Okay. Should we get started here? Good afternoon. My name is Kristen Caldera. I thank you all for attending the later afternoon sessions today. If you manage baclofen pumps, I'm certain that we may be able to add a little mud to the room here. I'm going to start with some announcements which I've been asked to do. Thank you for participating in the session. Please make sure that your cell phones are off or non-ringing, no audio or video recording. Please be sure to fill out the evaluation forms. They are enormously helpful in letting us know if you found it interesting, positive and negative, and a reminder to visit the Kaminar Pavilion. Okay. If you manage baclofen pumps, I am certain that there have been times that you have wanted to bounce ideas off of people, called a friend, emailed a past friend as well. I reached out to some of our experts in the field and thought that it would be invaluable to hear some of their campfire stories. There should be time between speakers as well as at the end for comments and questions from the audience. So I'm going to go ahead and lead off. I have nothing to disclose. These are the objectives that all of us are going to cover through our lectures. It is not an exclusive list and have everything included on what may need to be done for troubleshooting when you note baclofen pump problems. However, we're going to touch on some of these. So this is an algorithm from one of our speakers who participated in this, Dr. Salino and colleagues, which draws a starting path for troubleshooting intrathecal baclofen pumps. I'm going to focus on the right side here on catheter access port studies as well as plain old x-rays. Dr. Skulsky, who I heard is running around here somewhere, and his colleagues published a paper in which they looked at catheter access port studies as a screening tool for ITB catheter patency. It was a retrospective study with 91 adult and pediatric patients in a single center. They found that 15 patients had catheters that they were not able to aspirate. Of note, these patients, once they had their catheters revised, ended up having a 65% reduction in their intrathecal baclofen dose. This suggests that the catheters may need to be routinely screened for patency as well as for troubleshooting. Another tool for troubleshooting is the plain old x-ray. Please be sure to get two views of the catheter. View the catheter, the catheter connection to the pump, as well as the tip if possible. A Shun series can be helpful if the patient has an intraventricular catheter, if you guys have some patients that may have those. Be sure to compare the catheter tip with prior x-rays if you happen to have them to see if the tip may have moved. Of note, the Endura catheter was used prior to 2011 and is indeed radio-opaque and is seen on x-ray. The new catheter, the Ascenda, is not easily seen on x-ray with the exception of the radio-opaque catheter tip. So in both instances x-rays can still be helpful. Please be sure to look at your own x-rays. To demonstrate these two ideas, this is one case of a 29-year-old with cerebral palsy and spastic quadriparesis. He has a GMFCS of 5. Didn't report any changes to his tone and he presents to clinic for planning for an elective pump replacement. His initial pump was placed several years ago, 2007. At that time it was the Endura catheter, which he had, and since then he has had pump replacements, most recently in 2019. No changes done to the catheter. In 2024, present day, I see him in clinic and he's about ready for an elective pump replacement and so, as in my clinic, we do a catheter access port. No fluid came back. He had reported no problems. So I said, okay, well either I didn't get in the port or there could be something wrong. So I sent him for an x-ray and this is what we found. That's one view. That's two views. I know it's super hard to see, so I'm going to draw it for you. It's worth getting. It was a difficult study to do, the access port, and I was a little bit doubtful whether I really, really got in. I said, well, let's just start with an x-ray. Got the x-ray and found the problem. Our radiologists can also be very helpful, although I do encourage you to look at your own x-rays. They have really big machines and they can see things in dark rooms. So I do sometimes call them as well. So this next patient is a 58-year-old with spastic diplesia secondary to cervical stenosis with myelopathy. He ambulates with a spastic gait. His intrathecal pump and ascenda catheter were implanted six months ago. He initially had a really good response and decreased spasticity and improved mobility. Four months later, he calls with some increased spasticity. We try increasing the dose. He says, eh, maybe it helped, maybe it didn't. So he calls me and I say, all right, come on down to clinic, but on your way, please stop and get an x-ray. This is what we found. Yes, I will make sure we address his constipation. Can anyone see? So I told you what kind of catheter he has, right? Can't see a catheter. And that's why I wanted to show this one to you. You might be like, why am I getting this? There it is. Is that catheter tip intrathecal? No, no way, not intrathecal. So I'm gonna leave you with two more pieces of catheter art, and then I'm gonna pass along the mic. This one, known as the bow tie. I don't know how these things happen. This person is not my patient, but I was told also did not have any symptoms of withdrawal or changes in spasticity. And this one is the pig's tail. Again, I don't know how these things happen. Make sure you get your x-rays. Thank you. Can you go back, please? I want to talk about this one. Which one? Go back three slides. One, two, three. Can I steal that? Yes, you may come up. Anyone know what this is? Oh, hang on, you have to speak in this. You have to speak in there. Anyone know what that is? The surgeon leave a straight needle in there? No, it's a connector piece. That connects the one radiolucent piece of catheter to the second, and it's just behind there. So this has happened to me about six times where some radiologist got an x-ray for some other reason saying there's a retained needle, and it isn't. Who goes next? All right, Dr. Kimberly Heckert is next. Yeah. Thanks for coming today. I see some friends in the audience. Thank you for being here. I'm Kimberly Heckert. I'm the Director of the Specificity Management Fellowship at Thomas Jefferson, where I'm also