Intrathecal analgesia

Epidural/Intrathecal- Presence of infection at the injection microinfusion site concomitant anticoagulant therapy uncontrolled bleeding diathesis parenterally administered corticosteroids within a 2-week period, other concomitant drug therapy or medical condition that would contraindicate the technique of epidural or intrathecal analgesia acute bronchial asthma upper airway obstruction. 

It is mainly indicated for analgesia, as preanaesthetic medication, for epidural and intrathecal analgesia. 

Dautheribes M, Guerin J. Analgesic par voie intrathecal Aproposde 50 cas. [Intrathecal analgesia. Apropos of 50 cases.] Neurochirurgie 1988 34(3) 194-7. 

Cohen SP, Dragovich A. Intrathecal analgesia. Med Clin North Am 2007 91(2) 251-270. 

Contraindications Prialt is contraindicated in patients with a known hypersensitivity to ziconotide or any of its formulation components and in patients with any other concomitant treatment or medical condition that would render intrathecal administration hazardous. Patients with a preexisting history of psychosis should not be treated with ziconotide. Contraindications to the use of intrathecal analgesia include conditions such as the presence of infection at the microinfusion injection site, uncontrolled bleeding diathesis, and spinal canal obstruction that impairs circulation of CSF. 

Johnston IN, Milligan ED, Wieseler-Frank J, Frank MG, Zapata V, Campisi J (2004) A role for proinflammatory cytokines and fractaUdne in analgesia, tolerance, and subsequent pain facilitation induced by chronic intrathecal morphine. J Neurosci 24(33) 7353-7365 Kim YS, Panganiban AT (1993) The full-length tat protein is required for TAR-independent, post-transcriptional trans activation of human immunodeficiency virus type 1 env gene expression. J Virol 67(7) 3739-3747... 

Epidural analgesia is frequently used for lower extremity procedures and pain (e.g., knee surgery, labor pain, and some abdominal procedures). Intermittent bolus or continuous infusion of preservative-free opioids (morphine, hydromorphone, or fentanyl) and local anesthetics (bupivacaine) may be used for epidural analgesia. Opiates given by this route may cause pruritus that is relieved by naloxone. Adverse effects including respiratory depression, hypotension, and urinary retention may occur. When epidural routes are used in narcotic-dependent patients, systemic analgesics must also be used to prevent withdrawal since the opioid is not absorbed and remains in the epidural space. Doses of opioids used in epidural analgesia are 10 times less than intravenous doses, and intrathecal doses are 10 times less than epidural doses (i.e., 10 mg of IV morphine is equivalent to 1 mg epidural morphine and 0.1 mg of intrathecally administered morphine).45... 

Intrathecal (IT) Into the subarachnoid space between two of the membranes (meninges) separating the spinal cord from the vertebral column. This route is used for drugs that do not penetrate the blood-brain barrier, but which are required for their central action (e.g., antibiotics). Drugs can also be injected spinally (into the epidural space) for local anaesthesia or analgesia. 

Regional analgesia with local anesthetics (Table 54-6) can provide relief of both acute and chronic pain. Anesthetics can be positioned by injection (i.e., in joints, in the epidural or intrathecal space, along nerve roots) or applied topically. 

Proudfit, H. K., and Hammond, D. L. (1981) Alterations in nociceptive threshold and morphine-induced analgesia by intrathecally administered amine antagonists. Brain Res.. 218 393-399. 

Similar to tobacco, lobelia may also have analgesic effects. However, it depends on the mode of administration (Damaj et al. 1997). Intrathecal lobeline produces analgesia on the tail-flick test, but subcutaneous administration is ineffective. On the other hand, subcutaneous lobeline dose-dependently enhances nicotine analgesia. Tolerance develops to this effect of lobeline after 10 days. Lobeline can also produce hyperalgesic effects when administered into the dorsal posterior mesencephalic tegmentum (Hamann and Martin 1994). However, the relevance of this to peripheral administration of lobelia is questionable because chronic injections (IP) of lobeline in rats induced no changes in tail-flick latencies (Sopranzi et al. 1991). 

Vercauteren MP et al. Levobupivacaine combined with sufentanil and epinephrine for intrathecal labor analgesia A comparison with racemic bupivacaine. Anesth Analg 2001 93 996-1000. 

Epidural and intrathecal opioids are widely used for postoperative and obstetric analgesia. In contrast to local anaesthetics, spinal opioids cause minimal sympathetic efferent and motor blockade. Pethidine, which has local anaesthetic activity, can produce sensory and motor blockade. Because remifentanil is formulated with glycine as a vehicle, it should not be used epidurally or intrathecally, since glycine is neurotoxic. 

R. Debon, E. Boselli, R. Guyot, et al., Chronopharmacology of Intrathecal Sufentanil for Labor Analgesia Daily Variations in Duration of Action, Anesthesiology 101 (2004) 978-982. 

Dosages and routes of administration Morphine is available in different salt forms but the hydrochloride and sulfate (Vermeire and Remon, 1999) are used preferentially. The compound can be administered by the oral, parenteral or intraspinal route. Oral application is preferred for chronic pain treatment and various slow release forms have been developed to reduce the administration frequency to 2-3 times per day (Bourke et al., 2000). Parenteral morphine is used in intravenous or intramuscular doses of 10 mg, mostly for postoperative pain and self-administration devices are available for patient-controlled analgesia (PCA). Morphine is additionally used for intraspinal (epidural or intrathecal) administration. Morphine is absorbed reasonably well in the lower gastrointestinal tract and can be given as suppositories. 

Mandabach, M. G. Intrathecal and epidural analgesia. Crit. Care Clin. 1999, 15,105-118. 

Intrathecal A form of intraspinal anaesthesia or analgesia in which the agent is injected through the dura mater and arachnoid membrane into the cerebro-spinal fluid which surrounds the spinal cord. 

NK-1, NK-2, and NK-3). Moreover, being metabolically unstable, substance P is proteolyzed rapidly upon in vivo administration, yielding various fragments that are responsible for the bizarre symptoms. The receptor-selective analogues produce dramatically different, and clear cut, behavioral effects when injected intrathecally into rats. Ac-Arg-septide caused profound pain symptoms, whereas senktide caused profound analgesia.132331... 

One case of Staphylococcus aureus meningitis, a rare complication of epidural analgesia, has been published. The same patient developed a cauda equina syndrome of uncertain etiology, although neural ischemia as a result of meningitis secondary to immunosuppression was possible (SEDA-21,420 456). A unique case of transient profound paralysis after epidural glucocorticoid injection (acute paraplegia) has now been reported (SEDA-22, 451 457). Diplopia associated with the peridural or intrathecal infiltration of prednisolone have not been previously reported (SEDA-22, 451 458). 

Tobias JD. A review of intrathecal and epidural analgesia after spinal surgery in children. Anesth Analg. 2004 98 956-965. 

Small quantities of opiate injected intrathecally or epidurally produce segmental analgesia. This observation led to the clinical use of spinal and epidural opiates during surgical procedures and for the relief of postoperative and chronic pain. As with local anesthesia, analgesia is confined to sensory nerves that enter the spinal cord dorsal horn in the vicinity of the injection. Presynaptic opioid receptors inhibit the release of substance P and other neurotransmitters from primary afferents, whereas postsynaptic opioid receptors decrease the activity of certain dorsal horn neurons in the spinothalamic tracts. 

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