuous spinal blockade: an old technique revisited. South Med J 1988;81:17%80. 4. Johnson MD, Hurley RJ, Gilbertson LI, Datta S. Continuous microcatheter spinal anesthesia with subarachnoid meperidine for labor and delivery. Anesth Analg 1990;70:658-61. 5. Bevacqua BK, Slucky AV, Adusumilli SB. Post-operative analgesia with continuous intrathecal lidocaine infusion (abstract). Anesthesiology 1990;73:A833. 6 . Rigler ML, Drasner K, Krejcie TC, et al. Cauda equina syndrome after continuous spinal anesthesia. Anesth Anal 1991; 72275-81. 7. Lambert DH, Hurley RJ. Cauda equina syndrome and continuous spinal anesthesia. Anesth Analg 1991;72:817-9. 8. White PF. Use of patient-controlled analgesia for management of acute pain. JAMA 1988;259:243-7. 9. Stene JK, Simjee S, Jaberi M, Burns B. Lack of infections from long term post-trauma epidural analgesia (abstract). Anesthesiology 1989;71:A747. 10. Bevacqua B, Slucky A, Nemec D. Is post-operative intrathecal catheter use associated with CNS infections (abstract). Anesthesiology 1990;73:A791. 11. Denny N, Masters R, Pearson D, Read J, Sihota M, Selander D.
ANESTH ANALG 1992;75:45%5
Postdural puncture headache after continuous spinal anesthesia. Anesth Analg 1987;66:7914. 12. Giuffrida JG, Bizzarri DV, Masi R, Bondoc R. Continuous procaine spinal anesthesia for cesarean section. Anesth Analg 1972;51:117-24. 13. White PF. Mishaps with patient-controlled analgesia (PCA). Anesthesiology 1987;66:81-3.
CASE REPORTS
455
14. Ready LB. Acute peridural narcotic therapy. In: Brown D, ed. Problems in anesthesia: perioperative analgesia. Philadelphia: JB Lippincott, 1988:327-38. 15. Glass PSA, Estok P, Ginsberg B, Goldberg JS, Sladen RN. Use of patient-controlled analgesia to compare the efficacy of epidural to intravenous fentanyl administration. Anesth Analg 1992;74:345-51.
DO,
and David Tarantino,
MD
Department of Anesthesiology, Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland
W
ith continuous spinal anesthesia, maintaining the catheter for postoperative analgesia can be a natural extension of its intraoperative use. The use of a continuous intrathecal catheter for patient-controlled analgesia (PCA) has not been reported. We report a case of patient-controlled spinal analgesia with fentanyl.
Case Report A 70-yr-old woman (111kg, 157 cm) presented with a comminuted subtrochanteric fracture of the right hip. Her medical history included chronic obstructive pulmonary disease, deep venous thrombosis of both lower extremities, and peripheral vascular disease; medications included lorazepam and furosemide. The scheduled procedure was a right femoral intramedullary nailing with a Russell-Taylor Recon nail and cerclage wiring. With the patient in the left lateral decubitus position, a 17-gauge Tuohy needle was placed at the L2-3 interspace, and a 18-gauge catheter (Perifix, Burron, Bethlehem, Pa.) was inserted 3 cm into the subarachnoid space; no paresthesias were elicited during placement. A millipore filter was connected to the catheter. The patient was turned to the supine position, and a total of 50 mg of 5% lidocaine with 7.5% glucose was injected incrementally over 15 min, resulting in a sensory blockade to T-10. The patient was then repositioned supine on a fracture table by the surgeons. Another 50 mg of lidocaine and 12.5 pg of preservative-free fentanyl was injected incrementally through the intrathecal catheter 1 h later, just before making the surgical incision. During the 4.5-h procedure, an additional 150 mg of lidocaine in divided doses was administered through the catheter to maintain a sensory blockade to T-10. The patient was maintained in the horizontal position throughout all Accepted for publication April 17, 1992. Address correspondence to Dr. Domsky, Wayne State University, Department of Anesthesiology, Detroit Receiving Hospital, 4201 St. Antoine, Detroit, MI 48201. 01992 by the International Anesthesia Research Society 0003-2999/92/$5.00
