Introduction

Risk Mitigation and Monitoring Protocols in Intrathecal Opioid Pump Therapy for Chronic

Pain: A National SurveyDavid Kim M.D. and Alan Hillstead MD.

Henry Ford Hospital, Department of Anesthesiology,, Division of Pain Management, Detroit MI

• Recent studies by Coffey et al. (1-2) have shown elevated mortality and morbidity due to respiratory depression with the use intrathecal opioid pump therapy (ITP) for chronic pain. This has been seen especially at initiation of the therapy or pump replacement. Specific risk mitigation measures were recommended including close attention to the starting intrathecal opioid dose (or restarting dose after therapy interruption, monitoring for respiratory depression at least 24 hours, avoidance of other respiratory depressants.

• American Society of Anesthesiology (ASA) has specific guidelines for monitoring after single injection or continuous infusion of neuro-axial opioids in the acute pain setting but does not comment on its application to chronic pain (3). Our current survey attempts to give a picture of current monitoring practices throughout the pain medicine community.

Introduction

A national registry of ITP implanters were obtained from Medtronic and 980 surveys were mailed.

The survey included:1) number of implants performed each year2)region of practice, 3)method of trialing,4) length and setting of monitoring5) frequency of vital signs (VS) at < 12 hrs and 12-24 hrs6) use of monitoring equipment such as pulsoximetry or end tidal CO2,7)avoidance of other respiratory depressants, and maximum starting doses.

Method

• The response rate was 6.8% (n=68). • 17.6% (n=12) implanted < 5 pumps a year

with 19% (n=1) >100 but the highest proportion at 30.9 % (n=21) implanted between 10-25.

• The largest group practiced in the Midwest at 26.5 % (n=18) with the smallest in the northwest 5.9% (n=4).

Results

Trial methods

IT Catheter Epidural catheter

single shot0

5

10

15

20

25

30

3534

20

14

0.5 0.294 0.206

# of MD's% 0f MDColumn1

Length of Monitoring

Inpt 24 hrs Discharge same day

0

10

20

30

40

50

60

50

18

0.735 0.2652 2

# MD% MDSeries 3

Vital signs frequency first 12 hrs

Q 1 hr Q 2 hr Q 4 hr Q 8 hr0

5

10

15

20

25

30

35

20

12

31

5

0.294 0.192 0.455 0.075

# MD% MDColumn1

Vital signs frequency after 12 hrs

Q 1 hr Q 4 hr0

5

10

15

20

25

30

35

7

31

0.059 0.41

# MD% MDColumn1

The sizable minority of 38.2 % (n=26) did not use pulsoximetry or end tidal CO2 monitors. 20.6% (n=14) did not avoid the use of other repiratory depressants. 70.6% (n=48) monitored patient on a general medical floor. 33.8% (n=23) did not set a maximum starting opioid dose

• There is variation in monitoring of patients with ITP therapy.

• A sizable minority of providers would be outside the recommendations suggested by recent literature and would be outside of compliance if ASA monitoring guidelines were used for chronic pain.

• This has implications on patient safety and requires further research

Conclusion