malignant pain the role of idds
Download
Skip this Video
Download Presentation
Malignant Pain The Role of IDDS

Loading in 2 Seconds...

play fullscreen
1 / 41

Malignant Pain The Role of IDDS - PowerPoint PPT Presentation


  • 157 Views
  • Uploaded on

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?.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Malignant Pain The Role of IDDS' - chavez


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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
ad