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EM07 Pain Management.Indd CASE STUDIES IN PAIN MANAGEMENT NEW! Series Editor: Knox Todd, MD, MPH Emergency Department Evaluation of Patients With Intrathecal Pumps Resistant pain syndromes may require the use of more invasive therapies, including a wide variety of nerve blocks and procedures designed to alleviate pain, improve function, and enhance quality of life. The authors review intrathecal pumps, their mechanism of operation, initiation of therapy, and potential complications. By Karen J. Doblin, NP, CCRN, Suelane Do Ouro, MD, and Knox Todd, MD, MPH hronic pain is prevalent among those in the day. Her medical history includes arthritis and presenting to the emergency depart- chronic back pain due to postlaminectomy syndrome. ment and is often associated with severe She has no history of epilepsy. Her daily regimen for suffering and disability. Treatment may pain management consists of three doses of oral Cinvolve a variety of nonpharmacologic and pharma- methadone 10 mg, one tablet of 5/325 mg oxyco- cologic interventions, including opioids; however, done/acetaminophen up to three times as needed, many patients who have been on a trial of opioids and a mixture of morphine, bupivacaine, and baclofen and have developed tolerance are unable to with- through the intrathecal pump. Her seizures have re- stand high-dose opioid regimens, due to well-known sponded to intravenous lorazepam and the remain- adverse effects. der of her physical exam is unremarkable. Her pain Many interventional pain practices offer patients physician is paged. intrathecal therapies, often with fewer side effects Case 2. A 55-year-old man with failed back syn- than with an equianalgesic dose of systemic opioids.1 drome treated with a neuraxial intrathecal infusion Intrathecal pumps were initially used as treatment for pump presents with pain, anxiety, nausea, and fa- cancer patients with a high pain burden unresponsive tigue after a fall. He reports that the pump, which to systemic analgesics and other interventional treat- has been delivering a combination of ziconotide, ments; increasingly, however, these systems are being fentanyl, and clonidine, was refilled uneventfully 2 used to treat chronic nonmalignant pain. days ago. Interrogation of the pump with an exter- nal programmer shows no malfunction. A CT scan PATIENT PRESENTATIONS confirms a break in the catheter. An equianalgesic dose of opioids is given intravenously while the pain Case 1. A 35-year-old woman with a history of physician is paged. chronic pain treated with an implanted neuraxial in- Case 3. A 48-year-old woman presents with severe trathecal pump arrives by ambulance with active right upper quadrant abdominal pain and vomiting. seizures after a minor motor vehicle collision earlier The patient has a history of chronic intractable back pain treated with a neuraxial intrathecal pump con- Ms. Doblin is a nurse practitioner at Beth Israel Medical taining morphine, bupivacaine, and clonidine. She Center in New York City. Dr. Do Ouro is an attending describes the abdominal pain as steady and aching. physician in the department of pain medicine and palliative care at Beth Israel Medical Center and an associate She displays a positive Murphy’s sign but no peri- professor of anesthesiology at Albert Einstein College of toneal signs. The emergency physician is concerned Medicine in New York City. Dr. Todd, editor of this series, that an infectious complication of the patient’s intra- is director of the Pain and Emergency Medicine Institute at thecal pump is causing her symptoms. Preparation Beth Israel Medical Center and a professor of emergency medicine at Albert Einstein College of Medicine. He is also for ultrasound examination is initiated and her pain a member of the EMERGENCY MEDICINE editorial board. physician is contacted. www.emedmag.com JULY 2009 | EMERGENCY MEDICINE 23 CASE STUDIES IN PAIN MANAGEMENT DISCUSSION program required. Nonprogrammable pumps, which are rarely used, have their infusion rates set at the Opioid receptors in the spinal cord are the primary factory. To modify the infusion regimen for this type site of opioid-induced analgesia. By delivering of pump, the concentration or contents of the medica- medication directly to those receptors, an intrathe- tion mixture must be changed. These pumps do not cal pump can achieve a high degree of pain relief have a battery and last until they are removed. using a relatively small quantity of medication. This Only a few medications are considered eligible direct approach decreases opioid-induced sedation for use in intrathecal pumps. All must be preserva- and many of the gastrointestinal side effects that are tive-free. Morphine is the most commonly employed commonly seen with oral opioid use.2 opioid; however, hydromorphone