Infraclavicular Fossa as an Alternate Site for Placement of Intrathecal Infusion Pumps

Abstract OBJECTIVE Intrathecal infusion using an implantable pump is a common method of delivering medication for spasticity or chronic pain. The classic site for placement of the pump is in the abdominal wall. In some patients, there are confounding factors that make placement of an abdominal pump impractical. The purpose of this study was to report the implantation of Synchromed II pumps (Medtronic, Inc, Minneapolis, Minnesota) in the infraclavicular fossa. METHODS Four patients, aged 13 to 33 years, underwent infraclavicular placement of a Synchromed II infusion pump. In one patient, severe scoliosis and hip joint contractures precluded placement of the pump in the traditional position. Another patient had several ostomies on the abdominal wall, leaving no place for the pump. In a third, a combination of scoliosis and ostomy rendered the abdomen inappropriate for pump placement. RESULTS In 3 patients, a 20-mL pump was placed in the infraclavicular fossa. In the fourth, a 40-mL pump was placed in the left infraclavicular fossa. All patients tolerated the operation well. There were no postoperative reports of local pain or discomfort. One patient died from unrelated respiratory compromise several months after pump placement. At last follow-up (average of 11 months), the pumps were functioning well, and there were no wound-related complications. Selected pre- and postoperative photographs are presented. CONCLUSION The infraclavicular fossa is a viable alternative to the abdomen as the site for placement of a drug infusion pump.

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Development and in vitro evaluation of a flow-adjustable elastic drug infusion pump

Proceedings of the Institution of Mechanical Engineers Part H Journal of Engineering in Medicine ◽

10.1177/0954411911419008 ◽

2011 ◽

Vol 225 (11) ◽

pp. 1070-1077 ◽

Cited By ~ 1

Author(s):

S-W Choi ◽

S-M Kang ◽

H-Y Kim ◽

K-W Nam

Keyword(s):

Flow Pattern ◽

Infusion Pump ◽

Injection Rate ◽

Chamber Pressure ◽

Elastic Membrane ◽

Physiological Status ◽

Drug Infusion ◽

Short Term ◽

Infusion Pumps

Passive-type drug infusion pumps have several advantages over active-type pumps including a simple drug chamber structure and relatively high operational stability. However, conventional passive-type infusion pumps also have several limitations compared to active ejection pumps, such as a fixed flowrate and monotonic flow pattern. To enhance the clinical feasibility of using passive-type drug infusion pumps, flow readjustment and flow regulation abilities are needed. This paper proposes a new portable elastic drug infusion pump that integrates the advantages of active and passive infusion pumps to improve clinical feasibility. The proposed infusion pump incorporates a passively driven drug chamber and an actively adjusted flow controller, which can adjust and regulate various target flowrates and adjust the flow pattern in accordance with the patient’s time-varying physiological status. The proposed infusion pump uses the contraction force of an expanded elastic membrane to extract the drug from the drug chamber for delivery into the patient’s body through an outlet catheter. It also utilizes a flow sensor, a flow resistor, and a motor-driven flow restrictor that can monitor the real-time flowrate through the outlet catheter and automatically regulate the actual flowrate around the target value. Experiments on the proposed system resulted in actual injection rates of 0.49 ± 0.03 (mean ± standard deviation), 0.98 ± 0.03, 1.49 ± 0.04, and 1.99 ± 0.03 ml/h when the target injection rate was set to 0.5, 1.0, 1.5, and 2.0 ml/h, respectively. During the entire period of operation from the fully filled state to the totally empty state, an inner-chamber pressure of >100 mmHg was maintained, which shows that the proposed infusion pump can stably maintain its target flowrate as the amount of drug remaining to be injected decreases. It appears that the proposed drug infusion pump can be applied to a wide variety of patient treatments that require short-term, accurate, and stable drug delivery.

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Body Mass Index: A Central Indicator for Alternative Intrathecal Infusion Pump Placement

PsycEXTRA Dataset ◽

10.1037/e685842012-137 ◽

2012 ◽

Author(s):

Maegan Wagner ◽

Meghan Carlin ◽

Pennie Seibert ◽

Jennifer Valerio ◽

Yustina Rafla ◽

...

