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Background and Objectives: The PENCAN 25-gauge spinal needle is a new pencil-point needle with an inner diameter of 0.32 mm resulting in a relatively high cerebrospinal fluid (CSF) flow. The PENCAN 25-gauge needle was tested for ease of identification of a successful dural puncture, the failure rate of spinal anesthesia, and the incidence of postdural puncture headache (PDPH)., Methods: In a multicenter trial, the needle was tested in patients undergoing spinal anesthesia. A questionnaire evaluated the characteristics of the dural puncture. A second questionnaire was used to assess postspinal side effects (PDPH, atypical headache, audiovisual disturbances)., Results: In 1,193 patients, dural puncture was evaluated as easy in 85.2%, as moderate in 6.2%, as difficult in 6.7%, and as impossible in 1.9%. Needle performance was assessed as excellent or satisfactory in 96.9%. In 95.9% of patients, CSF appeared within 2 seconds. A perceptible "click" was noticed in 78.4% of patients. In 1.9%, CSF could not be obtained, because of spine deformities, obesity, or bending of the needle. In 1,166 patients, postpuncture complaints were evaluated, involving 635 women (54.5%), 773 patients (66.3%) under the age of 50 years old, and 170 (14.6%) cesarean deliveries. The overall incidence of PDPH was 1.3% (n = 15). A bloodpatch was needed in five patients. After cesarean delivery the incidence of PDPH was 3.4%, all responding to conservative treatment. Atypical headache and isolated audiovisual disturbances occurred in 7.5% and 1.5% of patients, respectively., Conclusions: A failure rate of 1.9% together with a 1.3% incidence of PDPH were comparable to other 25-gauge pencil-point needles. The rapid appearance of CSF and a perceptible "click" made prompt recognition of successful dural puncture possible.

Acute aortoiliac occlusion, or Leriche's syndrome, carries a risk of the development of severe ischemia-reperfusion injury, characterized by electrolyte and acid-base balance disturbances. These injuries are often fatal, because of the rapid deterioration of multiple organ systems. We present a case in which we intraoperatively and postoperatively treated hyperkalemia and metabolic acidosis by high-volume, continuous, veno-venous hemofiltration, which is a recently developed form of continuous renal replacement therapy.

Background: As the number of terminal cancer patients receiving continuous intrathecal infusion of opioids and local anesthetics for relief of pain increases, we decided to investigate the post-mortem findings of the spinal cord, meninges and nerve roots of patients after continuous intrathecal administration of morphine and combined with bupivacaine., Methods: Neurohistopathological findings were obtained from 10 cancer patients [2 men and 8 women, 29-69 (median 52) yrs old] and 4 controls [4 men, 46-75 (median 64) yrs old]. The cancer patients had been treated for a mean of 98 (range 8-452) d with morphine/NaCl 0.9% or morphine/bupivacaine, administered through a polyamide lumbar catheter. Concomitant radiation therapy and chemotherapeutic drugs had been given to 5 and 6 patients, respectively. Cumulative doses of morphine ranged from 22 to 3895 mg, those of bupivacaine from 0 to 3250 mg and of sodium metabisulfite (antioxidant) from 0.6 to 97.4 mg., Results: No macroscopic abnormalities of the catheter tract, dura, leptomeninges, nerve roots or spinal cord were found. Microscopically, focal foreign body giant cells were seen in 2 cases in the area of the catheter pathway both without any sign of inflammation. In one case treated for 103 d, an intrathecal reaction was found. This consisted of small aggregates of lymphocytes predominantly in the leptomeninges and focally in the cord parenchyma. No abnormalities were found in the other cases when using hematoxylin-eosin and Kluver or Bodian stained specimens, indicating neither myelin nor axonal damage. Microglial reactions were similar in both cancer patients and controls., Conclusion: The discrete and limited neurohistopathological findings in both catheter patients and controls suggest that intrathecal infusion of morphine and bupivacaine via a polyamide catheter is devoid of significant neurotoxic effects in cancer patients.

Terminally ill patients suffering from intractable cancer pain are treated in our hospital on an outpatient basis with a percutaneous intrathecal (i.t.) catheter and a portable pump delivering morphine continuously. In a patient showing an increased demand of morphine the dose was raised from 1.5 to 2 mg/h, but pain intensity did not decrease. Subsequently a 1.5 ml dose of 5% lidocaine was administered; however, no motor or sensory block was observed. After controlling the catheter position and passage through the catheter, a sample of cerebrospinal fluid (CSF) was taken and the pH was measured. It was found to be outside the physiological range of 7.19 (normal range: 7.27-7.37), possibly explaining the decreased activity of the local anesthetic. The purpose of this study was to determine the influence of morphine, with or without sodium metabisulfite, on pH in vitro, using artificial CSF (ACSF) and on pH in vivo during i.t. administration of morphine. An in vitro model was used to measure pH changes by adding a morphine solution (concentrations of 0.5, 2, 5 and 10 mg/ml) with and without sodium metabisulfite to ACSF solutions (Elliott B). Fourteen patients were consecutively selected for continuous administration of morphine. An i.t. catheter was inserted, tunnelled and connected with an external pump (Provider 5500, Abbott, Chicago, IL). CSF was aspirated and pH was measured with a blood-gas system (Ciba-Corning 288, Medfield, USA). In vitro, morphine solutions with or without sodium metabisulfite added to an Elliott B solution (pH = 7.47, 37 degrees C) caused a concentration-related decrease in pH.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To record the daily morphine doses, the influence of the treatment on quality of life and the incidence of side-effects and complications of continuous intrathecal morphine administration., Setting: Academic Hospital, Free University, Amsterdam., Design: Prospective., Methods: Forty terminal patients with intractable cancer pain, who had either insufficient pain relief or severe side effects from systemic analgesics were selected for continuous intrathecal administration of morphine. An intrathecal catheter was implanted, tunnelled and connected with a portable infusion pump delivering morphine constantly and if needed on demand. In a pain diary the patients recorded: the number of daily doses of morphine, concomitant medication, pain scores on a visual analogue scale (VAS), extra doses and activities., Results: The total number of catheter days was 1486. Patients were treated for a mean of 37.2 (range 2-183) days. The mean dose of daily administered morphine was in 30 patients (75%) less than 20 mg. Sufficient pain relief (VAS score < 5) was achieved in 37 patients (92.5%). Three patients had pain due to spinal cord compression, hardly responding to intrathecal morphine. Withdrawal symptoms, post-puncture headache and leakage of fluid could been treated conservatively. The catheter was removed inadvertently 6 times and could be replaced on outpatient basis. Meningitis occurred in 2 patients, who were adequately treated with antibiotics. The catheter could be re-inserted within 10 days., Conclusion: In terminally ill cancer patients, the continuous intrathecal administration of morphine may be recommended if conventional pain relief fails.