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Published byBridget Holland Modified over 9 years ago
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Malignant Pain The Role of IDDS Mark Schlesinger, MD Schlesinger Pain Centers www.schlespain.com
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Malignant Pain When I graduated from medical school over 30 years ago, I never promised to cure anyone, but I did promise to relieve pain and allay suffering.
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What is Malignant Pain?
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Pain caused by the cancer itself
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What is Malignant Pain? Pain caused by the cancer itself What will not be discussed?
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What is Malignant Pain? Pain caused by the cancer itself What will not be discussed? Post-Surgical Pain Radiation Neuritis Post-Chemotherapy Pain Pain in Cancer Survivors
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Pain Sub Types Nociceptive Pain – Bone Metastases Neuropathic Pain – Nerve Root Invasion – Spinal Cord Invasion – Brachial or Lumbar Plexus Invasion Visceral Pain – Pancreatic Cancer Involving Celiac Plexus
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What is IDDS? Intrathecal Drug Delivery Systems Direct Administration of Drugs to Spinal Cord Fully Implantable Therapies Programmable vs. Non-Programmable
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Why IDDS? Potency – Multiple Spinal Receptors Opiate Receptors Sodium Channels Calcium Channels Adrenergic Receptors NMDA Receptors
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Why IDDS? Side Effects Systemic OpiatesSpinal Opiates/Drugs Decreased LOCPruritis DepressionPedal Edema Respiratory Depression Decreased Gag Reflex Pulmonary Aspiration Decreased Appetite Nausea & Vomiting Constipation Immune Suppression Decreased Libido
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Intrathecal Drugs Mostly Off-Label Uses ApprovedCommonly Used MorphineHydromorphone ZiconitideFentanyl BaclofenSufentanyl Bupivacaine Ropivacaine Clonidine Ketamine Not used:Demerol due to side effects & drug interactions
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Intrathecal Drug Mixtures Double, double toil and trouble; Fire burn and cauldron bubble.
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Intrathecal Drug Mixtures
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Non-Programmable Pumps Codman 3000 – Three Sizes 16 cc, 30 cc & 50 cc – Fixed Flow Rates 16 cc size, 4 models delivering 0.3-1.3 cc per day 30 cc size, 4 models delivering 0.3-1.7 cc per day 50 cc size, 3 models delivering 0.5-3.4 cc per day – Dose Controlled Changing Drug Concentration
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Programmable Pumps Codman MedstreamMedtronic Synchromed II
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Programmable Pumps Codman Medstream – Pump Type:Gas Driven Piston Pump – Service Life:8 years – Minimum Flow Rate:0.10 cc per day Medtronic Synchromed II – Pump Type:Gas Driven Roller Pump – Service Life:7 years – Minimum Flow Rate:0.05 cc per day
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Programmable Pumps Codman Medstream Pump – Diameter76.0 mm 20 ccThickness21.6 mmWeight150 gm 40 ccThickness28.2 mmWeight155 gm Medtronic Synchromed II Pump – Diameter87.5 mm 20 ccThickness19.5 mmWeight165 gm 40 ccThickness26.0 mmWeight 175 gm
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Programmable Pumps Codman Medstream Pump – MRI Compatibility Certified to 3 Tesla Effect of Magnetic Field? Medtronic Synchromed II Pump – MRI Compatibility Certified to 3 Tesla Effect of Magnetic FieldRotor Lock-Up, Restarts
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Programmable Pumps Medtronic Synchromed II Pump – Programming Modes Simple Continuous – for baseline pain Bolus Delivery – for sudden adjustments Flex Mode – Multiple Programmable Steps PTM – Intrathecal PCA, with all the bells & whistles – Therapy modeled after intravenous & epidural PCA – Advantages » Better Pain Control » Lower Total Dose of Medication » Fewer Side Effects
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PCA Basics Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase steady state levels.
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PCA Basics Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase steady state levels. Continuous Infusion – the normal rate of infusion of the drug. This determines the steady state level of the drug and thereby the effectiveness of therapy.
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PCA Basics Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase steady state levels. Continuous Infusion – the normal rate of infusion of the drug. This determines the steady state level of the drug and thereby the effectiveness of therapy. PCA Dose – the patient controlled analgesia dose. This is the amount that the patient can administer at any one time.
