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Published on 3 June 2008

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Striking fear into the hearts of oncologists… but not neurologists

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In the realms of oncology and pharmacy, the word ‘intrathecal’ strikes fear – or at least a great deal of caution – into the hearts of those who work with chemotherapies.

There is a baffling array of protocols associated with the handling of intrathecal chemotherapy. And the rituals involved in actually making and giving them would put a Japanese tea ceremony to shame.

The NPSA has stretched out its gloved hand and offered to lead us through the minefield of intrathecal local anaesthetics and opiates. We now have yellow, stripey bags of epidural fluid. Special cupboards plastered brazenly with the words “for intrathecal use only” confront us in our operating theatres.

Many of us are familiar with the hundreds of thousands of pounds in compensation due to the families of those who have tragically died after the accidental administration of vincristine (or other vinca alkaloids) intrathecally. Yet in our neurology and neurosurgical services, we often make antibiotic solutions intended for intrathecal use on the bench in the ward. Worse still, many of us don’t have protocols for this practice.

We have precious little publication in the area, and we certainly don’t have anything like a learned body issuing decrees or guidance based on expert opinion and a body of evidence. But then, who would do such a thing anyway?  The Association of British Neurologists?  The Royal College of Pathologists?  NICE?  The Cochrane Review Group?  The Royal College of Surgeons?  Who would wish to take responsibility for it?

How does one monitor the progress of the treatment? Are the risks of ototoxicity higher after intrathecal administration?  Should we perform drug levels?

If you have an acute renal failure patient requiring colomycin intrathecal therapy for a multiply resistant organism, it is possible to obtain clinically relevant plasma levels in the vasculature?

In non-communicating ventriculitis, where multiple drains are in situ, does one administer half of the dose to either side of the blockage, or the full dose in either side, or something else entirely?  In the case of slit ventricles, what portion of the dose should be administered?  In hydrocephalus, do you double the dose?

There is a veritable minefield of unanswered questions around this issue. Of course one can find ‘experts’ who will recommend one course or another, but the body of evidence is simply not sufficient to make firm recommendations.

In a good-sized tertiary hospital, such as the one I work in, it is not uncommon to find three or four cases of ventriculitis per month. Some of you may see even more than this. I am keen as mustard to hear of your local practice.

As for my hospital, we issue guidance as explicit as we dare, given the paucity of good solid research. Which means that the poor doctors are left to muddle their way through their patient care, learning from their experiences, which are often guided by a more senior and experienced doctor who would also have learned in much the same way.

Is this really the best way forward, or is the subject doomed to be neglected because the money and politics lie elsewhere?  I would suggest that simply owing to the nature of the problem and the route of administration, it is an issue worth focussing on, before something happens to focus our minds on it.



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