Intrathecal chemotherapy: potential for medication error.

BACKGROUND: The central nervous system is a unique sanctuary site for malignant disease. To ensure optimal disease control, intrathecal (IT) chemotherapy is commonly given in conjunction with standard chemotherapy protocols, thus providing the opportunity for medication errors. OBJECTIVE: A systematic review of the current literature on medication errors associated with the administration of IT chemotherapy was conducted. METHODS: English-language literature published from January 1960 through June 2013 was accessed. Case reports, clinical studies, and review articles pertaining to IT medication errors were included in the review. References of all relevant articles were searched for additional citations. RESULTS: Twenty-two cases of accidental IT overdoses have been reported with methotrexate and 1 with cytarabine. There have been numerous cases of antineoplastic agents intended for administration by the parenteral route being inadvertently given intrathecally. Vincristine has been implicated 31 times (25 deaths), as well as vindesine, asparaginase, bortezomib, daunorubicin, and dactinomycin. This has led to profound toxicity and, commonly, death. Unfortunately, many cases go unrecognized or unreported. CONCLUSIONS: The best method for eliminating the risk of IT medication errors is to develop effective methods of prevention and incorporate them into oncology and hematology practice internationally. Strategies include abolishing the syringe as a method of vinca alkaloid administration and substituting small-volume intravenous bags, and developing novel methods for intraspinal drug administration. IMPLICATIONS FOR PRACTICE: The nursing profession is in a unique position to influence change and lead the way in establishing preventative strategies into current practice.

Spinal opioids in postoperative pain relief 1: pharmacology.

This is a two-part unit on using spinal opioids to manage postoperative pain. Part 1 outlines the pharmacology and adverse effects. For details on spinal anatomy and dose levels, plus a table that outlines the differences between spinal anaesthesia and analgesia, and epidural analgesia, see Portfolio Pages at nursingtimes.net.

Spinal opioids in postoperative pain relief. 2: Adverse effects.

This is a two-part unit on using spinal opioids to manage postoperative pain. Part 1 outlined the pharmacology of spinal opioids. Part 2 discusses the selection of patients and their nursing care. It also focuses on the incidence of and response to adverse effects. For further information on contraindications, nursing care and patients' clinical requirements, see Portfolio Pages on nursingtimes.net.

Intrathecal baclofen therapy in adults and guideline for clinical nursing care.

Advancements in healthcare technology for patients with spasticity are promising. Nurses are expected to be well-versed in the use of technology to provide individualized and safe care. The focus of this article is on the current nursing care of patients who use technology such as intrathecal baclofen pumps to manage spasticity. Three phrases of intrathecal baclofen therapy and concurrent clinical nursing care are outlined. A fundamental understanding of the intrathecal baclofen pump allows nurses to provide cutting-edge technological and individualized care with compassion.

Administración de analgesia por catéter espinal / Analgesia administration by spinal catheter

En éste artículo se expone la técnica de administración de analgesia peridural por catéter espinal. Se especifica el uso de las vías epidural e intratectal para administrar analgesia que alivie el dolor, especialmente en pacientes oncológicos. Estas vías permiten la infusión de dosis más bajas de analgésicos que por otras vías parenterales (AU)

Acceso venoso subcutáneo implantable. Manejo / Subcutaneous venous access implants. Handling

En esta segunda parte del artículo sobre accesos venosos subcutáneos implantables se aborda en profundidad el tema de su manejo. Nomenclatura, indicaciones, complicaciones, colocación del dispositivo y cuidados de enfermería son los grandes epígrafes de que consta. En el apartado de cuidados de enfermería se desarrollan los cuidados y mantenimiento, las normas generales, qué hacer ante una resistencia inusual de la inyección, el tratamiento fibrinolítico y el sistema intraespinal (AU)

Current treatment approaches for neoplastic meningitis: nursing management of patients receiving intrathecal DepoCyt.

PURPOSE/OBJECTIVES: To review neoplastic meningitis and the nursing implications for the intrathecal administration of chemotherapy. DATA SOURCES: Published research and educational manuscripts, books, conference proceedings, and personal experience. DATA SYNTHESIS: Standard treatment for neoplastic meningitis includes radiotherapy to the neuraxis to palliate symptomatic disease, intrathecal chemotherapy to eradicate cancer cells in the cerebrospinal axis, and systemic chemotherapy. Intrathecal liposomal cytarabine (DepoCyt), a novel lipid-encapsulated chemotherapeutic agent, prolongs tumor exposure to cytotoxic levels of cytarabine, improves patient response rates, and prolongs time to clinical progression. CONCLUSIONS: DepoCyt prolongs the half-life of cytarabine in the central nervous system, resulting in improved patient response to therapy and delayed disease progression. IMPLICATIONS FOR NURSING PRACTICE: The clinical success of DepoCyt treatment depends on effective implementation of the treatment regimen, attentiveness to patient and family education, and adverse-event management.

Acute pain services in Europe: a 17-nation survey of 105 hospitals. The EuroPain Acute Pain Working Party.

