Vol. 41 No. 1 January 2011 185Schedule with Abstracts

Rounding with the Stars (309)

12:15e1:15 pm

Paper Sessions

Adverse Effects and ParenteralHydromorphone Use in Renal Failure(310-A)Eric Prommer, MD, Mayo Clinic, Phoenix, AZ.Gobi Paramanandam, MD MHSM, Center forPain and Support Care, Scottsdale, AZ.(Prommer has disclosed no relevant financialrelationships. Paramanandam has disclosedthe following relevant financial relationships:is a speaker for Medtronic and received anhonorarium.)

Objectives1. Recognize the conditions associated with neu-

rotoxicity when hydromorphone is used inthe setting of renal insufficiency.

2. Discuss the prevalence of neuroexcitatorysymptoms when hydromorphone is given inthe setting of renal insufficiency.

3. Discuss the toxicities of hydromorphonemetabolites.

Background. Hydromorphone is a semi-syn-thetic derivative of morphine that differs struc-turally from morphine by the presence of a 6-keto group and a hydrogenated double bondat the 7-8 position of the molecule. Hydromor-phone is metabolized to hydromorphone-3-glucoronide (H3G), a compound that has no an-algesic properties but one that may contribute tothe development of neurotoxicity. In renal insuf-ficiency, H3G accumulates and has been shownto cause myoclonus, agitation, and seizures ina dose dependent manner when infused intothe cerebrospinal fluid of rats. In humans, thereis conflicting evidence as to whether hydromor-phone causes neuroexcitatory toxicities whengiven to patients with renal insufficiency.Research objectives. Determine the prevalenceof neuroexcitation in patients with renal failuregiven hydromorphone, as measured by the glo-merular filtration rate and to investigate factorsassociated with increased risk of neuroexcitationin this patient group.Methods. For the 12-month period from June2007 through June 2008, charts of inpatient hos-pice patients with a glomerular filtration rate of< 60 (ml/min/1.73 m2) and who had received

hydromorphone for pain control parenterallywere reviewed for the occurrence of neuroexci-tatory effects including tremor, myoclonus, agi-tation, cognitive dysfunction, and seizures. Theeffect of dose and duration of therapy wasevaluated.Results. There was a strong and graded increaseinneuroexcitatory effects with increasing quartileof dose or duration of hydromorphone for agita-tion (dose, P< 0.0001; duration, P< 0.0001) andcognitive dysfunction (dose, P < 0.0002;duration, P < 0.002). Consistent but weakertrends were observed for tremor and myoclonus.Conclusion. Parenteral hydromorphone is asso-ciated with neuroexcitatory symptoms whena neuroexcitatory threshold is reached.Implications for research, policy, or practice.When hydromorphone is given in the renalfailure setting, a neurotoxic threshold can bereached beyond which there is a greater occur-rence of neuroexcitatory effects. This meansthat hydromorphone should be used cautiouslyin the setting of renal insufficiency.

DomainPhysical Aspects of Care

Segmental Spinal Myoclonus FollowingHigh-Dose Intrathecal HydromorphoneInfusion (310-B)Tanya Nikolova, MD, Memorial Sloan-KetteringCancer Center, New York, NY. Yvona Griffo,MD, Memorial Sloan-Kettering Cancer Center,New York, NY.(All speakers for this session have disclosed norelevant financial relationships)

Objectives1. Recognize the clinical picture of segmental

spinal myoclonus, a possible rare complica-tion of spinal opioid infusion.

2. Discuss the treatment of this rare but seriouscondition.

Background. Myoclonus is a well-described sideeffect of opioid therapy. Segmental spinal myoc-lonus is generated at a particular segment of thespinal cord and can be observed with certain spi-nal cord disorders or injuries. Segmental spinalmyoclonus is a very rare complication of epidu-ral or intrathecal opioid infusion.Case description. We will report the case of 47-year-old gentleman who developed segmentalspinal myoclonus following administration ofhigh-dose intrathecal hydromorphone.

