Fentanyl Overdose Caused by Malfunction of SynchroMed II Intrathecal Pump: Two Case Reports

An unusual intrathecal baclofen pump failure thirteen months after implantation

Objective

To report a case of intrathecal pump failure following months of diminishing benefit from intrathecal baclofen, and to heighten awareness that intrathecal pump malfunction can occur without precipitating events.

Case report

A 40 year-old woman with multiple sclerosis and spastic paraplegia developed worsening spasticity after ten months of therapeutic stability with intrathecal baclofen. After other causes were pursued, this was discovered to be due to pump malfunction only thirteen months after implantation. After pump interrogation and discussion with the manufacturer the pump was replaced urgently and the patient regained therapeutic benefit and had no further complications.

Conclusions

We present herein what we believe to be the first report of a verified pump malfunction resulting in disruption of intrathecal baclofen delivery within thirteen months of implantation. Due to the possible severity of acute baclofen withdrawal, the pump was replaced urgently after diagnosis. Because of the patient's and her healthcare providers' vigilance, she experienced no adverse events. Healthcare providers are encouraged to acknowledge the possibility of intrathecal pump malfunction in similar scenarios, ensuring patient safety while systematically examining the underlying problem.

Advanced implantable drug delivery technologies: transforming the clinical landscape of therapeutics for chronic diseases

Chronic diseases account for the majority of all deaths worldwide, and their prevalence is expected to escalate in the next 10 years. Because chronic disorders require long-term therapy, the healthcare system must address the needs of an increasing number of patients. The use of new drug administration routes, specifically implantable drug delivery devices, has the potential to reduce treatment-monitoring clinical visits and follow-ups with healthcare providers. Also, implantable drug delivery devices can be designed to maintain drug concentrations in the therapeutic window to achieve controlled, continuous release of therapeutics over extended periods, eliminating the risk of patient non-compliance to oral treatment. A higher local drug concentration can be achieved if the device is implanted in the affected tissue, reducing systemic adverse side effects and decreasing the challenges and discomfort of parenteral treatment. Although implantable drug delivery devices have existed for some time, interest in their therapeutic potential is growing, with a global market expected to reach over $12 billion USD by 2018. This review discusses implantable drug delivery technologies in an advanced stage of development or in clinical use and focuses on the state-of-the-art of reservoir-based implants including pumps, electromechanical systems, and polymers, sites of implantation and side effects, and deployment in developing countries.

Tailoring Formulations for Intranasal Nose-to-Brain Delivery: A Review on Architecture, Physico-Chemical Characteristics and Mucociliary Clearance of the Nasal Olfactory Mucosa

The blood-brain barrier and the blood-cerebrospinal fluid barrier are major obstacles in central nervous system (CNS) drug delivery, since they block most molecules from entering the brain. Alternative drug delivery routes like intraparenchymal or intrathecal are invasive methods with a remaining risk of infections. In contrast, nose-to-brain delivery is a minimally invasive drug administration pathway, which bypasses the blood-brain barrier as the drug is directed from the nasal cavity to the brain. In particular, the skull base located at the roof of the nasal cavity is in close vicinity to the CNS. This area is covered with olfactory mucosa. To design and tailor suitable formulations for nose-to-brain drug delivery, the architecture, structure and physico-chemical characteristics of the mucosa are important criteria. Hence, here we review the state-of-the-art knowledge about the characteristics of the nasal and, in particular, the olfactory mucosa needed for a rational design of intranasal formulations and dosage forms. Also, the information is suitable for the development of systemic or local intranasal drug delivery as well as for intranasal vaccinations.

Injury and Liability Associated with Implantable Devices for Chronic Pain

BACKGROUND

Due to an increase in implantable device-related anesthesia pain medicine claims, the authors investigated anesthesia liability associated with these devices.

METHODS

After institutional review board approval, the authors identified 148 pain medicine device claims from 1990 or later in the Anesthesia Closed Claims Project Database. Device-related damaging events included medication administration events, infections, hematomas, retained catheter fragments, cerebrospinal fluid leaks, cord or cauda equina trauma, device placed at wrong level, stimulator incorrectly programmed, delay in recognition of granuloma formation, and other issues.

RESULTS

The most common devices were implantable drug delivery systems (IDDS; 64%) and spinal cord stimulators (29%). Device-related care consisted of surgical device procedures (n = 107) and IDDS maintenance (n = 41). Severity of injury was greater in IDDS maintenance claims (56% death or severe permanent injury) than in surgical device procedures (26%, P < 0.001). Death and brain damage in IDDS maintenance claims resulted from medication administration errors (n = 13; 32%); spinal cord injury resulted from delayed recognition of granuloma formation (n = 9; 22%). The most common damaging events for surgical device procedures were infections, inadequate pain relief, cord trauma, retained catheter fragments, and subcutaneous hygroma. Care was more commonly assessed as less than appropriate (78%) and payments more common (63%) in IDDS maintenance than in surgical device procedure claims (P < 0.001).

CONCLUSIONS

Half of IDDS maintenance claims were associated with death or permanent severe injury, most commonly from medication errors or failure to recognize progressive neurologic deterioration. Practitioners implanting or managing devices for chronic pain should exercise caution in these areas to minimize patient harm.

CE: Intrathecal Pumps for Managing Cancer Pain

: It is estimated that more than 1.6 million new cases of cancer were diagnosed in the United States in 2014. Among patients with cancer, moderate to severe pain is prevalent and can be refractory, even with the use of systemic opioids, which may cause adverse effects that are difficult to manage at the doses required to control pain. When delivered intrathecally, however, opioids and adjuvant analgesics may provide greater pain relief at dramatically lower doses and with fewer adverse effects. Although the use of intrathecal drug delivery systems for cancer pain management has increased dramatically over the past several years and is expected to continue growing, patients with intrathecal pumps often report interactions with nurses unfamiliar with the technology. This article provides an overview of intrathecal pump therapy and explains how it prolongs duration of action and improves the efficacy of certain analgesics while reducing their adverse effects. The author discusses the costs involved, the patients most likely to derive benefit, the types of pumps currently used in the United States, the medications that can be delivered intrathecally, the potential risks and complications associated with intrathecal therapy, and the nursing care required by patients who use an intrathecal pump.

Managing intrathecal drug delivery (ITDD) in cancer patients

Pain is a commonly reported symptom in cancer patients. Patients with cancer pain often fail conservative medical management or have significant side effects to systemic medications. The implantation of an intrathecal drug delivery (ITDD) system may be the most effective treatment option for these patients and can improve their quality of life. This article aims to discuss the choice of intrathecal medications for patients suffering from intractable cancer pain, the management of ITDD throughout a patient's disease course, and the management of complications related to the ITDD system and intrathecal medications.