Malignant pain the role of idds
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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

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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 pain

What is Malignant Pain?


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 OpiatesSpinal Opiates/Drugs

    Decreased LOCPruritis

    DepressionPedal 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

    ApprovedCommonly Used

    MorphineHydromorphone

    ZiconitideFentanyl

    BaclofenSufentanyl

    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.


Intrathecal drug mixtures1

Intrathecal Drug Mixtures


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 MedstreamMedtronic 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

    • 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


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 FieldRotor 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 PainNot the best practice.

  • Side EffectsPreferred 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 study2

Case Study

2006


Case study3

Case Study

2007


Case study4

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


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

  • 03/02/09Hospitalized with abdominal pain

    • Pump Increased


Case study9

Case Study

  • 03/02/09Hospitalized with abdominal pain

    • Pump Increased

  • 03/03/09 AMSymptoms worsen

    • Decreased Appetite

    • Nausea and Vomiting

    • Low Grade Fever


Case study10

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


Case study11

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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