Edema caused by continuous epidural hydromorphone infusion: A case report and review of the literature

Authors

  • Xiulu Ruan, MD
  • Riaz Tadia, MD
  • Hainan Liu, MS
  • John Patrick Couch, MD
  • John Keun-Sang Lee, MD, PhD

DOI:

https://doi.org/10.5055/jom.2008.0029

Keywords:

edema, epidural hydromorphone infusion, epidural morphine infusion, intraspinal drug delivery, failed back surgery syndrome

Abstract

Background: Intraspinal drug delivery (IDD) therapy has been increasingly employed in patients with intractable, nonmalignant pain. Before implantation of permanent intraspinal pump, an intraspinal opioid screening trial is conducted to demonstrate the efficacy. The patient-controlled continuous epidural opioid infusion trail, performed in an outpatient setting, is widely accepted by many interventional pain specialists.
Objective: To report a case of severe edema observed during the continuous epidural hydromorphone infusion trial.
Case Report: An otherwise healthy 68-year-old lady with a 5-year history of severe low back pain and bilateral leg pain because of failed back surgery syndrome was referred to our clinic for IDD therapy.
A tunneled lumbar epidural catheter was placed at L2- L3 with catheter tip advanced to L1 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The catheter was then tunneled subcutaneously and connected to a Microject™ patient-controlled epidural analgesia (PCEA) pump (Codman, Raynham, MA). The pump was programmed to deliver hydromorphone (0.1 mg/ml) at basal rate of 0.3 ml/h. The bolus dose was 0.1 ml with a 60-minute lockout interval. The patient was instructed how to operate the infusion pump. During the following infusion trial, she reported satisfactory analgesia (>70 percent pain reduction) and was able to wean off her other systemic opioids. However, she developed diffuse edema and gained over 16 pounds during the 5-day infusion trial. Her edema finally resolved 3-4 days after termination of the epidural infusion.
Conclusion: Edema may occur and persist during epidural hydromorphone infusion. This report represents the first case report, to the best of our knowledge, describing severe edema in a patient on continuous epidural hydromorphone administration during an outpatient epidural infusion trial.

Author Biographies

Xiulu Ruan, MD

Associate Medical Director, Physicians’ Pain Specialists of Alabama, Mobile, Alabama; Adjunct Assistant Professor of Neurology, College of Medicine, University of South Alabama, Mobile, Alabama.

Riaz Tadia, MD

Department of Neurology, College of Medicine, University of South Alabama, Mobile, Alabama.

Hainan Liu, MS

Department of Urology, Qilu Hospital, 44 Wen Hua Xi Road, Shandong University, Jinan, Shandong, China.

John Patrick Couch, MD

Medical Director, Physicians’ Pain Specialists of Alabama, Mobile, Alabama; Adjunct Assistant Professor of Neurology, College of Medicine, University of South Alabama, Mobile, Alabama.

John Keun-Sang Lee, MD, PhD

Lac, Medical Director, Jefferson Pain and Rehabilitation Center and the Migraine Center, Pittsburgh, Pennsylvania; Clinical Professor, College of Medicine, Korea University, Seoul, Korea.

References

Krames, E: Intraspinal analgesia for nonmalignant pain. In Waldman SD (ed.): Interventional Pain Management, 2nd ed. Philadelphia, Pennsylvania: W.B. Saunders Company, Vol. 60. 2001: 609-619.

Raphael JH, Southall JL, Gnanadurai TV, et al.: Long-term experience with implanted intrathecal drug administration systems for failed back syndrome and mechanical low back pain. BMC Musculoskeletal Disord. 2002; 3: 17.

Deer T, Chapple I, Classen A, et al.: Intrathecal drug delivery for treatment of chronic low back pain: Report from the National Outcomes Registry for Low Back Pain. Pain Med. 2004; 5: 6-13.

Kumar K, Kelly M, Pirlot T: Continuous intrathecal morphine treatment for chronic pain of nonmalignant etiology: Long-term benefits and efficacy. Surg Neurol. 2001; 55: 79-88.

Anderson VC, Burchiel KJ: A prospective study of long-term intrathecal morphine in the management of chronic nonmaligmant pain. Congr Neurol Surg. 1999; 44(2): 289-300.

Paice JA, Penn RD, Shott S: Intraspinal morphine for chronic pain: A retrospective multicenter study. J Pain Symptom Manage. 1996; 11(2): 71-80.

Panchal SJ, Rogers, J: Suggested Guideline: Implantable intrathecal morphine pump trial protocol, Brochure from Codman and Shurtleff. 2002.