Keyword(s):

Body Mass Index ◽

Body Mass ◽

Infusion Pump ◽

Pump Placement ◽

Intrathecal Infusion

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Chronic Lumbar Radiculopathy

Pain Neurosurgery ◽

10.1093/med/9780190887674.003.0012 ◽

2019 ◽

pp. 95-104

Author(s):

Brian J. A. Gill ◽

Farhan A. Khan ◽

Christopher J. Winfree

Keyword(s):

Infusion Pump ◽

Failed Back Surgery Syndrome ◽

Neurological Deficits ◽

Lumbar Radiculopathy ◽

Lumbar Surgery ◽

Failed Back Surgery ◽

Pump Placement ◽

Surgical Options ◽

Intrathecal Infusion

Failed back surgery syndrome (FBSS), or post-laminectomy syndrome, is a form of chronic lumbar radiculopathy characterized by persistent pain following spinal surgery. When medical management for FBSS fails, three surgical options remain: revision lumbar surgery, spinal cord stimulation (SCS), or intrathecal infusion pump placement. If faced with neurological deficits and correlative compressive lesions, revision lumbar surgery is often indicated. But in the absence of such complications, surgeons and their patients can explore the two latter options. Thus, this chapter will implement a case study to navigate the decision making involved when choosing either SCS or intrathecal infusion pump placement.

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Intrathecal Catheter-Syringe Adaptor for Short-Term Intrathecal Analgesia with an Externalized Pump: A Case Report

January 2018 - Pain Physician ◽

10.36076/ppj.2010/13/151 ◽

2010 ◽

Vol 2;13 (1;2) ◽

pp. 151-156

Author(s):

Denise WIlkes

Keyword(s):

Health Care ◽

Cancer Pain ◽

Pain Control ◽

Infusion Pump ◽

Drug Infusion ◽

Intrathecal Catheter ◽

Infusion Pumps ◽

Filling Device ◽

Introducer Needle ◽

Intrathecal Analgesia

Background: In most patients, cancer pain is effectively treated with conservative medical management consisting of oral and/or transdermal analgesics. Cancer patients tend to fail conservative medical management near the end of their life expectancy, thus requiring alternative routes of analgesia such as intravenous, epidural, or intrathecal. The intrathecal route provides the most effective analgesia due to the close proximity of the opioid receptors in the spinal cord. Though there are many techniques that exist for intrathecal drug delivery, complications can limit effectiveness such as infection, bleeding, cerebrospinal fluid (CSF) leaks, post-dural puncture headaches (PDPH), pump and/or catheter malfunctions, or limitations of technical expertise. Therefore, an important goal in palliative cancer pain therapy is to use equipment that is going to have the fewest number of complications and will be the most familiar to the health care providers. We describe the combination of the Medtronic Indura 1P catheter, which has the least catheter-related complications and can be used with any external drug infusion pump. These are regular infusion pumps that the health care workers are familiar with so they can provide excellent and efficient service to the patient. Methods: In an operating room, the intrathecal catheter was placed using sterile technique under fluoroscopic guidance. The epidural space was identified with loss of resistance technique. Then the introducer needle (supplied in the Indura 1P catheter kit) was advanced until free-flowing CSF was obtained. The spinal catheter was advanced into the intrathecal space through the introducer needle to lumbar 2-3 level. The catheter was tunneled subcutaneously 10 cm lateral to the catheter exit site. A syringe filling device was inserted into the catheter opening and was secured with silk suture. A luer lock syringe was attached to the syringe filling device and CSF was aspirated. The syringe filling device was capped and later attached to an external drug infusion pump. Results: We report the successful use of the Medtronic Indura 1P, one piece intrathecal catheter, connected to the external drug pump for a 3 week period in a patient with metastatic cervical cancer for palliative pain control. Limitations: Case report only. Conclusion: This technique is simple to perform by pain specialists. The catheter modification allows the use of the Medtronic intrathecal catheter with standard external drug infusion pumps. This facilitates the patient’s care in the hospice setting. Key words: Intrathecal drug delivery, palliative medicine, intrathecal analgesia, intrathecal catheter complications, cancer pain, end of life pain control

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Optimizing drug infusion schedules towards personalized cancer chronotherapy

10.1101/688606 ◽

2019 ◽

Cited By ~ 1

Author(s):

Roger J. W. Hill ◽

Pasquale F. Innominato ◽

Francis Lévi ◽

Annabelle Ballesta

Keyword(s):

