Schroeder has no relevant conflicts. Borden, Ludwig, and Wilson have no pertinent conflicts of interest. Newsletter The official journal of the anesthesia patient safety foundation. Summary: Medication labelling can be confusing for agents that might be administered into the intrathecal or epidural space. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits.
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This category only includes cookies that ensures basic functionalities and security features of the website. These cookies do not store any personal information. The cookie is used to store and identify a users' unique session ID for the purpose of managing user session on the website. In large cohort studies of TFESIs performed according to practice guidelines, there is a zero prevalence of ischemic neurological events. In the case of a preservative-free dexamethasone shortage, providers must carefully consider various options to optimize safety and effectiveness during an epidural steroid injection.
Currently, there are no published guidelines addressing the advisability of using steroids from compounding pharmacies. Several factors must be considered that may affect the risk profile of an epidural injection. Concern exists surrounding the use of steroid preparations that contain PEs for epidural injection ESIs.
This is largely due to the possibility of neurotoxicity if the PE is inadvertently injected into the intrathecal space.
Neurotoxicity has been reported in association with benzyl alcohol, polyethylene glycol, and benzalkonium chloride, among other PEs. The body of literature regarding neurotoxicity due to spinal administration of medication was summarized in ; it was suggested that neurotoxicity due to PEs is unlikely at the dosages and concentrations used in humans.
Since this review was published, no significant new literature has emerged to further guide clinical decision-making.
Benzyl alcohol is the primary PE in commercially available preparations of dexamethasone. Animal studies demonstrate no difference in neurotoxicity for benzyl alcohol doses ranging from 0. Seizures were observed following injection of a 4.
Aside from neurotoxicity, concern has been raised with regard to the potential for a hypersensitivity allergic reaction to benzyl alcohol. It should be noted that allergy to benzyl alcohol is relatively rare. Furthermore, through the process of skin testing, all components of the dexamethasone solution have been identified as potential sources of hypersensitivity reactions. This includes dexamethasone in its native form before esterification , the succinate ester moiety added for solubility , sodium citrate, citric acid, sodium hydroxide, and other minor excipients such as lactose, carboxymethylcellulose, and polyethylene glycol.
Elimination of the preservative component of dexamethasone, therefore, does not eliminate the risk of hypersensitivity reactions. Preservative-free dexamethasone remains the preferred corticosteroid for TFESI, but given the paucity of evidence of neurotoxicity associated with benzyl alcohol, the use of dexamethasone-containing preservative is a reasonable alternative.
It is possible to obtain preservative-free dexamethasone from a compounding pharmacy. However, significant concerns exist regarding sterility assurance in relation to agents prepared by compounding pharmacies, which were brought to light during the fungal meningitis outbreak that originated from the New England Compounding Company.
Multiple routes of access to the epidural space are possible. A complete review of the differences in the safety and effectiveness of epidural steroid injections via the transforaminal vs interlaminar vs caudal routes is beyond the scope of this position statement. Physicians should carefully weigh the risks and benefits of using various steroid agents and approaches for epidural steroid injection and involve patients in the process of shared decision-making before proceeding.
Transforaminal Injections. Particulate steroid should never be injected via the cervical transforaminal route, leaving dexamethasone as the only safe steroid choice.
In the absence of preservative-free dexamethasone, particulate steroids e. If a lumbar TFESI with particulate steroid is performed, physicians should strongly consider use of all available risk-mitigation strategies to minimize the possibility of intra-arterial injection, including the use of an infraneural approach, a local anesthetic test dose, and use of DSI beyond the requisite live-fluoroscopic observation of contrast medium injection through extension tubing.
It should be noted that commercially available particulate steroids contain preservatives, so use of particulate steroid does not eliminate the possible effects of PEs. When using an interlaminar or caudal route of entry, there is no evidence to suggest that use of nonparticulate dexamethasone confers any safety benefit over particulate steroids such as triamcinolone, betamethasone, and methylprednisolone.
To date, there have been no published cases of ischemic neurologic infarction related to a particulate steroid injected via the caudal or interlaminar epidural space.
Instead, the relevant increased risk associated with nontransforaminal routes of access is epidural hematoma. Epidural hematoma risk is considered equal for all corticosteroid agents and is present regardless of anticoagulation status.
Only nonparticulate steroids should be used for cervical transforaminal injections. For interlaminar or caudal epidural steroid injections, the evidence supports the use of either particulate or nonparticulate corticosteroids, as there is no evidence of superior safety for one agent over another.
Skin testing for immediate hypersensitivity to corticosteroid: A case series and review of the literature. Clin Exp Allergy ; 45 3 : — Although epidural-related neurological complications are rare, we speculate that neurotoxic potential of sulphites in epinephrine may be reduced by the low dose used or modified by the presence of sodium bicarbonate to raise the pH of the injected solution.
Our local drug information service has advised us that preservative-free epinephrine is not available in the United Kingdom and we take this opportunity to draw the attention of our colleagues who use epinephrine in neuraxial blocks. We would be interested to hear of others experiences in this area. MacPherson RD. Pharmaceutics for the anaesthetist. Anaesthesia ; Brooks H, May A. Epidural block: technical aspects and complications.
Current Opinion in Anaesthesiology ; Obstetric epidurals and chronic adhesive arachnoiditis. British Journal of Anaesthesia ; Trade shows Newsroom Careers Contact. Fagron Sterile Services. Stay Informed Sign up for our e-mail updates to get the latest in product releases, customer notifications, and company news. Sign Up Now. Stay Informed.
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