Cloudy Intrathecal medication

[Tramadeezy]

Have you guys seen this before? 2nd refill on same patient with intrathecal hydromorphone looking very cloudy when it is withdrawn from the pump. Have sent it off twice now for infectious work up which has come back negative. She did have a headache with mild fever about a month ago; work up in ER was negative for meningitis etc... All of our pump meds come from the same pharmacy and are never expired when we put them in. Patient is very reliable and hasn't had any aberrant behaviors. I guess she could be accessing pump and filling it with some random solution but the meds in/out always add up. Did a quick google search and nothing seemed to pop up. Just curious if you anyone has seen this before.

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[willabeast]

probably irrelevant but i did a spinal tap on a woman once and got very cloudy fluid. turned out it was lymphoma cells (lots of them).
only reason i did the tap was a colleague asked me if i could help because they were having trouble getting in.
so i do not have any more history, i think i wrote a note and left, found out later what the Dx was.
Lymphoma cells in cerebrospinal fluid confirmed by chromosome analysis

 

[NOSfan]

Have you guys seen this before? 2nd refill on same patient with intrathecal hydromorphone looking very cloudy when it is withdrawn from the pump. Have sent it off twice now for infectious work up which has come back negative. She did have a headache with mild fever about a month ago; work up in ER was negative for meningitis etc... All of our pump meds come from the same pharmacy and are never expired when we put them in. Patient is very reliable and hasn't had any aberrant behaviors. I guess she could be accessing pump and filling it with some random solution but the meds in/out always add up. Did a quick google search and nothing seemed to pop up. Just curious if you anyone has seen this before.

? Poor compounding to cause precipitation?
Also send aspirate for Cell count, protein, cytology AND Drug Screen.

 

[Aether2000]

High concentrations of opioids may cause microcrystals to form. Higher concentrations may cause overt crystallization. Inadequate pH adjustment (too acidic) may cause precipitation esp. if bupivicaine is used. Agree on getting a cell culture.