intrathecal pain pumps

[kstarm]

I am trying to figure out the best way to manage patients with IT pumps for pain. Specifically the issue has been that they come into the hospital and will need a refill before leaving the hospital. We do not have the ability to refill them while they are inpatient. Currently the recommendation from the people who place these pumps (outside our system) is to turn the rate down to the lowest rate possible and treat with oral and IV opioids until they discharge and can be refilled. I have very little experience with pumps.

I am wondering when I should expect onset of withdrawal symptoms once the rate is decreased, I would assume 12-24hrs, but would appreciate anyone more knowledgeable helping me out.

I am also wondering what type of opioid conversion should be used to supplement the decreased rate? I know the IV/oral to IT conversions but what I have been reading suggests that it doesn't go both ways. I appreciate any thoughts.

---

Members don't see this ad.

 

[lobelsteve]

Call those idiots up and tell them to come in and refill their pumps while patient is in the hospital.

I inherited a lady years ago who was on IT morphine. She was due for refill but missed appointment. Hospital called and asked me to help out. She had big MI and was in ICU minimally responsive. They wanted pump refilled and no changes made so tbey could eliminate it as part of her problem. Refilled and programmed in ICU bed.

 

[SeniorWrangler]

Elective surgeries should and could be timed to avoid running out of pump medication, but if you need to manage this, don't go by the 100fold conversion factors that are referenced for intrathecal opioids. I have found ketamine infusions to be helpful in these situations.

However, *somebody* needs to be able to refill pumps. If you ask Medtronic, they will be happy to educate you and your team and come out to walk you through the procedure.
You can always put the chronic pain patient on a PCA, the patient with a baclofen pump who is running out of baclofen is going to get very sick and you really can't replace the baclofen PO/IV. That's a true pump emergency.

 

[Aether2000]

The person filling the pump may not have privileges in the hospital where the patient ends up hospitalized, and in such cases cannot fill a pump or delegate it to be done by their staff. Most pumps have an alarm set/refill date days to weeks early before the pump runs dry, so there is some latitude, however in the case of baclofen pumps, these should not be allowed to run dry. If there is no one in the hospital trained to fill and reprogram the pump, then you are just stuck dealing with the repercussions of a pump running dry, but should not attempt to learn to fill and reprogram these on the fly. Mistakes in programming are a common cause of overdose or death, and programming is not always easy. Mistakes in filling can kill the person within 30 minutes. The old equivalence rate was quoted as 1mg/day IT MS = 300mg oral MS but there is significant variability in this ratio. Titrating IV can help, but you will not know if the pump is truly out of meds until the person goes into withdrawal because the calculated residual volume is just that, and may vary by 14.5% either direction and still be within tolerance of what is expected of pump residual volume. Hospitals can usually obtain concentrated commercial morphine without compounding and may be able to compound dilaudid. Any further compounding of other agents would require a substantial financial outlay for the raw materials (eg. powdered bupivicaine, clonidine, etc) but these are not always necessary if the primary goal is to prevent withdrawal, and since these additives may only affect pain by an additional 20% in most cases. But again, the issue is the filling and programming. If there is someone on staff trained to do so, then great. Ideally, the pain doc or whoever fills their pumps would come to the hospital and provide this service if they have privileges.

 

[Ducttape]

Seems ludicrous that the hospital based practice (if there is one) would not be able to fill these pumps...

I have, on (a very) rare occasion.

 

[kstarm]

Thank you for the responses. The three main pump placers in the community do not have privileges at the hospital and this does not seem like something they are interested in pursuing. I think I could learn how to refill the pumps and did a few during fellowship and a number more for baclofen during residency, though Part of the issue is the volume. This has come up once in 3 years since I started at the hospital, thus for reasons Algos stated I have been hesitant to become the "pump guy". One of the main barriers is getting the compounded medication through our pharmacy as well. We do have a process for filling baclofen pumps here.

Thanks again for the insights.

 

[SSdoc33]

effing nightmare.

spending 3 hours of your time because somebody else decided to put in a pump when they (probably) shouldnt have.

not a good use of your time.

 

[Agast]

I think I could learn how to refill the pumps and did a few during fellowship and a number more for baclofen during residency, though Part of the issue is the volume. This has come up once in 3 years since I started at the hospital, thus for reasons Algos stated I have been hesitant to become the "pump guy". One of the main barriers is getting the compounded medication through our pharmacy as well. We do have a process for filling baclofen pumps here.

Don't do it. There's only a few ways you could kill a patient in pain management and this is one of them. The biggest risk is your pharmacy isn't used to compounding these meds and they might mess up the concentration. I know of that happening at least once where pharmacy was off by 100x. Outcome not good. And you have no way of verifying what you're actually injecting.

 

[101N]

Call Medtronic and tell them that this is their problem. They have nurses around the state that can come in and provide this service to hospitalized patients.

Pumps for CNP are MAT by another name.

 

[drusso]

Call Medtronic and tell them that this is their problem. They have nurses around the state that can come in and provide this service to hospitalized patients.

Pumps for CNP are MAT by another name.

I trained (for free) a CRNA at our local hospital on how to interrogate pumps and how to print out status strips. Medtronic gave the hospital an interrogator and printer. On the print out is the name of the of "implanting physician." I took the hospital social worker out for lunch and showed her examples of various print-out and also gave her a list of contact information for most pain physicians in our state. When a patient with a pump gets hospitalized, they know who to call (not me). My expectation is that the implanting doctor will call my office and coordinate care for their patient. If not, then not my problem. I will refill baclofen pumps for patients in the hospital as baclofen withdrawal can be life threatening.

Also, be careful about framing intrathecal therapy as medically-assisted therapy as this would be considered "off-label" and not consistent with the device's 510(k) cleared intended use. Anyone using the device for this kind of therapy (basically as an addiction treatment) risks running afoul of the FDA. It is not approved for addiction therapy.