technical nuances of surgical implantation of intrathecal pain pumps susan garruto msn,crnp,rnfa...
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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
• 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
• 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-opOperating Room
• Pre-operative antibiotics
• Patient positioned in full lateral decubitus- may have to be creative!
• Gel pressure points
• Prep and drape back and abdomen simultaneously.
Intra-opOperating 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 T10-T11 level
• Acute hospital length of stay is 3-5 days
Posterior lumbarAnchoring 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
• 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-opOperating Room
• Interrogate system before closure
• Meticulous closure
• Antibiotic ointment
• Tegaderm dressing
• Abdominal binder to prevent migration of generator
• Flat for 12 hours
Post-op
• Pain medications
• Antibiotics for 24 hours
• Bathing instructions
• Wound care instructions
• Watch for complications- lack of drug delivery, infection
Thomas Jefferson UniversityPhiladelphia, PA – USA
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