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
Ongoing anticoagulation therapy
Child before fusion of the epiphyses
Occult infection possible
Recovering drug addict
Lack of social or family support
Lack of access to medical care
Allergy to implant materials
Allergy to intended medications
Certain psychological-behavioral features
Pain type and generator appropriate
Demonstration of opioid responsiveness
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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