Morphine
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Hyperalgesia and myoclonus following intrathecal infusion: case report A 49-year-old woman developed hyperalgesia and myoclonus, after intrathecal infusion of morphine for complex regional pain syndrome secondary to multiple knee surgeries. The woman had been receiving intrathecal morphine 50 mg/mL and concomitant clonidine infusions for several years. Most recently she was receiving intrathecal morphine 21mg daily with clonidine. She presented to an emergency department with a 1-month history of increasing pain [exact time to reaction onset not stated]. Considering possible tolerance to morphine, bupivacaine was added to her infusion regime. Later that day she returned to the emergency department, again reporting increased pain. The woman was administered an intrathecal bolus dose of 0.3mL of a mixture containing morphine 15mg, clonidine and bupivacaine. Afterwards she had several minutes of analgesia, but about 10–15 minutes later she experienced increasing pain and violent jerking, myoclonic actions and rigors. A second dose again provided temporary pain relief, before the pain returned. A total of 75mg intrathecal morphine, with clonidine and bupivacaine, was administered over 5 bolus doses in the next few hours. After each dose there was initial analgesia followed by myoclonic jerking and rigors, and significantly increased pain. Fentanyl was admininstered, but without relief. An MRI excluded serious pathology. She received several doses of ketamine over 3 hours, each of which resulted in immediate pain relief followed by a return of her pain. She was admitted to the ICU, where she was kept overnight on an infusion of ketamine and midazolam. The next morning her intrathecal medication was changed to a mixture of clonidine, bupivacaine and sufentanil. The combination of ketamine and midazolam resulted in good pain control, and she was discharged from the ICU. Author comment: "[H]er acute exacerbation of pain and new symptoms (myoclonus, rigors) is most likely attributed to the bolus of intrathecal morphine." Singla A, et al. A differential diagnosis of hyperalgesia, toxicity, and withdrawal from intrathecal morphine infusion. Anesthesia and Analgesia 105: 1816-1819, No. 801095510 6, Dec 2007 - USA
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Reactions 12 Jan 2008 No. 1184
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