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PCA Basics Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase steady state levels. Continuous Infusion – the normal rate of infusion of the drug. This determines the steady state level of the drug and thereby the effectiveness of therapy. PCA Dose – the patient controlled analgesia dose. This is the amount that the patient can administer at any one time. Lockout Interval – the minimum time between allowable PCA doses. The larger the lockout interval the lower the risk of overdose and the higher the risk of underdose.
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PCA Basics Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase steady state levels. Continuous Infusion – the normal rate of infusion of the drug. This determines the steady state level of the drug and thereby the effectiveness of therapy. PCA Dose – the patient controlled analgesia dose. This is the amount that the patient can administer at any one time. Lockout Interval – the minimum time between allowable PCA doses. The larger the lockout interval the lower the risk of overdose and the higher the risk of underdose. Maximum Daily PCA Dose – the maximum number of times that the patient can give themselves a PCA dose. Again the lower the maximum dose, the lower the risk of overdose, but the higher the risk of underdose.
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PCA Basics Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase steady state levels. Continuous Infusion – the normal rate of infusion of the drug. This determines the steady state level of the drug and thereby the effectiveness of therapy. PCA Dose – the patient controlled analgesia dose. This is the amount that the patient can administer at any one time. Lockout Interval – the minimum time between allowable PCA doses. The larger the lockout interval the lower the risk of overdose and the higher the risk of underdose. Maximum Daily PCA Dose – the maximum number of times that the patient can give themselves a PCA dose. Again the lower the maximum dose, the lower the risk of overdose, but the higher the risk of underdose. Maximum Periodic PCA Dose – this allows the physician to set the maximum number of doses for a 2, 4, 8 or 12 hour period. This is most useful to allow a greater number of daytime as opposed to nighttime injections.
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Who Is A Candidate? Pain Syndromes at or below clavicle Nociceptive, Neuropathic or Visceral Pain Life Expectancy at least 3-6 months Unrelieved PainNot the best practice. Side EffectsPreferred reason! – Usually at the level of Oxycontin 60mg per day
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Epidural Trial Office Procedure Catheters placed within 24 hours Trials up to 2 weeks long
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Final Implantation Day Surgery Procedure Lumbar Needle Entry Catheter Tip: Cervical, Thoracic or Lumbar Pump in R or L Buttock
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Follow Up Care Initial Care – Everyday for 2-3 days – Twice a week for two weeks – Every month or so thereafter Long Term – Dozens of Patients – Hundreds of Syringes Shifts in Pain Patterns
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Case Study PB 48 YO W male presents in 2000
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Case Study Radical Prostatectomy Radiation Chemotherapy Hormone Manipulation
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Case Study 2006
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Case Study 2007
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Case Study 04/08/08Initial Consultation – Pain Primarily in Pelvis 04/10/08Epidural Trial Placement 04/17/08Permanent Implantation – Morphine 0.7 mg per day c good relief of pain
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Case Study Summer 2008 – Increased pain despite increased morphine dose – Add Bupivacaine
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Case Study Summer 2008 – Increased pain despite increased morphine dose – Add Bupivacaine Fall 2008 – Increased pain despite increased combined dose – Add Clonidine
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Case Study Summer 2008 – Increased pain despite increased morphine dose – Add Bupivacaine Fall 2008 – Increased pain despite increased combined dose – Add Clonidine Christmas 2008 – Therapy Failing – Increased pain despite increased combined dose – Pain Shifting to legs – Add Ziconitide
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Case Study 03/02/09Hospitalized with abdominal pain – Pump Increased
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Case Study 03/02/09Hospitalized with abdominal pain – Pump Increased 03/03/09 AMSymptoms worsen – Decreased Appetite – Nausea and Vomiting – Low Grade Fever
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Case Study 03/02/09Hospitalized with abdominal pain – Pump Increased 03/03/09 AMSymptoms worsen – Decreased Appetite – Nausea and Vomiting – Low Grade Fever 03/03/09 PMDx: Intraabdominal Process – CAT Scan of Abdomen – Surgical Consultation – Sigmoid Colectomy
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Case Study 03/02/09Hospitalized with abdominal pain – Pump Increased 03/03/09 AMSymptoms worsen – Decreased Appetite – Nausea and Vomiting – Low Grade Fever 03/03/09 PMDx: Intraabdominal Process – CAT Scan of Abdomen – Surgical Consultation – Sigmoid Colectomy 03/08/09Discharged in good condition
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