DuPen S, DuPen A: Tunneled epidural catheters: Practical considerations and implantation techniques. In Waldman SD (ed.): Interventional Pain Management, 2nd ed. Philadelphia, Pennsylvania: W.B. Saunders Company, Vol. 60. 2001: 627-643.

Gardner-Nix J: Opioids causing peripheral edema. J Pain Symptom Manage. 2002; 23(6): 453-455.

O’Conor LM, Woody G, Yeh HS, et al.: Methadone and edema. J Subst Abuse Treat. 1991; 8(3): 153-155.

Rosow CE, Moss J, Philbin DM, et al.: Histamine release during morphine and fentanyl anesthesia. Anesthesiology. 1982; 56(2): 93-96.

Flacke JW, Flacke WE, Bloor BC, et al.: Histamine release by four narcotics: A double-blind study in humans. Anesth Analg. 1987; 66(8): 723-730.

Grossmann M, Abiose A, Tangphao O, et al.: Morphineinduced venodilation in humans. Clin Pharmacol Ther. 1996; 60(5): 554-560.

Philbin DM, Moss J, Akins CW, et al.: The use of H1 and H2 histamine antagonists with morphine anesthesia: A doubleblind study. Anesthesiology. 1981; 55(3): 292-296.

Rapp SE, Egan KJ, Ross BK, et al.: A multi-dimensional comparison of morphine and hydromorphone patient-controlled analgesia. Anesth Analg. 1996; 82: 1043-1048.

Guedes AG, Papich MG, Rude EP, et al.: Comparison of plasma histamine levels after administration of hydromorphone and morphine in dogs. J Vet Pharmacol Ther. 2007; 30(6): 516-522.

American Pain Society: Principles of Analgesic Use in the Treatement of Acute Pain and Cancer Pain, Fifth Edition. Glenview, IL: American Pain Society, 2003: 22.

De Bodo RC: The antidiuretic action of morphine and its metabolism. J Pharmacol Exp Ther. 1944; 82: 74-85.

Bisset GW, Chowdrey HS, Feldberg W, et al.: Release of vasopressin by enkephalin. Br. J. Pharmacol. 1978; 62: 370-372.

Chaney MA: Side effects of intrathecal and epidural opioids. Can J Anaesth. 1995; 42: 891-993.

Grell S, Christensen JD, Fjalland B, et al.: Morphine antidiuresis in conscieous rats: Contribution of vasopressin and blood pressure. Acta Pharmacol Toxicol (Copenh). 1985; 56(1): 38-43.

Aziz LA, Forsling ML, Woolf CJ, et al.: The effect of intracerebroventricular injections of morphine on vasopressin release in rat. J Physiol. 1981; 311: 401-409.

Firemark HM, Weitzman RE: Effects of beta-endormphin, morphine and naloxone on arginine vasopressin secretion and the electroencephalogram. Neuroscience. 1979; 4(12): 1895-1902.

Walker LA, Murphy JC: Antinatriuretic effect of acute morphine administration in conscious rats. J Pharmacol Exp Ther. 1984; 229(2): 404-408.

Huidobro-Toro J, Huidobro F: Central effects of morphine, levorphanol, (_)-methadone and the opioid-like peptides betaendorphin and D-alanine2-methionine enkephalinamide on urine volume outflow and electrolytes. J Pharmacol Exp Ther. 1981; 217: 570-585.

Danesh S, Walker L: Effects of central administration of morphine on renal function in conscious rats. J Pharmacol Exp Ther. 1988; 244(2): 640-645.

Aldrete JA, Couto da Silva JM: Leg edema from intrathecal opiate infusions. Eur J Pain. 2000; 4(4): 361-365.

Anderson VC, Cooke B, Burchiel KJ, et al.: Intrathecal hydromorphone for chronic nonmalignant pain: A retrospective study. Pain Med. 2001; 2(4): 287-297.

Winkelmuller M, Winkelmuller, W: Long-term effects of continuous intrathecal opioid treatment in chronic pain of nonmalignant etiology. J Neurosurg. 1996; 85(3): 458-467.

Ruan X: Drug-related side effects of long-term intrathecal morphine therapy: Focused review. Pain Physician. 2007; 10: 357-365.

Downloads

Published

01/30/2018

How to Cite

Ruan, MD, X., R. Tadia, MD, H. Liu, MS, J. P. Couch, MD, and J. K.-S. Lee, MD, PhD. “Edema Caused by Continuous Epidural Hydromorphone Infusion: A Case Report and Review of the Literature”. Journal of Opioid Management, vol. 4, no. 4, Jan. 2018, pp. 255-9, doi:10.5055/jom.2008.0029.

Issue

Section

Case Studies