Precision Medicine ◽

Hepatic Artery ◽

Drug Administration ◽

Infusion Pump ◽

Patient Specific ◽

Mathematical Framework ◽

Drug Infusion ◽

Infusion Pumps ◽

Patient Model ◽

Personalized Cancer

AbstractAimsPrecision medicine requires accurate technologies for drug administration and proper systems pharmacology approaches for patient data analysis. Here, plasma pharmacokinetics (PK) data of the OPTILIV trial in which cancer patients received oxaliplatin, 5-fluorouracil and irinotecan via chronomodulated schedules delivered by an infusion pump into the hepatic artery were mathematically investigated.MethodsA pump-to-patient model was designed in order to accurately represent the drug solution dynamics from the pump to the patient blood. It was connected to semi-mechanistic PK models to analyse inter-patient variability in PK parameters.ResultsLarge time delays of up to 1h41 between the actual pump start and the time of drug detection in patient blood was predicted by the model and confirmed by PK data. Sudden delivery spike in the patient artery due to glucose rinse after drug administration accounted for up to 10.7% of the total drug dose. New model-guided delivery profiles were designed to precisely lead to the drug exposure intended by clinicians. Next, the complete mathematical framework achieved a very good fit to individual time-concentration PK profiles and concluded that inter-subject differences in PK parameters was the lowest for irinotecan, intermediate for oxaliplatin and the largest for 5-fluorouracil. Clustering patients according to their PK parameter values revealed two patient subgroups for each drug in which inter-patient variability was largely decreased compared to that in the total population.ConclusionsThis study provides a complete mathematical framework to optimize drug infusion pumps and inform on inter-patient PK variability, a step towards precise and personalized cancer chronotherapy.Author summaryAccuracy and safety of infusion pumps remain a critical issue in the clinics and the development of accurate mathematical models to optimize drug administration though such devices has a key part to play in the advancement of precision medicine. Here, PK data from cancer patient receiving irinotecan, oxaliplatin and 5-fluorouracil into the hepatic artery via an infusion pump was mathematically investigated. A pump-to-patient model was designed and revealed significant inconsistencies between intended drug profiles and actual plasma concentrations. This mathematical model was then used to suggest improved profiles in order to minimise error and optimise delivery. Physiologically-based PK models of the three drugs were then linked to the pump-to-patient model. The whole framework achieved a very good fit to data and allowed quantifying inter-patient variability in PK parameters and linking them to potential clinical biomarkers via patient clustering. The developed methodology improves our understanding of patient-specific drug pharmacokinetics towards personalized drug administration.

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Use Of External Intrathecal Infusion Pumps In The Management Of Septic Complications: A Case Report

Endocrine Metabolic & Immune Disorders - Drug Targets ◽

10.2174/1871530315666150506124127 ◽

2015 ◽

Vol 15 (4) ◽

pp. 293-296

Author(s):

Riccardo Marvulli ◽

Pierpaolo Chiumarulo ◽

Mattia Nisi ◽

Laura Barulli ◽

Gianfranco Megna ◽

...

Keyword(s):

Case Report ◽

Infusion Pumps ◽

Septic Complications ◽

Intrathecal Infusion

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Long-Term Clinical Outcomes of an Antibiotic-Coated Non–Cross-linked Porcine Acellular Dermal Graft for Abdominal Wall Reconstruction for High-Risk and Contaminated Wounds

The American Surgeon ◽

10.1177/00031348211023392 ◽

2021 ◽

pp. 000313482110233

Author(s):

Jordan Robinson ◽

Jesse K. Sulzer ◽

Benjamin Motz ◽

Erin H. Baker ◽

John B. Martinie ◽

...

Keyword(s):

High Risk ◽

Abdominal Wall ◽

Clinical Outcomes ◽

Open Abdomen ◽

Abdominal Wall Reconstruction ◽

Dermal Graft ◽

Elective Repair ◽

Acellular Dermal

Background Abdominal wall reconstruction in high-risk and contaminated cases remains a challenging surgical dilemma. We report long-term clinical outcomes for a rifampin-/minocycline-coated acellular dermal graft (XenMatrix™ AB) in complex abdominal wall reconstruction for patients with a prior open abdomen or contaminated wounds. Methods Patients undergoing abdominal wall reconstruction at our institution at high risk for surgical site occurrence and reconstructed with XenMatrix™ AB with intent-to-treat between 2014 and 2017 were included. Demographics, operative characteristics, and outcomes were collected. The primary outcome was hernia recurrence. The secondary outcomes included length of stay, surgical site occurrence, readmission, morbidity, and mortality. Results Twenty-two patients underwent abdominal wall reconstruction using XenMatrix™ AB during the study period. Two patients died while inpatient from progression of their comorbid diseases and were excluded. Sixty percent of patients had an open abdomen at the time of repair. All patients were from modified Ventral Hernia Working Group class 2 or 3. There were a total of four 30-day infectious complications including superficial cellulitis/fat necrosis (15%) and one intraperitoneal abscess (5%). No patients required reoperation or graft excision. Median clinical follow-up was 38.2 months with a mean of 35.2 +/− 18.5 months. Two asymptomatic recurrences and one symptomatic recurrence were noted during this period with one planning for elective repair of an eventration. Follow-up was extended by phone interview which identified no additional recurrences at a median of 45.5 and mean of 50.5 +/−12.7 months. Conclusion We present long-term outcomes for patients with high-risk and contaminated wounds who underwent abdominal wall reconstruction reinforced with XenMatrix™ AB to achieve early, permanent abdominal closure. Acceptable outcomes were noted.