the Director of Specificity Management, and I hope you enjoy these cases. These are my disclosures. I have been a speaker and been on some advisory boards for some of the toxin companies and my fellowship program received some support from industry. My first case is a case of loss of efficacy at a distinct time point. This is a 40-year-old man with chronic spastic paraplegia from a gunshot wound. Interestingly, I was meeting him as an attending, but I actually admitted him as a resident long before. And he had a loss of efficacy from his intrathecal baclofen therapy with worsening spasticity, and I would say he had mild withdrawal symptoms. The onset was about six months before I was reintroduced to him, just after he had been hospitalized for sepsis. During that hospitalization, he had a traumatic Foley insertion, and so temporarily, while his urethra was healing, he had a suprapubic tube placed. Then it was removed, and his spasticity was still worse than baseline. No other changes with his bowel, bladder, or skin asked about all the common stuff. So he was seeing a colleague of mine at a nearby hospital system, and escalating doses of his intrathecal baclofen didn't seem to affect his control. So he was referred to me to kind of figure out what was going on with the pump. At the time of his referral, he was on 300 micrograms per day, simple continuous. He had gone up higher than that, but it wasn't helpful, so he was brought down a little bit. He was on 2,000 mics per milk concentration. On physical exam, I found him to still be a paraplegic man. He was motor complete, and he had severe spasms that would extend both of his knees and plantar flex his ankles whenever he would move. So he wheeled in his wheelchair, looked fairly comfortable, but when he went to do the transfer, it was apparent that these were very severe spasms. He previously would just transfer, lift himself, and he was now requiring a transfer board because the spasms were so severe. So on a skin survey, there was no skin breakdown, but he did have this area of hypersensitivity around his suprapubic tube scar that made me a little bit suspicious. Does anybody have the time counter up? Yeah, where we are. I just wanna make sure I don't go over. No time counter for this one? Okay, I'll just go as long as I need. If I go over, somebody flag me. At any rate, I was a little suspicious of that area. So what I did upon meeting him, I interrogated his pump. There were no motor stalls listed on his logs. In the office that day, I performed a catheter access port aspiration. The fluid was very easily aspirated. I did send it for beta-2-transferrin, which is a protein that's found almost exclusively in the CSF, so that helps me confirm that, indeed, I was getting CSF out of the catheter. That was positive. I ordered x-rays of his abdomen and pelvis, and I scheduled him for a CT myelogram, and I also got a UA. His x-rays did show some HO in both hips, but there was no obvious catheter disruption, his urinalysis was negative. So I did bring him in for the CT myelogram study, so that's the same study, the same procedure that we did in the office, aspirating from the catheter access port and then introducing some OmniPig, and then running him through the CT scanner. That was a normal study. The dye was exactly where it should be, and there were no leaks outside of it. Interestingly, when I performed both catheter access port aspirations, both in the office and right before the CT myelogram, I then delivered a priming bolus, and he had temporary relief in his spasticity after that. He said, wow, that was great. I felt great for a little while both times after you did that. So that had me thinking about what could be happening to him. Additional interventions. At this point, the imaging's normal. He was only on 300, so I said, maybe it's just not gonna be enough for him right now, because we did see that he had some HO, so we have identified a painful condition here, and I thought, maybe his dose requirement's just gonna be higher now. So I removed what he had in his reservoir. I compared what the expected volume was to the actual volume. There's no variance there. I refilled him with a lower concentration in order to increase the flow, hoping that if it was a partial flow issue that that might be a temporizing measure for him, and then I started him on flex dosing, and thinking about the same principles. When you deliver a bolus dose, during the period of that bolus dose, the rate is higher, so the flow is higher, and when I did add the bolus dosing, he did have some temporary relief, but then shortly after that, he would go back to his mild withdrawal symptoms. So I started making the boluses bigger. Now I'm giving him 75 microgram boluses three times a day, to give you an idea of what that is. I mean, it's not the biggest bolus out there, but when you give somebody a trial of intrathecobaclofen via lumbar puncture, you're giving them a 50 microgram bolus dose at once, so it was more than a trial dose several times a day. When I first initiated that, he would feel relief. When I would go higher on the boluses, he would feel relief, but it was temporary, and then the same bolus dose would not provide relief. So something was smelling bad, but I couldn't identify what it was on imaging. Finally, I got him up to about 600 mics a day with the flex dosing, so I basically doubled his dose from when he came in, plus it was a lower concentration. So I was really thinking, I have a problem that I don't know I can solve with temporizing measures, and I can't really identify where it is on imaging. So I decided to retrial him, so to speak, gave him a 50 microgram bolus dose via lumbar puncture, and that gave him significantly better relief. He told me 100% initially over the program bolus that I was giving him through the pump. So at that point, I knew there was definitely a problem, because when I introduced it directly into the CSF via lumbar puncture, he had excellent relief. The same bolus that I was giving him through the pump was not providing that relief. So I referred him to neurosurgery. The pump was five years old at that point, so he had a full system replacement. Findings, the catheter at the site of the pump connection, so where the catheter connects to the pump, that first connection, that was embedded in scar tissue. That was the reason, and that would be very, very hard to see on any imaging. Even