OPERATIVE

• Timing: elective vs day after trial
• Anesthesia: general >>> local
• Duration: 1-2 hours
• Position: lateral decubitus - Variables: gastrostomy, scoliosis, and spasticity deformity position to allow access
  

Surgical Phase

• Pump is placed in subcutaneous abdominal pocket.
• Catheter is tunneled to midline lumbar region. Catheter placed with Tuohy needle, 16 gauge. Introduce below L-3; tip advanced to approximately T-10 to T-12 (=10cm above point of insertion) or for cerebral spasticity or attention to upper extremity spasticity catheter is advanced under fluoroscopy to T-4.
• Pump is implanted under intravenous deep sedation or general anesthesia. Intra-operative fluoroscopy confirms catheter placement into intrathecal sac, with no interruption, twisting or coiling.
  

Placement of SynchroMed Pump and Intrathecal Catheter:-

intra-abdominal location of pump and the course of the intraspinal catheter

• Preoperative Considerations
  • Pump Size: pediatric pump 1/3 smaller, but only 10cc reservoir
  • Pump Location Considerations: patient size; g-tube; previous operations; belts, straps, braces, clothing style
• Positioning - positioning is everything
• Keep the incision off of the pump
• Prophylactic antibiotics - whatever is used for vp shunts at the hospital
• Choosing the pump location
  • Critical Factors: pump must be 1" from surface to program; straps, braces must not rub over pump; g-tubes will always leak onto pump incision; avoid direct pressure on bladder; remember - the gall bladder and appendix are on the right side
  • Adults - where appearance is important - implant below umbilicus; Obese patients can be trouble, can't sew to fat; - fat can be 6" thick, Pump must be 1" from surface
  • Children: left side is first choice; right side if g-tube present; adult pump if patient over 50 pounds; can elevate umbilicus if necessary, can place pump subfascial
• Procedure - Overview
  • Warm the pump
  • Pump purge (remember to take off the white cap)
  • Lumbar puncture - catheter placement; positioning is everything; flouroscopy is essential if planning high catheter placement
  • Make pump pocket: make pocket large enough - must close over pump without tension; do not place incision over middle of pump; can do subfascial placement (pump protruding can be a problem, can be more painful)
  • Tunnel catheter: use shunt tunneler; one piece cather - most prefer two piece catheter 8703W (connect in back, tiny metal connector), REMBER TO RECORD THE CATHETER LENGTH
  • Anchor catheter
  • Aspirate and fill pump
  • Connect, insert, affix pump: dacron pouch, pump sideport at 9:00 on left or 6:00 on right, tie down sideport, use lots of big sutures to avoid flipping
  • Program pump: catheter fill calculation (bolus), continuous rate based on test dose, can add bolus to calculated bolus
• Postop Orders: bedrest x 24hours then mobilize, check for postural headache, apnea and cardiac monitor while in bed, antibiotics x 24hours (1 dose alternative), IV fluids maintenance + 25%, wound care