and fentanyl are The more common nonmalignant indications for also used. As patients may develop tolerance, adverse intrathecal analgesia include failed back syndrome, effects, or both even with intrathecal therapies, adju- chronic regional pain syndrome, and peripheral vant therapies—including the gamma-aminobutyric nerve injury.3 In addition to opioids, drugs delivered acid agonist baclofen, the local anesthetic bupiva- intrathecally may include local anesthetics, cloni- caine, and the alpha-adrenergic agent clonidine—are dine, baclofen, and ziconotide. also employed. Ziconotide is a newly available cal- Intrathecal pump implantation should be performed cium channel blocker that provides analgesia only only after careful patient screening and demonstration when administered by the intrathecal route. It was of a positive response to a trial of epidural or intra- synthesized to duplicate the chemical structure of thecal opioids. Typically during such trials, patients the venom secreted by the Conus magus snail. Clini- should exhibit at least a 50% decrease in pain inten- cal studies have shown ziconotide to be a safe and sity, accompanied by functional improvement.4 The effective treatment for refractory pain, and the FDA surgical technique for pump placement, which can be approved its use in 2005.4-6 Doses must be titrated performed by a pain physician or by a neurosurgeon, up slowly, and the pain physician should observe for involves placing an infusion catheter in the intrathecal increasing confusion, which is the main side effect. space and tunneling the catheter to a pump. The pump Ziconotide is now indicated as a therapy option for is placed subcutaneously in the right or left lower ab- patients whose pain is refractory to intrathecal mor- dominal quadrant and contains a reservoir that is per- phine. Experience has shown that it is better tolerated cutaneously refilled approximately every 2 to 3 months. when started at a low dose and titrated slowly, with An additional injection port allows direct injection into the dose increased no more than once a week.6 and aspiration from the intrathecal space. Some patients receiving intrathecal therapy may require oral opioids concomitantly despite even the PROGRAMMING THE PUMP best efforts to eliminate the need for them. For managing chronic pain, a programmable pump is usually chosen. The clinician uses a handheld input COMPLICATIONS OF PUMP device to program the pump to deliver an analgesic PLACEMENT AND OPERATION solution at a set rate. The pump can be programmed As with any procedure or device, intrathecal pumps for different rates at dif- carry associated risks and complications.7 Potential >>FAST TRACK<< ferent times of day and, if postplacement issues include bleeding, wound infec- Potential postplacement necessary, for bolus dosing tions, and cerebrospinal fluid leaks. complications include over a period of time when Bleeding. Bleeding in the epidural or intrathecal bleeding, wound the patient tends to experi- space, while extremely rare, is associated with increased infections, and ence increased pain. There neurologic morbidity. If persistent, it warrants intra- cerebrospinal fluid leaks. is also a new device, the operative consult for laminectomy. Persistent bleeding patient therapy manager, can lead to epidural hematoma, spinal cord compres- which allows the patient to deliver a bolus as needed sion, and paralysis.4 If a patient presents after pump using a preset rate and dosage. placement with signs and symptoms that are suspicious The programmable pumps have cadmium batteries for these complications, spinal MRI or CT must be that last approximately 5 to 6 years, depending on the performed as soon as possible to confirm. 24 EMERGENCY MEDICINE | JULY 2009 www.emedmag.com CASE STUDIES IN PAIN MANAGEMENT Infection. Sterile technique is of the utmost im- emergency departments are device related. Trau- portance when implanting and handling intrathecal matic disruption of the catheter may cause drug to pumps, and prophylaxis with preoperative intra- be deposited into surrounding soft tissue. Program- venous antibiotics and intraoperative antibiotic ir- mable pump delivery complications include overfill- rigation is an essential precaution. Infections should ing, battery failure, pump failure, and pump torsion, be cultured and treated aggressively with systemic which are preceded by loss of analgesia and can be antibiotics, and the patient should be observed for confirmed by radiographs or fluoroscopy. Program- symptoms of meningitis. Refractory infections may ming errors can result in oversedation, respiratory require pump removal.8 depression, and death. Inappropriate injection of Follett and colleagues reviewed data pertaining drug into the side port may result in
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