Dermot R. Fitzgibbon

Chronic Pain Management American Society of Anesthesiologists Closed Claims Project

BackgroundThe practice of chronic pain management has grown steadily in recent years. The purpose of this study was to identify and describe issues and trends in liability related to chronic pain management by anesthesiologists. MethodsData from 5,475 claims in the American Society of Anesthesiologists Closed Claims Project database between 1970 and 1999 were reviewed to compare liability related to chronic pain management with that related to surgical and obstetric (surgical/obstetric) anesthesia. Acute pain management claims were excluded from analysis. Outcomes and liability characteristics between 284 pain management claims and 5,125 surgical/obstetric claims were compared. ResultsClaims related to chronic pain management increased over time (P < 0.01) and accounted for 10% of all claims in the 1990s. Compensatory payment amounts were lower in chronic pain management claims than in surgical/obstetric anesthesia claims from 1970 to 1989 (P < 0.05), but during the 1990s, there was no difference in size of payments. Nerve injury and pneumothorax were the most common outcomes in invasive pain management claims. Epidural steroid injections accounted for 40% of all chronic pain management claims. Serious injuries, involving brain damage or death, occurred with epidural steroid injections with local anesthetics and/or opioids and with maintenance of implantable devices. ConclusionsFrequency and payments of claims associated with chronic pain management by anesthesiologists increased in the 1990s. Brain damage and death were associated with epidural steroid injection only when opioids or local anesthetics were included. Anesthesiologists involved in home care of patients with implanted devices such as morphine pumps and epidural injections or patient-controlled analgesia should be aware of potential complications that may have severe outcomes.

Management of bladder function after outpatient surgery.

BACKGROUND This study was designed to test a treatment algorithm for management of bladder function after outpatient general or local anesthesia. METHODS Three hundred twenty-four outpatients, stratified into risk categories for urinary retention, were studied. Patients in category 1 were low-risk patients (n = 227) having non-pelvic surgery and randomly assigned to receive 10 ml/kg or 2 ml/kg of intravenous fluid intraoperatively. They were discharged when otherwise ready, without being required to void. Patients in category 2 (n = 40), also presumed to be low risk, had gynecologic surgery. High-risk patients included 31 patients having hernia or anal surgery (category 3), and 31 patients with a history of retention (category 4). Bladder volumes were monitored by ultrasound in those in categories 2-4, and patients were required to void (or be catheterized) before discharge. The incidence of retention and urinary tract symptoms after surgery were determined for all categories. RESULT Urinary retention affected 0.5% of category 1 patients and none of category 2 patients. Median time to void after discharge was 75 min (interquartile range 120) in category 1 patients (n = 27) discharged without voiding. Fluids administered did not alter incidence of retention or time to void. Retention occurred in 5% of high-risk patients before discharge and recurred in 25% after discharge. CONCLUSION In reliable patients at low risk for retention, voiding before discharge appears unnecessary. In high-risk patients, continued observation until the bladder is emptied is indicated to avoid prolonged overdistention of the bladder.

Intravenous high-dose methadone administered by patient controlled analgesia and continuous infusion for the treatment of cancer pain refractory to high-dose morphine

The management of severe tumor-related pain in the patient with cancer may be problematic. Systemically administered opioids remain the cornerstone of treatment for moderate to severe cancer pain, while parenteral routes should be considered for patients who require rapid onset of analgesia, and for highly tolerant patients whose dose requirements cannot be conveniently administered. The use of intravenous methadone by patient controlled analgesia (PCA) is attractive for the management of severe, intractable cancer pain and may offer some advantages over morphine. We describe the safe and effective use of high-dose intravenous methadone by PCA and continuous infusion for a patient with intractable tumor-associated cancer pain who experienced inadequate pain control and dose-limiting side-effects with high-dose intravenous morphine.

Initial pharmacokinetic, safety and efficacy evaluation of nasal morphine gluconate for breakthrough pain in cancer patients

&NA; Patients with controlled background pain associated with cancer frequently also experience episodes of moderate to severe intensity breakthrough pain. Opioid pharmacotherapy, particularly with oral morphine, remains the cornerstone for the management of cancer pain. Nasal administration of opioids provides a mechanism for more rapid drug absorption and more rapid onset of pain relief compared with oral dosing. This non‐randomized, open‐label, uncontrolled investigation evaluated the pharmacokinetics, safety and efficacy of a single 40 mg dose of nasal morphine gluconate, administered to cancer patients in response to an episode of breakthrough pain. Single dose nasal morphine gluconate administered to 11 patients was associated with effective plasma morphine concentrations (mean Cmax 64 ng/ml; range 33.8–121 ng/ml) and low plasma morphine metabolites (morphine‐6‐glucuronide mean Cmax 114 ng/ml; range 46–189 ng/ml; morphine‐3‐glucuronide mean Cmax 572 ng/ml; range 257–990 ng/ml). Side effects were minor and limited to nasal irritation. Patients reported rapid onset of pain relief (perceptible pain relief achieved in 10/11 patients, time to onset 2.4±2.1 min; and meaningful pain relief, achieved in five patients, 6.8±7.3 min to onset, mean tmax 0.36 h). Pain intensity scores were significantly reduced at all times after dosing; pain relief scores were unchanged. Patient satisfaction ratings were high. These results show that nasal morphine has rapid absorption and apparent onset of effect. Additional multi‐dose, dose‐ranging and placebo‐controlled studies of nasal morphine for cancer pain are warranted.

