II. Mechanism

  1. Intrathecal drug delivery for maximal pain relief with less adverse effects
    1. Avoids the sedation of antispasmodics such as Baclofen
    2. Avoids the Nausea, Pruritus and sedation of systemic Opioids
  2. Catheter inserted into intrathecal space cerebrospinal fluid
    1. Catheter tunneled around Abdomen and into the lower abdominal wall
    2. Insertion by interventional pain management specialists or Neurosurgeons
  3. Pump refills
    1. Pump is battery operated and is typically implanted into Abdomen
    2. Pump port is accessed via needle through the skin

III. Preparations

  1. FDA approved agents to be used in Intrathecal Pumps
    1. Morphine
    2. Baclofen
    3. Ziconotide
  2. Off-Label medication uses within Intrathecal Pumps
    1. Hydromorphone
    2. Bupivicaine
    3. Fentanyl
    4. Clonidine

IV. Complications

  1. Clonidine Pump malfunction with Drug Withdrawal
    1. Clonide withdrawal results in hypertensive emergencies
  2. Baclofen Pump Malfunction with Drug Withdrawal
    1. See Baclofen Pump
  3. Overdose
    1. Less common
    2. May occur on attempted pump port refill, if the port site is missed
  4. Infection
    1. May occur immediately after implantation, however otherwise infections are uncommon
  5. Catheter Granuloma
    1. May result in local mass effect with pressure on spinal cord and risk of injury

V. Precautions

  1. Lumbar Puncture
    1. Interventionist may access side port of pump to withdraw CSF for analysis
    2. Do not perform blindly without identifying the course of the catheter
      1. XRay catheter region to determine involved levels
      2. Perform Lumbar Puncture under fluoroscopy if performing Lumbar Puncture in region of catheter
  2. MRI with implanted pump
    1. Consult specific pump guide or device consultant
    2. Precautions vary by pump
    3. Some pumps require medication to be withdrawn from reservoir before MRI due to risk of rapid infusion
  3. Anticoagulants and Thrombolytics
    1. Risk of intrathecal Hematoma in perioperative period (insertion or removal)
    2. Anticoagulants and Thrombolytics should be avoided in the first 48 hours of catheter procedure
  4. Pump interrogation (e.g. flow rate settings)
    1. May be performed by device consultants as well as some hospital pharmacists
  5. Pump maintenance
    1. Pump should be refilled every 6-12 weeks (or based on amount used and type of agent)
    2. Pump should be replaced every 3-5 years

VI. Management: Emergent Emptying of Pump Reservoir

  1. Consult pump manufacturer and provider managing pump
  2. Indications
    1. Medication Overdose due to pump malfunction
  3. Complications
    1. Infection
    2. Bleeding (esp. in Coagulopathy)
    3. Failed device access
    4. Damage to device or nearby structures
  4. Preparation
    1. Needle 22 gauge
    2. Three-way stopcock (or extension tubing with clamp
    3. Syringe 20 cc
    4. Antiseptic solution for Skin Preparation
    5. Ultrasound (with probe cover) for needle guidance
  5. Technique
    1. Skin Preparation with antiseptic solution and drape
    2. Connect needle to stopcock and syringe
      1. Keep the system closed until ready to aspirate
      2. Do not expose the system to open air (risk of triggering increased infusion rate)
    3. Direct needle toward fill port at center of the device
      1. Silicone port septum will be felt on needle entry
      2. Advance until it reaches the bottom of the fill port
    4. Withdraw fill port medication contents
      1. Open stopcock
      2. Aspirate medication until no bubbles or medication asprated in 5 seconds with negative pressure
      3. Close stopcock
    5. Withdraw the needle
    6. Record volume of medication withdrawn
  6. References
    1. Warrington (2017) Crit Dec Emerg Med 31(9): 19

VII. References

  1. Mishler and Lovecchio (2017) Crit Dec Emerg Med 31(11): 15-20
  2. Lin, Coralic and Poree in Herbert (2015) EM:Rap 15(11):4-5

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