A 17-nation survey was undertaken with the aim of studying the availability of acute pain services (APS) and the use of newer analgesic techniques, such as epidural and patient-controlled analgesia (PCA). A questionnaire was mailed to selected anaesthesiologists in 105 European hospitals from 17 countries. Depending on the population, between five and ten representative hospitals from each country were selected by a country coordinator. A total of 101 (96.2%) completed questionnaires were returned. A majority of respondents were dissatisfied with pain management on surgical wards. Pain management was better in post-anaesthesia care units (PACUs); however, 27% of participating hospitals did not have PACUs. There were no organized APS in 64% of hospitals, although anaesthesiologists from chronic pain centres were available for consultation. In the hospitals that had APS, the responsible person for the APS was either: (1) a junior anaesthesiologist (senior anaesthesiologist available for consultation); or (2) a specially trained nurse (supervised by consultant anaesthesiologists). Many anaesthesiologists were unable to introduce techniques such as PCA on wards because of the high equipment costs. Although 40% of hospitals used a visual analogue scale (VAS) or other methods for assessment of pain intensity, routine pain assessment and documenting on a vital sign chart was rarely practised. There was a great variation in routines for opioid prescription and documentation procedures. Nursing regulations regarding injection of drugs into epidural and intrathecal catheters also varied considerably between countries. This survey of 105 hospitals from 17 European countries showed that over 50% of anaesthesiologists were dissatisfied with post-operative pain management on surgical wards. Only 34% of hospitals had an organized APS, and very few hospitals used quality assurance measures such as frequent pain assessment and documentation. There is a need to establish organized APS in most hospitals and also a need for clearer definition of the role of anaesthesiologists in such APS.

Intrathecal baclofen for spasticity of cerebral palsy: project coordination and nursing care.

Spasticity caused by cerebral palsy is painful and disabling. Infusion of an intrathecal antispasmodic for relief is investigated in a multicenter, interdisciplinary clinical trial. Clinical nurse specialists coordinate local team endeavors. The nursing process serves as a functional framework for project development, protocol implementation and long-term patient follow-up.

Intraspinal devices for pain management.

Intraspinal drug delivery is one of several important pain management therapies. Numerous delivery methods and drugs are available for administration into the epidural or intrathecal space. The choice of systems and drugs is based on the nature and duration of the patient's pain, his or her other medical problems, and patient resources. Patients must be carefully selected to ensure optimal results. Nurses can assist in this screening and perform preoperative teaching, postoperative care, and long-term follow-up. Essential knowledge includes general pain management principles as well as principles of intraspinal drug delivery.

Using a ventricular reservoir to instill amphotericin B.

Intrathecal administration of amphotericin B is the best method of eradicating intracranial fungal infections. The Ommaya reservoir provides an easy and practical method for fungicidal medication administration. Treatment of coccidioidomycosis with amphotericin B may be accomplished via an Ommaya reservoir. Astute nursing care is essential to prevent complications associated with this procedure.

Intrathecal morphine in younger patients for postoperative pain following spinal fusion.

Intrathecal morphine in an average dose of 0.01 mg/kg was given to 33 patients between ages 11 and 16 years who had spinal arthrodesis for idiopathic scoliosis. The morphine was administered intrathecally as a 10 cc bolus at the conclusion of the arthrodesis, but before closure. The goal was to study safety in terms of respiratory depression and pain relief. Respirations occurred spontaneously in 30 of the 33 patients within 15 minutes of cessation of anesthesia. Respiratory depression occurred in five patients, four of whom had arterial blood pCO2 levels greater than 60 mm Hg. Thirty-one patients had relief of pain for 8 to greater than 40 hours, averaging 18 hours. Two patients had no noticeable pain relief. There appeared to be no relation between dose and pain relief in this limited dose range. We were unable to duplicate the long duration of pain relief reported elsewhere. We also were unable to decrease the side effects of respiratory depression and nausea to a level reported by others. It may be that the 10 cc bolus injected intrathecally circulates to the brain and ventricles faster than desired, or that factors relating to type of anesthesia or dose need to be considered. Low-dose intrathecal morphine does provide noticeable pain relief in younger patients undergoing spinal fusion. The side effects of nausea and respiratory depression can be managed safely with medication.

Intraspinal drug therapy.

Intraspinal drug delivery provides agents directly to their site of action. These sites, receptors within the spinal cord, are bound to a greater degree when drugs are administered intraspinally. The purpose for drug therapy, the acute or chronic nature of delivery, and the drug administration system affect the choice of epidural versus intrathecal route of delivery. Pharmacologic properties, such as solubility, pH, and pKa, aid in dictating the drug chosen for administration. Intraspinal opiates and anesthetics have been used extensively since the 1970s in postoperative, postpartum, and cancer populations. Various delivery systems are in use, including external catheters and implanted ports and pumps. Nursing care includes titration of doses, prevention and management of side effects, and maintenance of delivery systems. Intrathecal baclofen is a new treatment for severe spasticity for patients with multiple sclerosis or spinal cord injury. Candidates include patients who experience persistent spasticity unrelieved by antispasmodics or who experience unacceptable side effects to those oral drugs. Nurses assess spasticity, titrate the intrathecal baclofen to obtain an acceptable degree of spasticity, and manage side effects associated with intrathecal baclofen. A long-term benefit of intraspinal drug delivery, potentially providing benefit to many patients, is the identification of experimental agents that do not cross the blood-brain barrier but prove effective when delivered intraspinally. Pharmacologists and others then might undertake the costly modifications necessary to improve the solubility of the drug. The analogue then might be given orally. "The feasibility of an operation is not an indication for its performance." These words, attributed to the late Lord Cohen, also apply to intraspinal drug delivery. As with any therapy, the simplest and least invasive course should be taken. If, for example, the patient experiences good relief without side effects when given oral opiates or baclofen, there is no good rationale for inserting an intraspinal catheter. The potential for increased morbidity and the escalated expense make this an illogical choice. There are, however, many patients who cannot tolerate oral opiates or baclofen but obtain significant benefit from intraspinal drug delivery. Those who benefit should not be denied this therapy. Much research is necessary as this modality develops. Nurses who comprehend the science of intraspinal drug delivery, as well as the art of patient management, can contribute to this advancing field.