Malpractice Claims Associated with Medication Management for Chronic Pain

Background:Medication management is an integral part of chronic pain management. Prompted by an increase in the role of medication management in anesthesia chronic pain liability, we investigated the characteristics of malpractice claims collected from 2005 to 2008. Methods:After Institutional Review Board approval, we compared medication management claims with other chronic pain claims from the American Society of Anesthesiologists Closed Claims Database of 8,954 claims. Claims for death underwent in-depth analysis. Results:Medication management represented 17% of 295 chronic non-cancer pain claims. Compared with other chronic pain claims, medication management patients tended to be younger men (P < 0.01) with back pain. Most patients were prescribed opioids (94%) and also additional psychoactive medications (58%). Eighty percent of patients had at least one factor commonly associated with medication misuse and 24% had ≥ 3 factors. Most claims (82%) involved patients who did not cooperate in their care (69%) or inappropriate medication management by physicians (59%). Death was the most common outcome in medication management claims (57% vs. 9% in other chronic pain claims, P < 0.01). Factors associated with death included long-acting opioids, additional psychoactive medications, and ≥ 3 factors commonly associated with medication misuse. Alleged addiction from prescribed opioids was the complaint in 24%. Appropriateness of care and payments was similar for medication management versus other chronic pain claims. Conclusions:Most anesthesia malpractice claims for medication management problems involved patients with a history of risk behaviors commonly associated with medication misuse. Malpractice claims arising from medication management had a high proportion of deaths with both patient and physician contributions to the outcome.

Ultra-Low Dose Ketamine and Memantine Treatment for Pain in an Opioid-Tolerant Oncology Patient

Patients taking high-dose opioids chronically for tumor-related or neuropathic pain may develop pain that is refractory to opioids. One option for control of such pain is the use of the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine. We describe a case of opioid-refractory pain that responded to a low-dose IV infusion of ketamine in the inpatient setting. The patient was then successfully transitioned to oral memantine for long-term outpatient management, in a novel use of this oral NMDA receptor antagonist. We present recent findings from basic research on pain mechanisms to explain why opioid tolerance, as in this patient, may contribute to the analgesic benefit of NMDA receptor antagonists.

The control of severe cancer pain by continuous intrathecal infusion and patient controlled intrathecal analgesia with morphine, bupivacaine and clonidine

The management of severe cancer pain may be problematic in spite of recent advances in pain management. A small percentage of patients with severe intractable pain and/or intractable side effects may require more aggressive interventional pain management strategies including the administration of medications continuously by the intrathecal route. A variety of medications, including morphine, bupivacaine, and clonidine, may be used intrathecally for the control of cancer pain. Optimal use of these medications requires individual titration to the patients needs. We describe a case of severe cancer pain where these medications were used successfully by continuous intrathecal infusion and patient controlled intrathecal analgesia.

Computed tomography-guided neurolytic celiac plexus block with alcohol complicated by superior mesenteric venous thrombosis.

Neurolytic celiac plexus block (CPB) under radiological guidance is often performed to manage pain associated with pancreatic cancer. Serious complications related to the block are rare. Computed Tomography (CT)-guided neurolytic CPB is advocated to improve the efficacy of the block and to reduce the incidence of associated complications. We describe a case of superior mesenteric vein thrombosis associated with neurolytic CPB performed under CT guidance.

Rebound hypertension and acute withdrawal associated with discontinuation of an infusion of epidural clonidine

A small percentage of patients with cancer pain suffer from refractory pain despite aggressive therapy. 1 Intraspinal administration of opioids and local anesthetic agents may be helpful in such settings, but their use may be limited by side effects such as motor block and hemodynamic instability. 2,3 Clonidine is a centrally acting α 2 -adrenergic agonist with established analgesic effects 4,5 and has synergistic effects with spinal opioids 6,7 and spinal local anesthetics. 8,9 Epidural clonidine produces analgesia by a spinal mechanism in patients after surgery and in those with cancer pain, 10 and it appears to be an effective treatment for severe cancer pain in patients for whom other treatments are ineffective. 11 Although the risk of acute withdrawal and rebound hypertension is well recognized with sudden cessation of systemically administered clonidine, 12 no such reports exist with regard to epidurally administered clonidine. We describe a case of acute withdrawal and rebound hypertension after abrupt cessation of epidural clonidine in a patient with intractable cancer pain.

Injury and Liability Associated with Implantable Devices for Chronic Pain

Background:Due to an increase in implantable device–related anesthesia pain medicine claims, the authors investigated anesthesia liability associated with these devices. Methods:After institutional review board approval, the authors identified 148 pain medicine device claims from 1990 or later in the Anesthesia Closed Claims Project Database. Device-related damaging events included medication administration events, infections, hematomas, retained catheter fragments, cerebrospinal fluid leaks, cord or cauda equina trauma, device placed at wrong level, stimulator incorrectly programmed, delay in recognition of granuloma formation, and other issues. Results:The most common devices were implantable drug delivery systems (IDDS; 64%) and spinal cord stimulators (29%). Device-related care consisted of surgical device procedures (n = 107) and IDDS maintenance (n = 41). Severity of injury was greater in IDDS maintenance claims (56% death or severe permanent injury) than in surgical device procedures (26%, P < 0.001). Death and brain damage in IDDS maintenance claims resulted from medication administration errors (n = 13; 32%); spinal cord injury resulted from delayed recognition of granuloma formation (n = 9; 22%). The most common damaging events for surgical device procedures were infections, inadequate pain relief, cord trauma, retained catheter fragments, and subcutaneous hygroma. Care was more commonly assessed as less than appropriate (78%) and payments more common (63%) in IDDS maintenance than in surgical device procedure claims (P < 0.001). Conclusions:Half of IDDS maintenance claims were associated with death or permanent severe injury, most commonly from medication errors or failure to recognize progressive neurologic deterioration. Practitioners implanting or managing devices for chronic pain should exercise caution in these areas to minimize patient harm.