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Malignant Pain The Role of IDDS. Mark Schlesinger, MD Schlesinger Pain Centers www.schlespain.com. 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. What is Malignant Pain?.

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Malignant pain the role of idds

Malignant PainThe Role of IDDS

Mark Schlesinger, MD

Schlesinger Pain Centers

www.schlespain.com


Malignant pain
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.



What is malignant pain1
What is Malignant Pain?

  • Pain caused by the cancer itself


What is malignant pain2
What is Malignant Pain?

  • Pain caused by the cancer itself

  • What will not be discussed?


What is malignant pain3
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


Pain sub types
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


What is idds
What is IDDS?

  • Intrathecal Drug Delivery Systems

  • Direct Administration of Drugs to Spinal Cord

  • Fully Implantable Therapies

  • Programmable vs. Non-Programmable


Why idds
Why IDDS?

  • Potency

    • Multiple Spinal Receptors

      • Opiate Receptors

      • Sodium Channels

      • Calcium Channels

      • Adrenergic Receptors

      • NMDA Receptors


Why idds1
Why IDDS?

  • Side Effects

    Systemic Opiates Spinal Opiates/Drugs

    Decreased LOC Pruritis

    Depression Pedal Edema

    Respiratory Depression

    Decreased Gag Reflex

    Pulmonary Aspiration

    Decreased Appetite

    Nausea & Vomiting

    Constipation

    Immune Suppression

    Decreased Libido


Intrathecal drugs
Intrathecal Drugs

  • Mostly Off-Label Uses

    Approved Commonly Used

    Morphine Hydromorphone

    Ziconitide Fentanyl

    Baclofen Sufentanyl

    Bupivacaine

    Ropivacaine

    Clonidine

    Ketamine

    Not used: Demerol due to side effects & drug interactions


Intrathecal drug mixtures
Intrathecal Drug Mixtures

Double, double toil and trouble;

Fire burn and cauldron bubble.



Non programmable pumps
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


Programmable pumps
Programmable Pumps

  • Codman Medstream Medtronic Synchromed II


Programmable pumps1
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


Programmable pumps2
Programmable Pumps

  • Codman Medstream Pump

    • Diameter 76.0 mm

      • 20 cc Thickness 21.6 mm Weight 150 gm

      • 40 cc Thickness 28.2 mm Weight 155 gm

  • Medtronic Synchromed II Pump

    • Diameter 87.5 mm

      • 20 cc Thickness 19.5 mm Weight 165 gm

      • 40 cc Thickness 26.0 mm Weight 175 gm


Programmable pumps3
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 Field Rotor Lock-Up, Restarts


Programmable pumps4
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


Pca basics
PCA Basics

Bolus – an instantaneous injection of drug to suddenly initiate therapy or to increase steady state levels.


Pca basics1
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 basics2
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.


Pca basics3
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.


Pca basics4
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.


Pca basics5
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.


Who is a candidate
Who Is A Candidate?

  • Pain Syndromes at or below clavicle

  • Nociceptive, Neuropathic or Visceral Pain

  • Life Expectancy at least 3-6 months

  • Unrelieved Pain Not the best practice.

  • Side Effects Preferred reason!

    • Usually at the level of Oxycontin 60mg per day


Epidural trial
Epidural Trial

  • Office Procedure

  • Catheters placed within 24 hours

  • Trials up to 2 weeks long


Final implantation
Final Implantation

Day Surgery Procedure

Lumbar Needle Entry

Catheter Tip: Cervical, Thoracic or Lumbar

Pump in R or L Buttock


Follow up care
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


Case study
Case Study

  • PB 48 YO W male presents in 2000


Case study1
Case Study

Radical Prostatectomy

Radiation

Chemotherapy

Hormone Manipulation




Case study4
Case Study

  • 04/08/08 Initial Consultation

    • Pain Primarily in Pelvis

  • 04/10/08 Epidural Trial Placement

  • 04/17/08 Permanent Implantation

    • Morphine 0.7 mg per day c good relief of pain


Case study5
Case Study

  • Summer 2008

    • Increased pain despite increased morphine dose

    • Add Bupivacaine


Case study6
Case Study

  • Summer 2008

    • Increased pain despite increased morphine dose

    • Add Bupivacaine

  • Fall 2008

    • Increased pain despite increased combined dose

    • Add Clonidine


Case study7
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


Case study8
Case Study

  • 03/02/09 Hospitalized with abdominal pain

    • Pump Increased


Case study9
Case Study

  • 03/02/09 Hospitalized with abdominal pain

    • Pump Increased

  • 03/03/09 AM Symptoms worsen

    • Decreased Appetite

    • Nausea and Vomiting

    • Low Grade Fever


Case study10
Case Study

  • 03/02/09 Hospitalized with abdominal pain

    • Pump Increased

  • 03/03/09 AM Symptoms worsen

    • Decreased Appetite

    • Nausea and Vomiting

    • Low Grade Fever

  • 03/03/09 PM Dx: Intraabdominal Process

    • CAT Scan of Abdomen

    • Surgical Consultation

    • Sigmoid Colectomy


Case study11
Case Study

  • 03/02/09 Hospitalized with abdominal pain

    • Pump Increased

  • 03/03/09 AM Symptoms worsen

    • Decreased Appetite

    • Nausea and Vomiting

    • Low Grade Fever

  • 03/03/09 PM Dx: Intraabdominal Process

    • CAT Scan of Abdomen

    • Surgical Consultation

    • Sigmoid Colectomy

  • 03/08/09 Discharged in good condition


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