injections and for the duration of the procedure. A total of 6 mg of midazolam and 150 pg of fentanyl was administered intravenously throughout the procedure for sedation in support of the spinal anesthetic. The patient was moving her legs on arrival in the recovery room and complained of pain within 10 min. Her level of sensory blockade was to L-3. Analgesia was evaluated by a visual analogue scale (VAS) in which 10 cm indicated maximal pain and 0 cm complete pain relief. This patient’s pain score was 10. After injection of 12.5 pg of fentanyl through the catheter, her score decreased to 5 within 15 min. A PCA pump (Pancretec, Provider 5500, San Diego, Calif .) with a reservoir of fentanyl in preservative-free normal saline solution (2 pg/mL [250 mLJ) was connected to the catheter. Initial settings were for a 3-mL (6 pg) bolus dose with a lockout interval of 1.5 h. After the patient was instructed in the use of PCA, she was discharged to the stepdown unit with a VAS score of 5, feeling comfortable. Vital signs were monitored every 2 h. The VAS score and level of consciousness were documented every 8 h. Over the next 12 h, 24 mL (48 pg) of fentanyl was used. The patient made a total of 33 requests, 8 of which were delivered. Her VAS score remained 5. The lockout interval was decreased to 1 h. During the next 24 h, 21 rnL (42 pg) of fentanyl was used in seven doses (the patient made nine requests). Her VAS score ranged from 3 to 5. In the final 24-h period of catheter use, the patient’s activity was increased, and she was moved to a chair twice during the day. Fentanyl (33 mL [66 pg]) was administered on 11 occasions (in response to 21 requests). Her VAS score ranged from 1 to 3. Indomethacin and oxycodone with acetaminophen were administered orally. The catheter was removed without difficulty; the tip was sent for culture, and results were negative. The patient never experienced any signs of postdural puncture headache, nausea, pruritus, respiratory depression, or somnolence. She was discharged on the seventh postoperative day, pleased with her treatment. Anesth Analg 1992;75:45>5
453
454
CASE REPORTS
ANESTH ANALG 1992;7545>5
Discussion Renewed interest in continuous spinal anesthesia because of the availability of small-bore spinal catheters has led to a number of reports describing its advantages over both single-dose spinal and continuous epidural anesthesia, but few reports describe the catheter’s use for postoperative analgesia (14).If there are benefits for anesthesia, should there not be benefits for analgesia? Experience with both intrathecal narcotics and PCA led to our combined approach for this patient’s postoperative pain management. A recent study evaluating continuous intrathecal lidocaine infusions for postoperative analgesia found them extremely effective (5); yet other reports suggest that maldistribution and a relatively high dose of local anesthetic may lead to neurotoxicity (6,7). Therefore, we elected to use opioids alone. The high lipid solubility of fentanyl allows for rapid onset of analgesia and limited rostra1 spread. This results in minimal respiratory depression and a short duration of effective analgesia (3-4 h). Patient-controlled analgesia adds a psychologic advantage to postoperative pain management (8). The interval between the onset of pain and delivery of analgesic medication is minimized, and the measure of patients’ control over their own problem undoubtedly plays a significant role in overall comfort and satisfaction. The most serious potential complications associated with this technique include subarachnoid infection, postdural puncture headache, and respiratory depression. Although the incidence of infection should be no different than for a continuous epidural catheter, the sequelae of meningitis may be far greater. Recent studies suggest, however, that colonization and subsequent central nervous system infection should not be a commonly encountered problem (9,lO). Postdural puncture headache remains a controversial issue. Denny et al. (11) recently reported the incidence of postdural puncture headache to be 1.1%among a patient population with a mean age of 63 yr (18-gauge Hustaud needle, 20-gauge catheter). Others have shown a postdural puncture headache rate of 4% and 13% with various sizes of needles and catheters (1,lZ). Of note, the mean age of patients in these studies was significantly less than 63 yr. Suffice it to say that the smallest catheter available should be used in the youngest patients. Respiratory depression should be limited if vigilant patient assessment is performed hourly and optimal therapy is established. The most common problems with PCA therapy are related to operator errors, not the drug or the pump (13). This patient was sent to the stepdown unit postoperatively only because of the duration of her procedure and her overall medical condition. Ready (14) clearly showed that with exten-