if we had done nuclear scintigraphy, which is another way you can image it, I think it would have been very difficult to be able to find that problem. So after his pump was replaced, he was well-controlled on 225 micrograms a day, simple continuous. As of the time of this lecture, it's been more than two years, and he is stable on this dose. Take-home points here, normal CAP aspiration, normal CT myelogram. This does not rule out a catheter problem. Also another point, if the need for the dose escalation was attributed just to the HO, remember that was my initial thinking, painful condition, maybe he just needs more now than he did at a different point in his life. I think that's reasonable to think about. We have to allow people to change over time, but it should have stabilized. And everything that I did for him provided this temporary relief, and then he needed more. So that was my sign that we really had a broken system. How am I doing on time? Do I have time for a second case? Okay, great. Okay, case number two, intermittent withdrawal. The nemesis of anybody that does ITB management. A 20-year-old female, spastic diplegic cerebral palsy, referred for her transition of care from pediatrics. Now, do I have any PEDS PM&R colleagues in the audience? You do such a great job. You always send them to me packaged so well. All the equipment's new, they look good. They've had all the surgeries, they look great. This is my favorite visit, just getting to know them when they look wonderful. Thank you for that. Um, she had her pump placed in 2010. She had a replacement in 2016, and at that time they had to do a catheter revision because there was a broken piece that happened intraoperatively, and that broken piece remains. And then she had another replacement in 2022. She had good relief of spasticity at 215 micrograms a day, simple continuous. Everything looks great. I'm thinking we're wrapping up the visit, and then she says to me as she's leaving, oh, by the way, right? Your favorite words in medicine at the end of the visit. Uh, since the last replacement, occasionally she just has these episodes where she gets this temporary intense entire body itching accompanied by increased stiffness. And I'm so grateful that Dr. Skoblianko was in the front row, and what did I whisper in your ear that day after she told us? Go get the cab kit, right? We're not done here today. Okay. So, the episodes she described are infrequent, maybe once a month, maybe they last about six hours. How do they go away? Well, she has to lie down. She lies down, she'll eventually go to sleep, and when she wakes up, she feels better. Thank God. So, before leaving the office, Dr. Skoblianko grabs a cab kit, did the cab aspiration. It was normal, perfect flow. We sent it off, it comes back positive, beta-2 transfer, and okay. And you know, she looks good. I know she's getting something, but what's happening with these episodes? They're making me very nervous. So, she's about to leave. She's active. She's a college student. Her college is several hours from me. I'm left with like, what do I do about this? So, I said, why don't you keep a diary of these episodes? I want you to tell me what you're doing when they happen. Sometimes she had been lifting things when it happened. Tell me about the position you're in, the frequency. I want to know all the dirty details about why these episodes happen, and I want you to call me. I want you to tell me about it if it happens again, and I want you to have some oral baclofen with you, just in case you get into a scenario where you're up at school and you're far away from us. I want you to have some baclofen to take until you can get here, and I want you to kind of let me know where the nearest hospital is around your campus. So, we got some information. I set her up the best I could. Episodes continued about one or less per month for several months, but they kind of seemed to be decreasing in intensity, less specific about the position or activity, nothing I could really hang my hat on until they didn't. 10 months later, she came to the ED. Abrupt onset, whole body itching, increased spasms. And when did the spasms happen? She had had a virus go through her family, a GI bug. Everybody got sick, and she had been retching, and the gastroenteritis cleared up, but she was really spastic and itchy and irritable. So, she comes in, plain non-contrast CT was done, no obvious catheter disruption. Cap aspiration was normal. Again, beta-2 transferrin positive, and basal rate was increased. We delivered a bolus dose to try to mitigate the symptoms. They're not providing any benefit. Oral baclofen did provide some relief, so it really was smelling like withdrawal. She was observed, she had lots of studies to rule out infection, constipation, and other noxious stimuli, and all of that workup was negative. So, neurosurgery was a little hesitant to take her to the OR because we really didn't have anything wrong that we could see. I offered her a CT myelogram study, but she did not want it, because she'd already had a CT when she came in. She did not feel that the additional exposure was necessary. She'd had a whole lifetime of a lot of X-rays and CTs, and she did not want to wait 72 hours more for nuclear scintigraphy to be done as an inpatient, because she was very uncomfortable. And so, neurosurgery ultimately agreed to take her to the OR. They did a full pump replacement and a full catheter revision, and post-operatively, she was very well controlled, even below her baseline dose. Now, this case may be a little bit dissatisfying to some of you, and a little bit to me too, because I am a troubleshooter, and I couldn't really identify where the problem was. My suspicion is that possibly she had a subdural catheter or possibly a microfracture, but now she is stable, 17 months later, no itching or spasms, and here are my take-home points. Loss of efficacy, whether it be progressive, whether it be intermittent, it deserves investigation. Don't turn your head, turn to your fellow and say, go get the cap kit and work it up. In most cases, it is worth doing this workup, because we do find a problem, a lot of times, sometimes with a simple x-ray. But this young woman, who is an awesome person, by the way, I'm so grateful to get to be her physician, at a certain point, we looked at each other and said, it doesn't matter if they believe you, because neurosurgery didn't believe