186 Vol. 41 No. 1 January 2011Schedule with Abstracts

The patient has end-stage metastatic chordomathat was diagnosed 14 years ago. He was treatedin Europe and at our institution with multiplesurgeries, radiation, and chemotherapies. Hehas been followed at our pain and palliativecare clinic over the last several years.After exhausting all therapeutic options for hiscancer and continuous escalation of large dosesof oral methadone in February and March of2010 he was hospitalized for improvement ofpain control. Initially the patient was treatedwith intravenous methadone, only then intrathe-cal infusion with hydromorphone and bupiva-caine was added.On Day 2 after an intrathecal pump placementwhile receiving 18 mg hydromorphone intrathe-cally per day, the patient developed extremelypainful involuntary muscle jerks of his lowerbody with frequency approximately every 5e10seconds. The patient received intravenous dosesof lorazepam, which provided minimal relief. Se-vere muscle spasms resolved with significantdose reduction of intrathecal hydromorphone.Ultimately hydromorphone was replaced withsufentanil.Conclusion. Clinicians should be aware of theclinical presentation of segmental spinal myoclo-nus, which can develop as a complication ofintrathecal opioid infusion. Anticonvulsants, es-pecially benzodiazepines, can be used for symp-tomatic relief. For definitive treatment of thisrare condition, dose reduction of the intrathecalopioid or rotation to another opioid should beconsidered.

DomainPhysical Aspects of Care

Development of a Palliative CareIntervention and Clinical Pathwayfor Non-Surgical Management of HipFracture in Patients with AdvancedIllness (310-C)Ursula McVeigh, MD, UVM College of Medicine,Burlington, VT. Allan Ramsay, MD, FletcherAllen Health Care, Burlington, VT.(All speakers for this session have disclosed norelevant financial relationships.)

Objectives1. Describe how goals-of-care discussions impact

decisions regarding management of hip frac-tures in patients with advanced illness.

2. Review the development and impact of a palli-ative care clinical pathway for decisional sup-port and non-operative management of hipfracture.

Background. Patients with advanced illnesses of-ten undergo surgical hip fracture repair despitesignificant perioperative risk and limited chanceof preserving functional status or improving lifeexpectancy. There is a subset of patients with ad-vanced illness and limited life expectancy whowould benefit from noninvasive managementwhen primary goal of care is comfort. Thereare no protocols described in the medical litera-ture for discussing nonsurgical options, or theimpact of goals-of-care discussions on decisionsregarding hip fracture repair.The research on non-operative management ofhip fracture is very limited. A small retrospectivereview of hospice patients in 2001 found thatsurgical repair did not significantly benefit sur-vival or comfort. However, hip fracture repair isfrequently considered in this population, forthe goal of comfort, and sometimes functionand longevity. Patients with end-stage dementiahave a 50% 6-month mortality following hip frac-ture and suffer more postoperative complica-tions than cognitively intact patients, includingpain and delirium.Aim. To develop collaboration between palliativecare, orthopedic surgery and hospitalists to en-sure goals-of-care discussions occur when a pa-tient with advanced illness suffers a hipfracture and that the plan of care is most consis-tent with goals of care.Methods/session descriptions. Guidelines forinitiating a palliative care consult and a clinicalpathway for nonsurgical management of hipfracture were developed and implemented. Wereconciled the nuanced differentiation of surgi-cal decisions based on perioperative risk assess-ment versus decisions based on goals of care. Apre- and postintervention case review was con-ducted to determine impact of intervention ongoal setting and plan of care.Conclusion. In patients with advanced illnessand hip fracture, a collaboration between pallia-tive care physicians, orthopedic surgeons, andhospitalists can increase the likelihood of estab-lishing appropriate goals of care and of care,with or without surgery, that are most alignedwith patients’ goals.

DomainPhysical Aspects of Care