PUMP PROGRAMMING

• Programmer Description -laptop computer & printer
• Programming Telemetry Wand -magnet: protects against inadvertent programming
  

Initial Programming

• Purge
• Bolus to fill catheter + extra
• Initial daily rate 2X screening
• check duration of initial response
  

Intrathecal Baclofen: Post Operative Phase:

• Following implantation, the pump is programmed to begin operating first day post-implant. Begin ITB concentration of 500mcg/ml @ rate = 2 x bolus responsive dose or less if patient had prolonged effect (>12hours) from screening dose.
• Do not increase dose during first 24 hours. Observe effect. Increase 10-15% no more frequently than every 24 hours.
  

PHARMACOLOGY

Pharmacokinetics: bolus dose

• Onset of action in 30 - 60 minutes
• Peak spasmolytic effect in 4 - 6 hours
• Return to baseline in 8 - 24 hours

Pharmacokinetics Continuous Infusion:- unstable state

• After doseage change, effect apparent ~ 8 hours.
• Full effect occurs in ~ 24 - 48 hours.
• Make dose changes in pump at no less than 24 hour intervals.
  

Pharmacokinetics Continuous Infusion: - steady state

• Lumbar : Cervical Gradient - 4.1:1 range 2.0 :1 to 8.7:1
• Plasma : Lumbar levels - 1:200
• Average Range of dose for desired effect 300 - 800ug/day
  

Pharmacokinetics: Oral vs Intrathecal:

• 60mg daily oral dose has the equivalent intrathecal lumbar concentration of 24ug/L
• 600ug daily intrathecal dose has the equivalent intrathecal lumbar concentration of 1240ug/l
  

LAPTOP COMPUTER

Intrathecal Baclofen: Maintenance Phase - Adjusting the dose:

• Adjustment parameters include:
  • drug name and concentration
  • reservoir status (xx ml)
  • alarms (low battery; low reservoir)
  • infusion rate (0.004ml/hr to 0.90ml/hr)
  • infusion pattern (continuous, intermittent, complex)
• May increase by up to 15% each adjustment; recommend fine tuning adjustments no more frequently than weekly.
  

PROGRAMMING POSSIBILITIES:

• Constant Rate (simple continuous infusion rate)
• Variable Step Changes (complex continuous infusion - up to 12 different rate changes permitted)
• Single Bolus followed by Continuous Rate
• Single Bolus
• Pulsed Boluses (periodic delayed bolus)
• Stop Pump (method for emergency)
  

Advantages of Programmable System:

• Achieve indiviudalized optimal therapeutic effect during the post-implant dose titration phase and throughout course of treatment.
• Reduce or increase spasticity at certain times of the day.
• Enhance patients locomotion, ability to participate in rehabilitation and other activities, or improve sleep.
• Reduce adverse drug effects.
  

Intrathecal Baclofen:

Management Issues

• Overdosage as result of: too rapid increase in dosage, programming error.
• Withdrawal as a result of: catheter problem (kink or cut prevents flow to intrathecal space), empty reservoir (alarm alerts patient to low reservoir; can adjust alarm to alert patient at any time before refill procedure.
  

Intrathecal Baclofen: Management Issues

• Overdosage Signs and Symptoms:
  • drowsiness
  • lightheadedness
  • nausea
  • respiratory depression
  • weakness
  • fatigue
  • bradycardia
• Withdrawal Symptoms:
  • return of spasticity
  • agitation
  • confusion
  • fever
  • tachycardia
    

Intrathecal Baclofen: Maintenance Phase:

• Observe for swelling around pump (May represent accumulation of fluid not directed into port).
• Alert patients // caregivers to signs & symptoms of overdose and/or withdrawal.
• If signs & symptoms of overdose - withdrawal become evident, contact physician and // or take patient to hospital.

• Position patient.
• Read current settings.
• Check alarm, reservoir values, drug and concentration.
• Make changes - update as clinically indicated.
• Respond change query.
• Confirm changes.
• Print copy of changes for record/ chart.

Intrathecal Baclofen Therapy Dosage Adjustment Assessment

• Degree of muscle tone
• Severity and frequency of spasms
• Presence of adverse drug effects
• Patient-related conditions
• Functional assessment
• Systems functions
• Educate

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