itb-complications-device

Device Complications

Pouch - (backwards, hides refill port, flips - not anchored).
Pump - stalling, malfunction, pump empty (refill day missed), error in filling (septum missed), self-rotation of pump (flips in pouch).
Catheters - 10 - 25% break (hole, kink, break, disconnect); kink, migrate, break, invisible, obstructed, dislodgement, disconnection, infected, subcutaneous CSF collection, fibrosis.
Programmed overdose/underdose (withdrawal) - re: calculate catheter volume, length, rate, concentration.
Model - no side port.
Port - CSF leakage.

Differential Diagnosis of Increased Spasticity

(Patient previously well controlled)

Increased Stimulus	25%
Disease Progression (i.e. MS)	5%
Drug Tolerance	40%
Human Error	5%
Low Reservoir Volume	20%
Pump Mechanical Failure	2%
Catheter Malfunction	10%

Increased Spasticity:

Increased Stimulus (pain)
- urinary tract infection, constipation, decubitus, surgery, fracture
Disease Progression
- multiple sclerosis, degenerative diseases, not in cerebral palsy - spinal cord injury or traumatic brain injury
Drug Tolerance
- seen in first year more than in later years; gradual increase in spasticity
Human Error - highest probability in first 48 hours after pump has been programmed or filled
- error in programming, missed the septum when filling, wrong drug concentration
- drug 1/2 life at body temperature, check refill date and last refill date and determine if drug expired
Low Pump Reservoir Volume
- pump will slow rate automatically when volume less than 2cc's
Pump Mechanical Failure
- battery failure, rotor lock, computer error
Catheter Failure
- fracture, kink, plugging, dislodgment

Post Operative Problems with Pumps

Immediate postoperative problems with pumps
- Swelling around the pocket
  - Seroma: localized to pocket; first 2-3 weeks; most likely in obese patients; aspirate only if wound threatened
  - CSF Leak: early or late (catheter fracture); usually not as tense; associated with orthostatic (spinal) headache
  - Infection: redness; increased tenderness; wound breakdown
- Wound Problems
  - Infection
  - Breakdown
  - Tape Allergy
- Swelling around catheter insertion site
  - Catheter fracture
  - Catheter dislodgment
  - Seroma
- Spinal Headaches
  - Spinal headache is orthostatic
  - Treatment: flat in bed for 24 hours; force fluids; caffeine; after 24 hours allow up - if recurs, flat in bed for another 24 hours; if it persists - consider epidural blood patch
Late problems with pumps
- Skin problems
  - Breakdown under belts and braces
  - Pre-op assessment is essential
- Pump flip
  - Obese women > men
  - Pump must be within 1" of surface
  - Women have fat between abdominal wall and skin
  - Difficult to suture securely
  - Pump flips over - can't be refilled
- Pump mechanical failure
  - Interrogate & aspirate pump
  - Battery failure 4-7 years
  - Rotor Lock: under infusion of calculated dose; x-ray pump to identfy rotor roller; (flouroscopy to confirm movement of roller at high rate, high dose); repeat x-ray position later - roller position should have moved
- Catheter problems
  - Disconnection (may be seen on plain x-ray)
  - Kinking (may have to inject dye into side port to do catheter-o-gram to outline and identify problem on x-ray)
  - Dislodgment (may have to do catheter-o-gram)

Surgical Complications

Wound edge breakdown - sutured too loose, CSF under pressure, inadequate nutrition, pump too large.
Wound effusion // CSF leak - measure CSF pressure in screening LP ~ if >180 -> CT scan Brain, bed rest, abdominal binder when OOB 2-3 weeks, correct pump size.
Infection - hibiciens scrub pm before and am of surgery, prophylactic antibiotics, antibiotics given iv postop and then continued by mouth. Local skin or wound infection (superficial), catheter infection, infection at site catheter joint, contact dermatitis, Meningitis; scar infection.
Infection type: organisms - S aureus (7), S epi (1), P areuog (1).
Wound effusion / CSF leak: latent hydrocephalus, inadequate purse-string stitch, upright too early, Bad luck.
Surgical Trauma: tubing cut, local hematoma, sacral root trauma, spinal hygroma.
Seroma formation around pump in pocket - may require aspiration, often resolve spontaneously. (Consider possible CSF leak tracking catheter to pump pocket).
Headache: CSF withdrawal headache (intracranial hypotension).
Incisional Pain & Discomfort; Bleeding.