intrathecal drug delivery systems: best practices
DESCRIPTION
Intrathecal Drug Delivery Systems: Best Practices. Alon Y. Mogilner, MD, PhD Director, Center for Neuromodulation NYU Langone Medical Center. Disclosures. Medtronic neurological: Consultant, fellowship/grant support St. Jude Medical: Grant support, consultant Boston Scientific - PowerPoint PPT PresentationTRANSCRIPT
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Intrathecal Drug Delivery Systems: Best Practices
Alon Y. Mogilner, MD, PhDDirector, Center for Neuromodulation
NYU Langone Medical Center
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Disclosures
• Medtronic neurological:– Consultant, fellowship/grant support
• St. Jude Medical:– Grant support, consultant
• Boston Scientific– Grant Support
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Overview
• Patient selection• General Considerations for pump placement• Infection Prevention• Surgical Technique• Prevention of follow-up complications
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Patient Selection
• First step in minimizing complications• Chronic non-malignant pain:
– Appropriate candidate– Adequate trial– Appropriate follow-up care
• CSF leak– Assess for occult hydrocephalus (children, adults
with spasticity s/p TBI)
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Complication avoidance: Infection• History:
– Frequent wound infections– Cellulitis– Diabetes– Other immunosuppression
• Examine for:– Pressure ulcers– Non-healing wounds
• Preoperative skin swab for MRSA/MSSA:– pre-operative decontamination routine– Bactroban ointment– Oral antibiotics (controversial)– Appropriate perioperative antibiotics (Vancomycin vs. cephalosporin)
• Revisions following infection:– Make sure all hardware has been removed
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Pump Location
• Patient comfort• Ease of access• Minimize impingement on ribs or iliac crest• Stability
– Morbidly obese patients: prone to pump flipping– Consider Infraclavicular placement or scapular
placement– Mark position with patient standing
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Complication avoidance: Thin patients– Consider subfascial
implantation
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Catheter-Related Complications
Follett KA, Burchiel K, Deer T, et al. Prevention of Intrathecal Drug Delivery Catheter-Related Complications. Neuromodulation 2003; 6(1): 32-41
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Low Complication Technique for Catheter Implant
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Minimizing Complications• Paramedian oblique entry (compared to midline entry)
• May minimize catheter dislodgement • Reduces wear on catheter
• Anchoring may reduce catheter dislodgements• V-wing anchor at fascial entry point• Catheter connector/primary anchor
• Catheter slack at specific locations may reduce kinks• Loop catheter under pump• Slack in catheter by connector
• Anchoring pump may reduce catheter kinks and dislodgements• Suture loops or mesh pouch
• Product designs intended to reduce catheter kinks and holes• Thick wall proximal catheter • Strain-relief sleeve on catheter tubing
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Prep patient
Image courtesy of Dr. Joseph Dunn and Dr. Peter Kosek, Pain Consultants of Oregon, Eugene, OR.
• Mark pocket site • Position patient
– lateral position– lumbar region slightly
flexed • Adjust table and
drapes to view fluoroscopy
• Administer anesthesia
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Place needleSpinous Processes
Pedicles
Needle
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Place needle (continued)
Paramedian Oblique
~ 30°
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Place needle (continued)
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Thread catheter through needle Avoid pulling catheter back while threading
Introducer Needle
Catheter
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Attach the Sutureless Pump Connector to the Pump
Sutureless Pump Connector Catheter Port Connector Seal
Catheter Lumen
Enlargement of the Connection Image inside the Connection
Sutureless Connector (‘SC’) Intrathecal Catheters (Models 8709SC, 8731SC, 8596SC, 8578): Recommendations for Implant Techniques. June 2008: 1-4.
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Correct Sutureless Catheter Connection1. Verify CSF backflow through
the catheter.
2. Ensure alignment of Sutureless Connector to the pump.
3. Firmly squeeze precisely on the oval marks of the pump connector and press connector onto the catheter port until the connector fully covers the catheter port. The connector snaps into place.
4. Tug and rotate to check the connection.
Sutureless Connector (‘SC’) Intrathecal Catheters (Models 8709SC, 8731SC, 8596SC, 8578): Recommendations for Implant Techniques. June 2008: 1-4.
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Pump anchoring
• Pouch vs. Suture loops– Surgeon
preference– Pouch can be
problematic at time of replacement/removal
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Place and suture pump into the pocket, coiling excess catheter behind pump
Image Courtesy of Dr. Alessandro Dario, Centro di Neuromodulazione, Divisone di Neurochirurgia, Ospedale Macchi, Varese, Italy.
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Overview for low complication implant technique
Adapted from Follett KA, Burchiel K, Deer T, et al. Prevention of Intrathecal Drug Delivery Catheter-Related Complications. Neuromodulation 2003; 6(1): 32-41.
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Improved Catheter Design
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Granuloma prevention
• Granulomas have now been reported with most medications (including baclofen) and concentrations
• Prevailing wisdom suggests that the incidence is higher with higher doses/concentrations
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Best practices
• To date, a collection of consensus panel recommendations
• No evidence at any level to suggest any of these recommendations
• Many of them “common sense” recommendations
• Patient selection and continued follow-up care by trained practitioners remains a key…
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Thank you