Drug Selection

In drug selection for pain control, continuous intrathecal infusion of morphine is the gold standard. Other opioids used include hydromorphone, fentanyl, sufentanil, and meperi-dine. Local anesthetics may be combined with the opioid or infused alone. These include bupivacaine, ropivacaine, and tetracaine. Clonidine is an alpha agonist effective at the spinal cord level that may be added to the infusion for improved pain control as well

Table 13.2 Selection criteria for implantable intrathecal pump.

Exclusion criteria Relative

Emanciated patient

Ongoing anticoagulation therapy

Child before fusion of the epiphyses

Occult infection possible

Recovering drug addict

Lack of social or family support

Socioeconomic problems

Lack of access to medical care

Absolute

Aplastic anemia

Systemic infection

Allergy to implant materials

Allergy to intended medications

Certain psychological-behavioral features

Inclusion criteria

Pain type and generator appropriate

Demonstration of opioid responsiveness

Psychological clearance

Successful completion of screening trial

Adapted from Waldman (1996).

(Anderson 1984, Coombs et al. 1982, Hassenbusch et al. 1990, Krames et al. 1985, Magora et al. 1980, Shetter et al. 1986, Winkelmuller and Winkelmuller 1996, Deer et al. 2007, Fanciullo et al. 1999, Coombs et al. 1985, Hassenbusch and Porteney 2000) (Tables 13.3 and 13.4).

The medication infusate is highly concentrated to allow for a long duration between pump refills. Commercial preparations are available, and doses and mixtures can be tailored by a compounding pharmacy. The older Medtronic system (Synchromed EL) has a reservoir volume of 18 ml, and the updated system (the Synchromed II) is available with a reservoir volume of 20 or 40 ml.

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