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Abdominal Wall Expanding System. Intraoperative Abdominal Wall Expansion as a Technique to Repair Giant Incisional Hernia and Laparostoma. New and Long-Term Results From a Three-Center Feasibility Study

Surgical Innovation ◽

10.1177/15533506211041477 ◽

2021 ◽

pp. 155335062110414

Author(s):

Dietmar Eucker ◽

Nadine Rüedi ◽

Clinton Luedtke ◽

Oliver Stern ◽

Henning Niebuhr ◽

...

Keyword(s):

Abdominal Wall ◽

Abdominal Wall Reconstruction ◽

Long Term Results ◽

Anatomical Reconstruction ◽

Time Saving ◽

Lateral Abdominal Wall ◽

Hernia Size ◽

Midline Closure

Background The abdominal wall expanding system (AWEX) was first applied in 2012 and published in 2017. This novel technique was developed to reconstruct complex incisional hernias and residual skin-grafted laparostoma after treatment of an open abdomen, when primary midline closure was impossible. The main aim was the anatomical reconstruction of the abdominal wall and the avoidance of dissecting techniques (component separation). Methods Between 2012 and 2019, 33 patients underwent AWEX hernia repair in three certified hernia centers. The retracted abdominal wall was stretched with the AWEX system intraoperatively for approximately 30 min. Hernia size was measured preoperatively, on CT, and intraoperatively. The gain in length on the lateral abdominal wall (decrease in width of the defect) after stretching and any residual midline gap were determined in the OR. Results 33 patients underwent AWEX procedures. Six cases were evaluated separately because of additional procedures (TAR, four cases) and preoperative application of botulinum toxin (two cases). The median (95% confidence interval) measured width of hernia defects was 13 (12–16) cm, the median gain in length on the lateral abdominal wall was 12 (10–15) cm. After median follow-up of 29 (12–54) months, one recurrence from the broken mesh was observed. No method-related complications occurred. Conclusion Based on the 2017 and current results, the AWEX system represents an alternative or supplemental procedure to current techniques for complex abdominal wall reconstruction. The system proved again to be time-saving, safe, effective, and easy to learn. Further studies with enhanced technology are in progress.

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O50 ALTERATIONS IN THE ABDOMINAL WALL MUSCULATURE AFTER ENDOSCOPIC ANTERIOR AND OPEN POSTERIOR COMPONENT SEPARATION

British Journal of Surgery ◽

10.1093/bjs/znab396.049 ◽

2021 ◽

Vol 108 (Supplement_8) ◽

Author(s):

Erling Oma ◽

Jan Kim Christensen ◽

Jorge Daes ◽

Lars Nannestad Jorgensen

Keyword(s):

Abdominal Wall ◽

Case Series ◽

Muscle Thickness ◽

Component Separation ◽

Fascial Closure ◽

Lateral Abdominal Wall ◽

Transverse Abdominis ◽

Abdominal Wall Muscle ◽

Anterior Component Separation

Abstract Aim Effects of component separation (CS) on abdominal wall musculature have only been investigated in smaller case series. The study aimed to compare abdominal wall alterations following endoscopic anterior component separation (EACS) or transverse abdominis release (TAR). Material and Methods Computed tomography scans were evaluated in patients who underwent open ventral hernia repair with TAR or EACS. Lateral abdominal wall muscle thickness and displacement were compared with preoperative images after bilateral CS and the undivided side postoperatively after unilateral CS. Results In total, 105 patients were included. The mean defect width was 12.2 cm. Fifty-five (52%) and 15 (14%) underwent bilateral and unilateral EACS, respectively. Five (5%) and 14 (13%) underwent bilateral and unilateral TAR, respectively. Sixteen (15%) underwent unilateral EACS and contralateral TAR. Complete fascial closure was achieved in 103 (98%) patients. The external oblique and transverse abdominis muscles were significantly laterally displaced with a mean of 2.74 cm (95% CI 2.29-3.19 cm) and 0.82 cm (0.07-1.57 cm) after EACS and TAR, respectively. The combined thickness of the lateral muscles was significantly decreased after EACS (mean decrease 10.5% [5.8-15.6%]) and insignificantly decreased after TAR (mean decrease 2.6% [-4.8-9.5%]), mean reduction difference EACS versus TAR 0.22 cm (-0.01-0.46 cm). One (1%) patient developed an iatrogenic linea semilunaris hernia after EACS. The recurrence rate was 19% after mean 1.7 years follow-up. Conclusions The divided muscle was significantly more laterally displaced after EACS compared with TAR. The thickness of the lateral muscles was slightly decreased after EACS and unchanged after TAR.

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