that this was a pump problem. As long as you and I believe each other, then that is all that matters, and that meant a lot to her, and obviously she is in very good shape now, and so that built a very great trust between us. So in most cases, it can help, it doesn't always help, believe your patients. My last slide here is a slide of all of our fellows from the Jefferson Specificity Management Fellowship. My email here is, if you have questions for me, if you are interested in our fellowship program, the email for that is here as well. Thank you so much for your attention. Thank you. Can you, and last from the bottom. I'm not as good looking as Dr. Farrar, so you've got to put me two down from where you are. Michael. Oops, do I do that or? The second from the bottom. Michael? Yep. Good to go, thank you. My name is Mike Salino. I am Chair of Physical Medicine and Rehabilitation at Cooper University Healthcare. Certainly a real honor to join this elite group of detectives. I have certainly learned a lot from them over time and hopefully I will add a little bit of flavor to that also. So here are my disclosures. I do work with many of the device and pharmaceutical companies that are involved in pain and spasticity. There may be an off-label discussion, I'll try to point that out if it does come up, and because I hold a leadership position, I have to disclose that these opinions do not necessarily represent those of Cooper University Healthcare, but I can't imagine that they would have a major disagreement. The two points that I'm going to cover, I'm going to go into a little bit of a deeper dive into beta-2-transferrin testing that Dr. Hecker talked about, as well as how to execute that CT myelogram if you can't do a side port. I think that that's a nice skill to have in your bag of tricks. So first, what is beta-2-transferrin? This is a CSF almost exclusive protein. For those interested in molecular biology, that's what the molecular structure looks like in the bottom left-hand corner. It is found a little bit in ocular fluid and in the perilymph of the inner ear, but really should only be found in CSF. What this helps us with is if we do a catheter access port study, it should be beta-2-transferrin positive. If someone has beta-2-transferrin somewhere they shouldn't, then you have a leak. So it should be positive with a side port aspiration and should not be positive with a pump pocket seroma. If you do a seroma aspiration and find beta-2-transferrin, you probably have a leak because you don't have an intrathecal catheter anymore. You have a lumbar drain. Now, having said that, if it's right after surgery, you might have a little beta-2-transferrin in, but if it's more than a month or so out, you're pretty confident with that. If you get fluid back from a side port aspiration and don't have beta-2-transferrin, then like Dr. Caldara showed in her plane films, then the tip of your catheter is not in CSF where there's a disruption between the pump and the catheter tip. So this is what it looks like diagrammatically, my poor man's cartoon of pump, catheter, and CSF. Green is good. If you get beta-2-transferrin, then you're in the right place. Red is bad. If you have beta-2-transferrin there, then you have to suspect a catheter leak. So advantages and disadvantages of this therapy, it's really minimally invasive. It is relatively low cost. I haven't had any patient complain to me that they got a $10,000 bill from LabCorp or Quest for beta-2-transferrin testing. It may actually avoid the need for radiologic testing. If you do a side port and don't get CSF or you get fluid that does not have a beta-2-transferrin, you really don't need to do much else. You know that you need a catheter revision. In some settings, it may actually even be better than that. The biggest disadvantage is that it is not a rapid test. I would love for someone to create a dipstick test for this. The challenge is that beta-2-transferrin is in such low concentration that it's only analyzed by PCR, so you have to amplify it. Well, heck, if they could do PCR for COVID antigens, can't they do it for beta-2-transferrin? Can't some molecular biology grad student figure this out for me? What we don't know and what hopefully a bunch of us are trying to sort out is what are the sensitivities and specificities of beta-2-transferrin testing? We've initiated that a little bit here in our little Philadelphia cohort. We looked at 60 consecutive individuals that had beta-2-transferrin. Of those, 25 were chronic pain, 35 were spasticity. Sorry for the font error there. All individuals that had confirmation of what we suspected by either CT myelography or surgical revision, the overall concordance was 93%. The only times that it was incongruent is if we did a side port aspirate, be beta-2-transferrin and either had a subdural encapsulation, which I think is what Dr. Heckert described in case two, or a case of arachnoiditis, arachnoiditis being more common. Again, these folks are probably not in super acute withdrawal, at least not initially, so you're still going to go on and do your testing. This is kind of the diagram of our first 60 patients. Again, four seromas. All three were positive, confirmed surgically that there was catheter disruption. One was negative and was similarly confirmed. The side port aspirates, those that were positive, all had, 92% of them had normal CT myelograms. Those who didn't either had arachnoiditis or subdural encapsulation. Three were negative and was confirmed that the catheter was not in CSF. Again, this is a bedside test that we can utilize. We now have, Kim, four institutions doing this? Three institutions at least. We'd like to collapse all of our data, a multi-institutional study. Hopefully our current fellow will pick up the ball with that. We probably have at least in triple digit numbers now to hopefully elucidate the sensitivities and specificities a little bit better. Let's talk and go a little bit of a deeper dive into CT myelography. I think we should begin to call this procedure the Turner procedure because I first learned it from Mike Turner who was a pediatric neurosurgeon in Indianapolis who taught me how to do this. I think it was his brainchild. Unfortunately, Mike passed a few years ago from pancreatic cancer just a few months after his retirement. A real loss to our field and the world in general. How do you do this? Well, first thing before you do a