The History of Perioperative Nursing By: Ruth Crothers, RN BSN CNOR RNFA.
Technical Nuances of Surgical Implantation of Intrathecal Pain Pumps Susan Garruto MSN,CRNP,RNFA...
-
Upload
suzan-matthews -
Category
Documents
-
view
221 -
download
1
Transcript of Technical Nuances of Surgical Implantation of Intrathecal Pain Pumps Susan Garruto MSN,CRNP,RNFA...
Technical Nuances of Surgical Implantation of Intrathecal Pain
Pumps
Susan Garruto MSN,CRNP,RNFA
Thomas Jefferson University Hospital
Disclosure
• I have no affiliations to disclose
Objectives
• Identify patients who would benefit from intrathecal drug delivery
• Describe the technique used for catheter/pump implantation
• Explain the troubleshooting aspects of catheter/pump implantation
Applications for Intrathecal Pain Pumps
Spasticity (baclofen)• Multiple sclerosis• Traumatic brain injury• Cerebral Palsy• Cord injury• Paraparasis• Stroke
Chronic pain (morphine, prialt)
• Nociceptive pain
Upper Spasticity Patterns
Lower Spasticity Patterns
Spasticity Trial
• Single bolus injection (50 mcg)
• Check effect over 8 hours
• >8 hour- start with ½ dose
• <8 hour- start with 2X dose
• No effect- increase bolus for trial
• Baclofen (Lioresal)- concentration for direct delivery is much more effective than oral baclofen.
Pain Pump Trial
• Morphine
• Single bolus- will indicate adverse effects
• Indwelling catheter to increase morphine dose to gain starting point for dosage in permanent pump.
Patient selection
Diagnostic Work Up
• MRI
• CT
• Plain X-rays
• Labs, INR, PTT
Pre-op
• Pump size: 40 cc vs. 20 cc
• Drug of choice: Lioresal, other
• Chlorahexadine shower & wipes
• Revision- always have representative interrogate before surgery.
Pre-op
• Confirm pump size/ drug amount
• Confirm plan for admission-including rehabilitation unit
• Often involves caregiver
• Introduce representative
Intra-opOperating Room
• Pre-operative antibiotics
• Patient positioned in full lateral decubitus- may have to be creative!
• Gel pressure points
• Prep and drape back and abdomen simultaneously.
Intra-opOperating Room
• Local anesthesia• Minimal incision- don’t let the incision
sacrifice accuracy or angle of reach. Need room to secure catheter.
• Para-spinal lumbar puncture (L2-3-4) to prevent shearing of the catheter
• Brisk flow of CSF• C-arm fluoroscopy to check catheter
placement
Implantation
• Catheter is placed intrathecally (usually L3 or L4) and tunneled subcutaneously to the pump.
• Tip placement at the T10-T11 level
• Acute hospital length of stay is 3-5 days
Posterior lumbarAnchoring the catheter
• 2 pursestring sutures- with Touhy needle in place
• 2 butterfly anchors- anchor butterfly to catheter, anchor butterfly to fascia
• Need to have fascial tissue, not fat
• Protect catheter at all times (new catheter is not as delicate)
• Allow for strain relief loop
Abdomen
• Placement in RLQ or LLQ-patient preference• Below the waistline• 2.5 cm beneath the skin• Sub-fascial –extremely thin patients• Trim catheter- hand off excess to be measured• Check for CSF flow after tunneling• 2 sutures to anchor pump• Catheter lies posterior to the pump• Access pump to confirm CSF flow before closing
incision.• Copious antibiotic irrigation, anterior & posterior
Intra-opOperating Room
• Interrogate system before closure
• Meticulous closure
• Antibiotic ointment
• Tegaderm dressing
• Abdominal binder to prevent migration of generator
• Flat for 12 hours
Post-op
• Pain medications
• Antibiotics for 24 hours
• Bathing instructions
• Wound care instructions
• Watch for complications- lack of drug delivery, infection
Thomas Jefferson UniversityPhiladelphia, PA – USA
Short video