Weird Pump Reaction

[Tramadeezy]

Unfortunately I manage and fill about 30 IT pumps in my current gig. I feel like I have a good system down to make extra sure I am always through the port and in the pump before I ever inject any medicine. I accessed a patient's Medtronic pump earlier today, took out the old medicine without any problems. Needle stays firmly in pump, never moves. I go to inject the new medicine (40ml pump so difficult to inject as per usual tactile feedback) and after about 3-4 cc's the patient says that she is feeling a lot of stinging around the pump and then says she feels "weird". I stop injecting and withdraw what I had injected. She gets a glazed look in her eyes and for the next few minutes keeps saying she feels very strange, not dizzy or short of breath just feels weird all over. I hook her up to the monitor, vitals are normal. I end up filling her pump, watching her for about 15 minutes and send her on her way once she is back to feeling normal. Anyone experience anything like this? Im 1000% certain I was in the pump the whole time. Vasovagal reaction or anxiety attack? I have had several instances where patient's say that it stings when the new medication goes in and for the life of me can't understand why this would happen. Does the pump heat up when you fill it? Anyways, still scratching my head. Any thoughts??

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[drusso]

Unfortunately I manage and fill about 30 IT pumps in my current gig. I feel like I have a good system down to make extra sure I am always through the port and in the pump before I ever inject any medicine. I accessed a patient's Medtronic pump earlier today, took out the old medicine without any problems. Needle stays firmly in pump, never moves. I go to inject the new medicine (40ml pump so difficult to inject as per usual tactile feedback) and after about 3-4 cc's the patient says that she is feeling a lot of stinging around the pump and then says she feels "weird". I stop injecting and withdraw what I had injected. She gets a glazed look in her eyes and for the next few minutes keeps saying she feels very strange, not dizzy or short of breath just feels weird all over. I hook her up to the monitor, vitals are normal. I end up filling her pump, watching her for about 15 minutes and send her on her way once she is back to feeling normal. Anyone experience anything like this? Im 1000% certain I was in the pump the whole time. Vasovagal reaction or anxiety attack? I have had several instances where patient's say that it stings when the new medication goes in and for the life of me can't understand why this would happen. Does the pump heat up when you fill it? Anyways, still scratching my head. Any thoughts??

What the pump implanted in one of those mesh pouches?

 

[Orin]

What was the drug you were injecting?
Did you ultrasound the pump pocket?

The stinging could be a few things, but is often because in your zealousness to keep the needle in the pump, you're squishing abdominal wall nerves under the pump. The pump shouldn't heat up significantly with injection. You may also be partially in/partially out of the pump, creating a seroma and a rapid bolus effect of the medication, with some hydrodissection if it's a tight pocket with the old woven-Dacron pouch.

Pump fills can kill if you aren't careful, and the more confident you are, the more you need to check yourself before you break someone.

 

[callmeanesthesia]

Unfortunately I manage and fill about 30 IT pumps in my current gig. I feel like I have a good system down to make extra sure I am always through the port and in the pump before I ever inject any medicine. I accessed a patient's Medtronic pump earlier today, took out the old medicine without any problems. Needle stays firmly in pump, never moves. I go to inject the new medicine (40ml pump so difficult to inject as per usual tactile feedback) and after about 3-4 cc's the patient says that she is feeling a lot of stinging around the pump and then says she feels "weird". I stop injecting and withdraw what I had injected. She gets a glazed look in her eyes and for the next few minutes keeps saying she feels very strange, not dizzy or short of breath just feels weird all over. I hook her up to the monitor, vitals are normal. I end up filling her pump, watching her for about 15 minutes and send her on her way once she is back to feeling normal. Anyone experience anything like this? Im 1000% certain I was in the pump the whole time. Vasovagal reaction or anxiety attack? I have had several instances where patient's say that it stings when the new medication goes in and for the life of me can't understand why this would happen. Does the pump heat up when you fill it? Anyways, still scratching my head. Any thoughts??

What was the drug? If opioid I would expect a lot of bradycardia and obviously apnea.
Was the patient pretty established with refills or relatively new? If newer vasovagal seems more likely.
Sounds a lot like a vasovagal. Pocket fill probably wouldn’t have self resolved so quickly.

 

[Tramadeezy]

Hmmmm good question not sure about that. She was implanted several years ago with another doc outside of our group.

 

[Tramadeezy]

Medication was Hydromorphone 15mg/ml. Unfortunately no ultrasound at my shop. Ive filled her pump many times before without any issues. I would think a few ccs outside of the pump would take a few minutes to take any effect, her symptoms kicked in pretty quick. When she got the “im off to a different place” look in her eyes i got really nervous.