CT myelogram, make sure you do a CAP study in the office because the last thing you want to do is be in the CT suite and can't get fluid because then you're stuck. You remove two to three cc's of fluid, inject two to three cc's of isotonic contrast, Omnipecus, Dr. Heckard mentioned. You are doing this right in the CT suite. The patient is on the scanner table. You've already done your scalp film and you're ready to go. As soon as you inject, then they go in because if you do it in the office and have them go across campus to get their CT scan, all of the dye has now mixed with CSF and you're not going to get a good study. The patient is then scanned from two vertebral levels above the tip of the catheter all the way down through the abdomen. If possible, try to do 3D reconstructions. Unfortunately, Medicare does not pay for 3D reconstructions under these circumstances. Some commercial payers will. The advantages of this study is certainly you're getting much improved sensitivity compared to plain films, especially with the Ascenda catheter, and you get a quote unquote free CT scan of the abdomen, thorax, and lumbar, and thoracic spine. One of the first CT myelograms I ever did in my career was with a brain injured patient who had loss of effect. I was sure I was going to see an abnormality. The dye study was completely normal. It was that mass at the head of the pancreas that was causing the increasing spasticity. It was a pancreatic cancer in an insensate patient, so it did not have abdominal pain. Disadvantage is this requires a little bit of coordination. You just can't send the patient for this. Somebody who knows how to aspirate from the catheter access port needs to be in the CT suite. Sometimes you have to explain to an insurance company why you're doing this and not other studies. What I train the basic folks on is you don't do this unless you can aspirate from the side port. Why is that? If you just stick a needle into a patient and inject dye, you have now pushed the entire contents of the catheter into the CSF all at once. There have been people who have died in the United States for people not paying attention to this rule. For the basic level provider, if you cannot aspirate, then you don't do this study. We'll come back to a way around that in terms of advanced techniques in just a moment. This is what a normal study looks like looking at the axial images. Here you can see the catheter and the dye looks nice and level just like water in a glass. That's a completely normal study. This is what contrast loculation looks like. You can see that the dye flow is not normal, kind of side to side. You have a fluid level on one side that's not another here. You actually have a separate piece of fragmented catheter. These are individuals who have had arachnoiditis, meaning that their CSF does not have normal flow around the cord. This most commonly happens with individuals who have either had a hemorrhagic event during their spinal cord injury or have had blood in the ventricles and blood products has trickled down. This is a subdural catheter. You can see that the dye is now ventral to the cord. This is also loculated, meaning if you flip the patient over, the dye doesn't move. These are ticking time bombs for me because all of this fluid now is filled with drug. If that breaks open, you now get a rush of fluid all the time. Has anyone ever had a patient sort of oscillating back and forth between overdose and withdrawal? I see a couple of head nods. I think these are subdural catheters. To me, these folks don't need to be in the OR this afternoon, but they better get in the OR this week because you don't know when this bag of fluid is just going to rupture. This is actually dye extravasating in the paraspinal soft tissues. This was before we were doing beta-2 transferrin testing because this would have not been beta-2 positive. This is actually dye in the epidural space. This is dye kind of filling around the spinal canal and actually into the nerve route sheets. The presumption here is when someone was placing the catheter, they were in CSF but then drew the needle a little bit and advanced the catheter in the epidural space. Epidural baclofen and morphine and other agents will work, but it works at an efficacy about one-tenth that of intrathecal delivery. So that's why this individual needed high doses but underwent revision and got much better relief at a lower dose. This is contrasted filling an intrathecal granuloma, an inflammatory mass at the catheter tip. Really unheard of in the baclofen world. Only really seen with opiate therapy, but just for the sake of discussion. So how can we get around this problem of doing a CT myelogram if you can't aspirate? A couple of times I've been in these situations where patients lived a far distance away. There was no way that they were coming back four separate times for CT myelograms, but by the same token, I'm not CT myelograms, nuclear medicine studies, but by the same token weren't getting efficacy. So I thought about the problem a little bit. So the problem of the drug in the tubing is the concentration of the drug. What if we lowered the concentration so that the amount that you'd be bolusing would be a safe amount? And that's what we undertook. So what we do is we bring the patient in the week before their CT myelogram and put a dilute solution in. Program out the bridge bolus so that the old concentration clears the catheter. So now you have a lower concentration drug in the catheter, and now you can bolus safely. So we did this in 12 patients. For baclofen, we diluted the solution to 200 mics per cc. If you assume a 0.4 cc catheter volume, both internal and external catheter volume, that means you're only giving the patient an 80 microgram bolus. We give folks 50 microgram boluses all the time, and overdose is pretty unlikely. On the pain patients, we diluted morphine or hydromorphone down to 500 mics, which gave them a 200 mic bolus, a pretty safe dose for the opiates. Morphine is FDA approved for pain, hydromorphone is not. We did the exact same thing with the dilute solution. If the CT myelogram was normal, we went back and then put them on their regular concentration. If not, we've already weaned them down, and we can go right to revision. So in our 12 patients, we had eight spasticity patients, four chronic pain patients, all underwent the CT myelography as described. Nine of these patients, nine