In Office Pump Trials - Malignant Pain

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seamonkey

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I'm recently out of fellowship where we did all our pump trials as inpatient admits.
I'm getting my first metastatic prostate Ca patient in this week, and I'm interested in getting a pump into him sooner rather than later.
I am really trying to avoid putting this guy in the hospital anymore than he needs - he was just there with COPD issues last week, and doesnt need HAP or MRSA or other complications.
In my view, if he responds to po opioids he will respond to IT opiods, but its the logistics of the trial I'm trying to work out.

Anyone here do single-shot fentanyl trials in the office? How long do you keep them before sending them home. I don't feel comfortable doing IT morphine and sending him home.
Do you have them hold or titrate down current meds before the trial?
I was thinking of 100mcg fentanyl, watch for about 2 hours, then home. I am aware of CMS catheter requirements for pump trials....so maybe a CSE and thread the catheter, then pull before sending home.
Since I don't have any experience with the in-office approach, I'm open to suggestions.

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I'm recently out of fellowship where we did all our pump trials as inpatient admits.
I'm getting my first metastatic prostate Ca patient in this week, and I'm interested in getting a pump into him sooner rather than later.
I am really trying to avoid putting this guy in the hospital anymore than he needs - he was just there with COPD issues last week, and doesnt need HAP or MRSA or other complications.
In my view, if he responds to po opioids he will respond to IT opiods, but its the logistics of the trial I'm trying to work out.

Anyone here do single-shot fentanyl trials in the office? How long do you keep them before sending them home. I don't feel comfortable doing IT morphine and sending him home.
Do you have them hold or titrate down current meds before the trial?
I was thinking of 100mcg fentanyl, watch for about 2 hours, then home. I am aware of CMS catheter requirements for pump trials....so maybe a CSE and thread the catheter, then pull before sending home.
Since I don't have any experience with the in-office approach, I'm open to suggestions.


If you want to avoid putting this guy in the hospital, avoid the pump altogether. I could go on about the issues related to pumps but if your fellowship did a significant volume of pumps, you are already familiar.
 
In fellowship we did very few pumps - I only had one that i followed from trial to implant.
Trained in one of the largest cities in the US, and I saw lots of pumps from other programs come into our clinic and ED with all sorts of problems we had to address. As a result, I'm really only interested in putting them into patients with progressive / terminal cancer pain, and my goal is to get the pump in early. I'm very comfortable managing them
I live in a very different part of the country now.
I know this patient will need a brief (hopefully) i/p stay for the implant, just looking for advice on satisfying the trial requirements with a minimum of risk to the patient (and hassle for myself).
 
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I do trials for malignant pain in out-patient nursing at my hospital. I live in a rural area and, prior to me coming, the local neurosurgeon performed all trials and they were admitted to ICU for 23 hour obs. Obviously, overkill. I do the trial first thing in the morning and they can stay up to 12 hours in out-patient nursing and I generally make them stay the whole 12 hours. I could do it in my office but... Why? I do the procedure to help people and don't really make any money and don't need someone dying at home 3 hours after I did something. Not worth the risk IMHO.
 
Would avoid pumps if new in practice and if you have not set up protocols for staff, phone calls, the ER, etc. Single shot trials are not nearly as good as a 3 day hospital stay with dose titration and PT assessments.
 
Would avoid pumps if new in practice and if you have not set up protocols for staff, phone calls, the ER, etc. Single shot trials are not nearly as good as a 3 day hospital stay with dose titration and PT assessments.

Dear Steve, do you find that insurances will pay for a 3 day stay, or is that out of pocket? That's a very long hospital stay these days.
 
Agree with avoiding pumps if just out of fellowship. I find they are extremely beneficial in the correct population (malignant cancer when orals have failed and have responded adequately to a trial). I don't implant them... Neurosurgeon does and manages them as well.

Three day trials better but single shot not bad if that is your option (like me). Tried to do inpatient trial here but got the big red light from hospital even though neurosurgeon was admitting to ICU. I think they tolerated the neurosurgeon doing it but would not some little dude who didn't bring in adequate $ to the hospital as I am outpatient based.
 
I do single shot trials for terminal malignancy using PF Dilaudid in the office mainly due to the logistics involved in a hospital based trial. In office stay for 6 hours with close monitoring and patient and family aware of all risks. The conversion factor from PO to IT is not as clear cut as in Morphine so use your own diligence. At the time of implant I use a combination of bupivacaine and Dilaudid. You can do them in the office if you have a clear policy/plan, trained staff and after hours coverage. If not then don't do it!!!!
 
How much is Medicare / priv carriers paying for pump trials?
 
At my program insurance's pay for 3 day admission if you get the prior auth first
 
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