I agree these pumps can be deadly and thats why I take each fill very serious. I have a strict checkbox protocol in my head that I follow every time I do it. I was extra nervous about what happened because we recently had a code after pump fill situation at one of our clinics. Luckily patient survived.

 

[Ferrismonk]

I filled a bunch of pumps in fellowship, but there is a reason I don't deal with them on my own. If I ever fill a pump again, I would insist on ultrasound or flouro guidance. Risk injecting 600mg of Dilaudid sub-Q in my clinic by accident? Eff that.

 

[deleted131481]

I somewhat reluctantly have a couple baclofen pumps, but haven't had this happen.

If the medicine is refrigerated and you fill quickly, could it be a cold sensation patient is feeling?

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[iwumd07]

Did you use local in the skin before filling? Maybe local quickly absorbed into a small artery and she got a little local anesthetic toxicity.

 

[lobelsteve]

More likely psychosomatic.

 

[Tramadeezy]

No local when filling. Ya I agree likely some sort of psychosomatic reaction. The stinging followed by the intense reaction is what freaked me out. She is a reasonable/normal lady so it was way outside the norm of her usual pump fill. New experience for me, appreciate the input!

 

[Aether2000]

Agree psychosomatic is the most likely possibility. Many of these patients with pumps are bat**** crazy, and had pumps implanted to stop their incessant complaints about everything. Another possibility include leakage from the injection port around the needle and tracking subcutaneously. A rare cause would be transcatheter injection with a loop of catheter lying directly over the injection port.

 

[SommeRiver]

Fibro pump?

 

[10KHertz]

If you withdrew the same amount you infused initially , then boom you are 1000% in the reservoir. If you have issues finding the insertion site next time , use fluro.

Was the lady bradycardic or flushed when having somatic issues? If so, likely vasovagal. Give her Valium next refill(oral!).

And lastly, get rid of your pumps.... (with black box warnings and refill headaches just reserve for malignancy mediated pain).

 

[Tramadeezy]

Not a fibro pump Has failed back. She is someone I would consider a “successful pump patient”. She’s a teacher, comes in ever 6 months to get filled, not on oral meds. Not typical pump patient.

Ya withdrew same amount. Im certain it was some kind of reaction to the procedure. The stinging followed by the almost immediate glazed over look in her eyes is what scared me. Never seen anything like it when filling a pump.

I wish getting rid of my pump patients were that easy. Im employed and have about 30 inherited pumps at my location. Not sure I would have a job if I got rid of all of them... ive been out 4 years and have never actually ordered a new pump, and likely never will, all legacy patients.

 

[lobelsteve]

Not a fibro pump Has failed back. She is someone I would consider a “successful pump patient”. She’s a teacher, comes in ever 6 months to get filled, not on oral meds. Not typical pump patient.

Ya withdrew same amount. Im certain it was some kind of reaction to the procedure. The stinging followed by the almost immediate glazed over look in her eyes is what scared me. Never seen anything like it when filling a pump.

I wish getting rid of my pump patients were that easy. Im employed and have about 30 inherited pumps at my location. Not sure I would have a job if I got rid of all of them... ive been out 4 years and have never actually ordered a new pump, and likely never will, all legacy patients.

6 mo?

I don’t trust meds more than 100d. Remove and replace any leftover at 90d.

 

[SSdoc33]

Im getting a glazed look and feeling weird all over just knowing you have to refill 30 pumps

 

[Tramadeezy]

6 mo?

I don’t trust meds more than 100d. Remove and replace any leftover at 90d.

Maybe more like q4-5 months. I remember seeing the FDA recommended at least 6 months. I guess I should look at shortening the interval.

 

[Orin]

Maybe more like q4-5 months. I remember seeing the FDA recommended at least 6 months. I guess I should look at shortening the interval.

There's a few parts to this but a lower refill interval also allows for more diluted drug. I counsel for planning for a total of 120 days, with plans to refill q90d to stay compliant as if the patient were getting opioids systemically. The lower drug concentration/amount reduces the damage that could happen with a pocket fill, and also helps with drug stability issues. Some are advocating for saline rinse shenanigans during the fill to help reduce corrosion/build up in the reservoirs, but I have no data for that.

 

[Aether2000]

Drug stability issues have never been demonstrated except for admixtures, especially when the pH is very acidic (i.e., high bupivacaine concentrations). For morphine alone, there are no studies showing the medication decomposes at all over time, and it is the medication manufacturer arbitrarily setting expiration dates without justification that are the main issue that promotes a 120 day refill interval. 6 months works perfectly well if the concentration is not astronomical and single drug therapy is used.