of the 12, demonstrated catheter abnormalities and were subsequently referred on for revision, confirmed by surgical findings. Interestingly, though, three of these 12 patients had no abnormalities. So even though they didn't have a normal side port aspirate, we could not detect any abnormalities. And what would be interesting is Dr. Heckard's case about scar tissue embedded at that pump catheter junction, which we've actually been seeing a little bit more commonly now. We need to think a little bit about what kind of imaging study we could do to maybe cone down on just that region. I don't have an answer for that just yet. So quick summary through my little piece. I think beta-2 transferrin should be part of our armamentarium. It's a pretty easy thing to do. You just stick it in a red top tube, put it in a bag, and send it off to LabCorp or Quest. Should come back in a couple of days. If you've been doing this a while and feel comfortable with CT myelograms, it may be something to consider how to do a CT myelo without getting a positive side port aspiration study. Gotcha. Who does the baton go to next? The good doctor, Dr. Farrar. Thank you. Thank you, Dr. Salino and everyone else for another great talk. Let's see. I need to do that. I'm the second one. Dr. Farrid? Yeah. Yep, that's me. Thanks. Yeah. Right. So I'm Rez Farrid, University of Missouri. I am board certified in PEDS and adults. So I take care of some kids, but my partner takes care of most. We have between 100 and 150 pumps between us. And I love troubleshooting. I hope Dr. Caldera will give me my badge today. And I also want to remind everyone that this is a safe space. So if you have criticisms about how things went, you know, hey, take it easy on everybody. We're all trying to help. So, you know, Dr. Salino and his group put together algorithms to help us determine issues related to troubleshooting. I use these algorithms all the time, and I try to adhere to them. I have used Indium DTPA scanning a handful of times in my life, and very rarely have I found it to be helpful. But today, I hope to present the case for consideration of nuclear medicine scanning with pump, because I thought it was kind of cool. So in this case, it is a 16-year-old male who was doing fine, but his ERI was coming up and he came in for his elective replacement. His dose was 450 micrograms a day. And just for reference, and to hold myself accountable to you when I said it's a safe space, this date was in November, right? So over the timeline of, you know, I just want to see from your end, how long would it take to solve this problem in your hands? And if I'm slower than you, I apologize, but I was working through some, you know, emotionally difficult times. So this patient has his elective replacement and goes home the next day, or goes home the same day, I guess. And the next day, they're having spasms. Do they call the neurosurgeon's office? No. They call my office. I know he was scheduled that day, perhaps I've forgotten. So they asked for my resident on call, who, you know, receives regular education and training because troubleshooting is the part that keeps everyone from adopting the therapy. We're all afraid of that late night call and what to do. So that's why the algorithm's important, and that's why being comfortable with managing these issues is important. So the patient had, you know, the family, unlike some, the family was not particularly reliable. Mom had spent a few years in prison for certain things, and anyway, so when they went home after the OR, they didn't pick up their post-op pain medicine, so when they called my resident on call and said, well, they're having spasms, we're like, eh, maybe you should get your pain medicine. We're going to give you another prescription for some diazepam, if you could pick it up, you know, maybe that would help. I don't know. We at least knew he didn't have a fever and was doing okay. The next day he called, or mom called, I guess, because he's GMFCS4, and mom says, quote, the pump's not working, pain is big, 10 out of 10, tried oral baclofen, it didn't do any good, what can I do now? So this is now two days afterward. And I said, well, you need to come into clinic. So here it is, now almost a week later, he presents to clinic, his spasms, he's got clonus, unrelenting spasms, I had done an intrathecal baclofen trial on him, you know, years ago, I've known him, his tone was always well controlled, so this is a big change. I said, well, what would Dr. Salino have me do? Okay, I'm going to check the logs, I'm going to give a single bolus, I'm going to check the reservoir, I'm going to do all those things. So I give 100 mic single bolus, and I increase his dose, and I call the Medtronic rep. And I said, hey, you know, sometimes the surgeons, they're doing their own thing, they maybe leave out a few details, can you tell me how the surgery went? Did they, does everything go smoothly? Oh, yeah, Dr. Ferrett, it was great. It couldn't have gone better, they even did a catheter access port before they closed, and everything was just peachy. I was like, okay, well, I don't feel great about it. But I'm going to order some labs, check a CK, check some labs, make sure he's not constipated, give him some Miralax, et cetera. They do get the x-rays, and these are his x-rays, he had a spinal fusion years ago, and these x-rays didn't look too much, I mean, I can't see his catheter, I guess, way up high, if you really look, you can see a catheter tip, right up there. So these are generally unspectacular x-rays to me, and I was like, well, maybe some Miralax will help. So now it's nearly three weeks later, he hasn't gotten the labs drawn, he's still spastic, it's coming up on Thanksgiving, and he comes to clinic, and I do a catheter access port aspiration, and I do it a little differently than others, everybody, as long as you get your fluid, it's fine, but I like to put the needle in and see if I get some passive flow without withdrawing negative pressure, and sure enough, it flows nicely, and I, well, I got two and a half cc's. Let me just double check. I'm gonna get some more. And I got another cc and a half, and I'm feeling better about things. Aren't we all reassured? We've done a catheter access port. His Y is his dose higher. He had constipation. You know, mom says, oh no, I think the catheter's disconnected. I said, no, I just did it. It seems fine and reassuring. I