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Anesthesia & Analgesia:
doi: 10.1213/ane.0b013e3181a280e4
Letters to the Editor: Letters & Announcements

Intrathecal Morphine Pump Malfunction Due to Leakage at the Catheter Connection Site: A Rare Problem and Its Prevention

Wörner, Jakobea MD; Kothbauer, Karl MD; Gerber, Helmut MD

Section Editor(s): Saidman, Lawrence

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Department of Anesthesiology; Kantonsspital Luzern; Luzern, Switzerland; Jakobea.woerner@ksl.ch (Wörner)

Division of Neurosurgery; Department of Surgery; Kantonsspital Luzern; Luzern, Switzerland (Kothbauer)

Department of Anesthesiology; Kantonsspital Luzern; Luzern, Switzerland (Gerber)

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To the Editor:

Implanted intrathecal drug delivery systems provide excellent pain relief and reduced drug toxicity in patients with refractory cancer pain.1,2 Common complications include postpuncture headache (15%), external leakage of cerebrospinal fluid (3.5%), CSF hygroma (1.5%), catheter tip dislodgement (1.5%) and catheter system leakage (1.5%). Infection of implanted systems are a rare occurrence, mostly in the first 3 mo after implantation.3

We report a pump malfunction resulting from pump-catheter connection failure and a strategy to avoid this complication. A 72-yr-old patient with bladder cancer metastatic to the sacrum and lumbar plexus was receiving the equivalent of 750 mg morphine per day postoperatively, but with significant sedation and still inadequate pain control. A percutaneous intrathecal catheter was placed and an infusion of morphine begun. The patient improved rapidly, showing much lower pain scores while being alert and mobile. Subsequently, an intrathecal drug delivery pump (Medtronic Synchromed II 8637) was implanted. An epidural fibrin glue patch was performed at the catheter entry site to the dura to minimize the risk of cerebrospinal fluid leakage along the catheter.4 In the first postoperative days, the daily morphine dose had to be increased rapidly without improvement of the pain scores. At the same time, swelling and fluctuance over the pump pocket was noted. The pump pocket was punctured and blood-tinged fluid aspirated. The catheter side port of the pump was accessed under fluoroscopy and, upon injection of contrast medium, a leak was identified at the pump-catheter connection site (Fig. 1). Upon surgical revision, the catheter connector was in place but could be disconnected easily. The snap connector extension was replaced and the new piece reattached to the pump with considerable extra force. The connection was then manually tested for leak using a saline injection in the catheter access port while occluding the catheter distally, a procedure we now routinely use for all pump implantations. Laboratory examination of the aspirated fluid showed no bacterial growth and was positive for β transferrin, confirming a retrograde cerebrospinal fluid leakage to the pump pocket. According to an oral communication from the Medtronic Company, there have been three similar reports of malfunction of the snap connector.

Figure 1
Figure 1
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We recommend testing the pump-catheter connection at implantation by injecting a small amount of normal saline under pressure through the side port of the pump while occluding the distal catheter manually and applying fibrin glue epidurally around the spinal needle dural puncture site.4,5

Jakobea Wörner, MD

Department of Anesthesiology

Kantonsspital Luzern

Luzern, Switzerland

Jakobea.woerner@ksl.ch

Karl Kothbauer, MD

Division of Neurosurgery

Department of Surgery

Kantonsspital Luzern

Luzern, Switzerland

Helmut Gerber, MD

Department of Anesthesiology

Kantonsspital Luzern

Luzern, Switzerland

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REFERENCES

1. Smith TJ, Coyne PJ. Implantable drug delivery systems (IDDS) after failure of comprehensive medical management (CMM) can palliate symptoms in the most refractory cancer pain patients. J Palliat Med 2005;8:736–42

2. Nitescu P, Sjöberg M, Appelgren L, Curelaru I. Complications of intrathecal opioids and bupivacain in the treatment of “refractory” cancer pain. Clin J Pain 1995;11:45–62

3. Flückiger B, Knecht H, Grossmann S, Felleiter P. Device-related complications of long-term intrathecal drug therapy via implanted pumps. Spinal Cord 2008;46: 639–43

4. García-Aguado R, Gil F, Barcia JA, Aznar J, Hostalet F, Barberá J, Grau F. Prophylactic percutaneus sealing of lumbar postdural puncture hole with fibrin glue to prevent cerebrospinal fluid leakage in swine. Anesth Analg 2000;90:894–8

5. Gentili ME. Epidural fibrin glue injection stops postdural puncture headache in patient with long-term intrathecal catheterization. Reg Anesth Pain Med 2003;28:70

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