Technical Nuances of Surgical Implantation of Intrathecal Pain Pumps

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Technical Nuances of Surgical
Implantation of Intrathecal Pain
Pumps
Susan Garruto MSN,CRNP,RNFA
Thomas Jefferson University
Hospital
Disclosure
• I have no affiliations to disclose
Objectives
• Identify patients who would benefit from
intrathecal drug delivery
• Describe the technique used for
catheter/pump implantation
• Explain the troubleshooting aspects of
catheter/pump implantation
Applications for Intrathecal Pain
Pumps
Spasticity (baclofen)
• Multiple sclerosis
• Traumatic brain injury
• Cerebral Palsy
• Cord injury
• Paraparasis
• Stroke
Chronic pain
(morphine, prialt)
• Nociceptive pain
Upper Spasticity Patterns
Lower Spasticity Patterns
Spasticity Trial
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Single bolus injection (50 mcg)
Check effect over 8 hours
>8 hour- start with ½ dose
<8 hour- start with 2X dose
No effect- increase bolus for trial
Baclofen (Lioresal)- concentration for
direct delivery is much more effective than
oral baclofen.
Pain Pump Trial
• Morphine
• Single bolus- will indicate adverse effects
• Indwelling catheter to increase morphine
dose to gain starting point for dosage in
permanent pump.
Patient selection
Diagnostic Work Up
• MRI
• CT
• Plain X-rays
• Labs, INR, PTT
Pre-op
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Pump size: 40 cc vs. 20 cc
Drug of choice: Lioresal, other
Chlorahexadine shower & wipes
Revision- always have representative
interrogate before surgery.
Pre-op
• Confirm pump size/ drug amount
• Confirm plan for admission-including
rehabilitation unit
• Often involves caregiver
• Introduce representative
Intra-op
Operating Room
• Pre-operative antibiotics
• Patient positioned in full lateral decubitusmay have to be creative!
• Gel pressure points
• Prep and drape back and abdomen
simultaneously.
Intra-op
Operating Room
• Local anesthesia
• Minimal incision- don’t let the incision
sacrifice accuracy or angle of reach. Need
room to secure catheter.
• Para-spinal lumbar puncture (L2-3-4) to
prevent shearing of the catheter
• Brisk flow of CSF
• C-arm fluoroscopy to check catheter
placement
Implantation
• Catheter is placed
intrathecally (usually L3
or L4) and tunneled
subcutaneously to the
pump.
• Tip placement at the T10T11 level
• Acute hospital length of
stay is 3-5 days
Posterior lumbar
Anchoring the catheter
• 2 pursestring sutures- with Touhy needle
in place
• 2 butterfly anchors- anchor butterfly to
catheter, anchor butterfly to fascia
• Need to have fascial tissue, not fat
• Protect catheter at all times (new catheter
is not as delicate)
• Allow for strain relief loop
Abdomen
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Placement in RLQ or LLQ-patient preference
Below the waistline
2.5 cm beneath the skin
Sub-fascial –extremely thin patients
Trim catheter- hand off excess to be measured
Check for CSF flow after tunneling
2 sutures to anchor pump
Catheter lies posterior to the pump
Access pump to confirm CSF flow before closing
incision.
• Copious antibiotic irrigation, anterior & posterior
Intra-op
Operating Room
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Interrogate system before closure
Meticulous closure
Antibiotic ointment
Tegaderm dressing
Abdominal binder to prevent migration of
generator
• Flat for 12 hours
Post-op
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Pain medications
Antibiotics for 24 hours
Bathing instructions
Wound care instructions
Watch for complications- lack of drug
delivery, infection
Thomas Jefferson University
Philadelphia, PA – USA
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