checked the reservoir, make sure they didn't, they put medicine in the pump, right? We got all this done, yeah. There's medicine in there. And I had scheduled previously a contrasted CT study. And as Dr. Salino says, take somebody who's done that, right? You can't just have the radiologist, you know, radiologist isn't gonna know how to do that. You have to go to the CT scanner. You have to have the kit. You have to place the needle in the side port. You have to aspirate. And then you need to push. In my case, I use about three cc's of OmniPaque. And then we get a spiral CT scan. So that was the plan. And as Dr. Salino requires, these are the pictures that we see. And in my case, down here at the end, just like Dr. Salino's picture, I got a pretty nice picture. And when you can do things like Dr. Salino, you're feeling pretty good about it. So I, again, I'm reassuring myself, you know, things are looking good here. I kind of like what I'm seeing, but then I'm like, well, now what do I do? Mom's mad at me. She's already cursed at me before. The child looks terrible. Boy, I could love to do a lumbar puncture. Oh, wait, he's got that spinal fusion with all that instrumentation. How am I gonna get that scheduled? It's nearly Christmas. It's like, what can I do? So I decide to do something I don't usually do. And I order an indium DTPA study. As some people might hear of using technetium, which has a very short half-life. So I ordered indium. It has a 68-hour half-life. It has to be ordered then custom for that patient. So it's not like there's a stock of it in the hospital. So that's something he has to come back for. In my experience that I've done these now, although I'm adding about 0.7 to one cc of nuclear material into the pump, I don't generally, I no longer provide a bridge bolus or a change in concentration. I just let it flow. They usually will take a image initially for no particular reason, just to make sure I put it in the reservoir. And then we'll have the patient come back in three days and they'll take a nuclear image to see how that medication or how the contrast has made its way through the system and into the CSF. And when done properly over here on the left side of your screen, you should have some nucleotide tracer here and this ascending pathway in the CSF and in the brain. And when you see that, then you go, wow, that really feels nice because the CT contrast was done. We injected that three cc of heavy OmniPake as fast as it would go and it's hard on your thumb to get that to press in. But here it's going at physiologic speed. But this fella over here on the right was my guy and none of it went up. It just stayed right there in the pump and you can see in the bottom on that left side over here, it just kind of pooled and hung out there. I thought, well, that's quite something. So now I had to call neurosurgery. I thought I had enough ammunition now and I could say, it's your fault. So that's what I did. So I called neurosurgery and said, it's your fault. You've done something to my patient. And it took another, you know, it's Christmas, so they're not rushing it. He's already said, well, he's been this way for a month and a half. We'll get him into clinic. Gets him to clinic and now it's nearly, it's almost two months now that he finally gets a pump revision and they re-dose him at 100 micrograms a day. I'm like, okay, good. Now do I have, what do I have to hang my hat on? And so the rep calls me kind of excitedly and says, here, this is what we pulled out of your patient. This is the, not the pump, they just replaced the connector in the OR, but this was the connector part that they had taken out. And they present to me this, you know, frayed kind of catheter. And I'm saying, ha, solve the case. It's so beautiful. Let me take a high powered magnifying glass look at that catheter. So I take a high powered magnifying look at that catheter. And although the outer shell is frayed, the internal catheter itself, I couldn't find a hole. I was like, ah, it just doesn't make any sense to me. I have to be able to figure this out if I'm gonna get my detective badge. So I take a separate pump and I take that connector and I stick it onto my pump like you're supposed to. And I take a syringe of air and I put it in a pool of water and I take a syringe of air and it doesn't leak. I was like, oh, this is really bad. How can this be? So then I think, I'm gonna try one more time. So I take it now and now I'm pressing just a one CC syringe and this time, if I just very gently press on the tap on the top of the catheter at that connector, it leaks air just a little bit. And if I let go, it stops leaking. And you'll see the plunger kind of at this pace the whole time. So it was that fragile, that delicate of a connection as best I could deduce that was leading to the leak of the radio tracer in that pocket. The connector just did not seat quite like it needed to lead me a result. Now, is this 100% scientific? No, it's a different pump. It's a connector that's already been used, but it certainly shouldn't leak. No matter what you hook it up to, it should lock on there pretty tight and it should take a little more than a tiny bit of pressure with my finger to make it happen. So that's what I did. Let's see, so that's just the end of it with a little 30 gauge needle. And so now come eight months later, his dose is 220 micrograms a day and he's doing fine. And I see him on Wednesday coming up. Sorry, he couldn't get here. I'm sure he's doing fine because his mother would be yelling at me if he hadn't. So that is my case. Well, no, that's not quite, right? I did wanna leave you with more. So the other part that's hard to do, I work in an academic medical center, is I was left to wonder how expensive is all this stuff? Did I get paid for anything? Did radiology get paid? What does all this stuff cost? And that's impossible to find at an academic medical center, but I found some stuff. I found that I got paid some money for aspirating for the reservoir and reprogramming the pump because I'd increased the dose and he was there. I found radiology got paid for whatever codes they do to check the pump and to scan it, et cetera. And then I was like, I wonder how much is that medicine? How much is the tracer? I wonder if I could find that. Well, I found the charges. And so the charges for the tracer at my institution are $9,200, cheaper just to replace the pump, right? Like, my