sive nursing education, hourly observation for sedation and ventilatory rate, protocols for immediate treatment of complications, and immediate availability of medical personnel, patients can be cared for on conventional hospital wards without special monitors. Recently, Glass et al. (15) used a PCA pump to establish the efficacy of epidural versus intravenous administration of fentanyl. They found that once equieffective analgesia was obtained, both fentanyl utilization and plasma concentrations were similar between the two routes of administration. They suggest that there is little advantage to the epidural administration of fentanyl, because its high lipid solubility leads to rapid systemic absorption. The mean hourly cumulative dose of fentanyl in this 12-h study was 52.1 pg (VAS 2 4 ) . During the first 12 postoperative hours, our patient used a total of 60 pg and thereafter approximately 2 pg/h of fentanyl for the next 24 h (VAS 3-5). Perhaps intrathecal administration of fentanyl will prove to be more efficacious than either epidural or intravenous infusions, because substantially lower dosages of fentanyl may be required to achieve adequate analgesia. Ideal therapy for postoperative analgesia should provide rapid onset of analgesia, easy control, limited tolerance, and few or no side effects. Further investigation of patient-controlled spinal analgesia with fentanyl is necessary to define its role as another modality for postoperative pain management.
References 1. Hurley R], Lambert DH. Continuous spinal anesthesia with a microcatheter technique: preliminary experience. Anesth Analg 1990;70:97-102. 2. Sutter PA, Gamulin Z, Forster A. Comparison of continuous spinal and continuous epidural anaesthesia for lower limb surgery in elderly patients. A retrospective study. Anaesthesia 1989;44:47-50. 3. Shroff PK, Skerman JH, Blass NH. Continuous spinal blockade: an old technique revisited. South Med J 1988;81:17%80. 4. Johnson MD, Hurley RJ, Gilbertson LI, Datta S. Continuous microcatheter spinal anesthesia with subarachnoid meperidine for labor and delivery. Anesth Analg 1990;70:658-61. 5. Bevacqua BK, Slucky AV, Adusumilli SB. Post-operative analgesia with continuous intrathecal lidocaine infusion (abstract). Anesthesiology 1990;73:A833. 6 . Rigler ML, Drasner K, Krejcie TC, et al. Cauda equina syndrome after continuous spinal anesthesia. Anesth Anal 1991; 72275-81. 7. Lambert DH, Hurley RJ. Cauda equina syndrome and continuous spinal anesthesia. Anesth Analg 1991;72:817-9. 8. White PF. Use of patient-controlled analgesia for management of acute pain. JAMA 1988;259:243-7. 9. Stene JK, Simjee S, Jaberi M, Burns B. Lack of infections from long term post-trauma epidural analgesia (abstract). Anesthesiology 1989;71:A747. 10. Bevacqua B, Slucky A, Nemec D. Is post-operative intrathecal catheter use associated with CNS infections (abstract). Anesthesiology 1990;73:A791. 11. Denny N, Masters R, Pearson D, Read J, Sihota M, Selander D.
ANESTH ANALG 1992;75:45%5
Postdural puncture headache after continuous spinal anesthesia. Anesth Analg 1987;66:7914. 12. Giuffrida JG, Bizzarri DV, Masi R, Bondoc R. Continuous procaine spinal anesthesia for cesarean section. Anesth Analg 1972;51:117-24. 13. White PF. Mishaps with patient-controlled analgesia (PCA). Anesthesiology 1987;66:81-3.
CASE REPORTS
455
14. Ready LB. Acute peridural narcotic therapy. In: Brown D, ed. Problems in anesthesia: perioperative analgesia. Philadelphia: JB Lippincott, 1988:327-38. 15. Glass PSA, Estok P, Ginsberg B, Goldberg JS, Sladen RN. Use of patient-controlled analgesia to compare the efficacy of epidural to intravenous fentanyl administration. Anesth Analg 1992;74:345-51.
