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Malignant PainThe Role of IDDS
Mark Schlesinger, MDSchlesinger Pain Centerswww.schlespain.com
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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.
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What is Malignant Pain?
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What is Malignant Pain?• Pain caused by the cancer itself
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What is Malignant Pain?• Pain caused by the cancer itself• What will not be discussed?
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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
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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
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What is IDDS?
• Intrathecal Drug Delivery Systems• Direct Administration of Drugs to Spinal Cord• Fully Implantable Therapies• Programmable vs. Non-Programmable
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Why IDDS?
• Potency– Multiple Spinal Receptors• Opiate Receptors• Sodium Channels• Calcium Channels• Adrenergic Receptors• NMDA Receptors
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Why IDDS?
• Side EffectsSystemic Opiates Spinal Opiates/Drugs
Decreased LOC PruritisDepression
Pedal EdemaRespiratory DepressionDecreased Gag ReflexPulmonary AspirationDecreased AppetiteNausea & VomitingConstipationImmune SuppressionDecreased Libido
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Intrathecal Drugs• Mostly Off-Label Uses
Approved Commonly UsedMorphine HydromorphoneZiconitide FentanylBaclofenSufentanylBupivacaineRopivacaineClonidineKetamineNot used: Demerol due to side effects & drug interactions
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Intrathecal Drug Mixtures
Double, double toil and trouble;Fire burn and cauldron bubble.
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Intrathecal Drug Mixtures
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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
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Programmable Pumps
• Codman Medstream Medtronic Synchromed II
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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
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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
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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
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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
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PCA BasicsBolus – an instantaneous injection of drug to suddenly initiate therapy or to increase
steady state levels.
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PCA BasicsBolus – 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.
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PCA BasicsBolus – 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.
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PCA BasicsBolus – 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.
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PCA BasicsBolus – 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.
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PCA BasicsBolus – 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.
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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
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Epidural Trial
• Office Procedure• Catheters placed within 24 hours• Trials up to 2 weeks long
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Final Implantation
Day Surgery ProcedureLumbar Needle EntryCatheter Tip: Cervical, Thoracic or LumbarPump in R or L Buttock
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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
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Case Study
• PB 48 YO W male presents in 2000
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Case Study
Radical Prostatectomy
RadiationChemotherapyHormone Manipulation
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Case Study
2006
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Case Study
2007
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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
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Case Study• Summer 2008
– Increased pain despite increased morphine dose– Add Bupivacaine
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Case Study• Summer 2008
– Increased pain despite increased morphine dose– Add Bupivacaine
• Fall 2008– Increased pain despite increased combined dose– Add Clonidine
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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
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Case Study
• 03/02/09 Hospitalized with abdominal pain– Pump Increased
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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
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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
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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