gosh, the hospital did get their facility, of course, facility fees aren't outrageous, but the hospital did get, I don't know, $1,500 of facility fees, but Medicaid patient, they stiffed him on the drug and said it wasn't covered or something like that, regardless of whether we had it approved or not. So the hospital gave up chasing after the radio tracer reimbursement. I mean, even after, this has now been 10 months or 11 months, so I don't know how your hospital will ever, I think you should consider how much those things are and whether or not you can actually get reimbursed for it. When I called the director of nuclear medicine, I was like, hey, Dr. Singh, do you ever get reimbursed for this? He's like, oh, you got to talk to the billers. Like, dude, already did, they don't know. So sorry about that. There is a list of extra reading. If for those that have an interest in learning more, I certainly don't recommend you do many, but in the world of troubleshooting, maybe some indium scan has a potential role for you. Thank you very much. Dr. Toomer will be next. For you. And the last one. Oh. Thank you for staying till the end. So I am Andrea Toomer, and they're gonna pull up my presentation at some point, but I will just let you know that I am a physiatrist in New Orleans, and I am different than all of my colleagues in that I'm in private practice. So I don't have residents that are working with me. I am the team. I have a nurse. I do have neurosurgery partners who do the implants for us, and I do have some neurosurgery residents that are involved in part of the case, but our workup and the way that we do things in troubleshooting, it is me. So things are a little bit different. So I do have some disclosures. I am a speaker for a number of pharmaceutical and device agencies. So suspected withdrawal in a post-op case. That's what we're gonna talk about today. So kind of similar to Dr. Farad's case. So there's a lot of factors to consider. So you have a new pump now. Is there pump-to-pump variability when you replace that pump? Are they delivering a little bit differently, and is that why you're seeing some difference? Possibly you have a new or a revised catheter. There's also the effect of anesthesia and just the surgery itself, or their post-op complications with surgery, infection, those sorts of things. So when you're looking at an immediate post-op patient, it's not just that they're getting intrathecal backlog, and a whole lot of things just happened, and you have to consider all of those things. So my case is a 24-year-old female with spastic cerebral palsy, intrathecal baclofen therapy, long-standing before she came to me. I only treat adult patients, but I do take a lot of CP patients as they become adult age. So we have to go forward with an elective replacement due to the battery. So at the time, her dose is pretty high, almost 900 micrograms a day. And I'm thinking, I don't know you from before. There could be a little bit of pump-to-pump variability. You're about to get general anesthesia. I feel comfortable maybe lowering your dose just a little bit when we do that increase, that pump change. So we're gonna do a 15% decrease just to be on the safe side, since your dose is so high. So she doesn't live close to me. She comes to my practice, but there is a neurosurgeon at a surgery center closer to her that will do the pump replacement, and the family would like to go to this neurosurgeon because of the proximity to their home. So he's familiar with doing lots of pumps. He does a lot of pain pumps, not so much intrathecal baclofen, but he's going to do the procedure, and this is gonna be happening about 40 miles away from my practice at a surgery center. So that's the plan. So on post-op day one, mom calls me, and she says she's increasing, she's having more spasms. I said, why don't you come on into the office? Maybe that 15% lowering that I did wasn't a good idea. Maybe we need to undo that. So I bring her dose back up to what it was previously, and I also gave her 25-microgram bullets right there in the office. I said, let's see if this helps. Maybe just that dosing difference caused her increase in spasms. Let's give you a little bit extra and get you back to that dose, and let's see if we can get you feeling better. Hang out a little bit since you live a bit far away. Mom says she's starting to look better. I think she's getting back to her baseline. We wanna leave. Sure, we're good. We're gonna send you home. So, of course, post-op day two is Saturday, so that's when all the fun stuff happens. Mom calls, and she says, okay, she's really not looking better. I thought she was looking better in the office, but really, she's looking worse. She's having a lot of spasms. She's having a lot of clonus. I said, you need to get into the hospital. You need to come to an ER, either to our facility or to closer to home, but you need to get evaluated. Now, of course, when she came in to the office the day before, I interrogated the pump. Everything was working just fine. There's no alarms going, none of that stuff. So, we know the pump itself is working, but now she's clinically looking like something's happening, and she's not getting that medication. So, they decide they're gonna go to the outside ER, but the ER doctor calls me so that we can talk through the whole case. So, I updated him on everything that was going on so far, and I said, we need to look for other causes of increased spasticity. She's clearly having an increase in her spasms, and yes, it could be a problem with the pump or the catheter, and the fact that she just had surgery clouds our whole picture, but we need to be looking for other causes. What could be going on causing her increased spasms? So, they start doing that, and I talk to them about bowel and bladder. That's our top things that we need to be looking at. So, they did a KUB. He said it showed some stool, doesn't look bad. Her last bowel movement was the day before surgery. Mom says that's kind of her normal pattern every couple of days, so nobody's worried about that, but then they straight catheter for 850 cc's, and I go, wow, that was great. So, he said, okay, we found the problem. Everything looks wonderful. Great. He calls me back, and he says, how long does it take for her to get better? So, okay, she's not better. This is not our cause. So, even though we had some bladder retention and we emptied the bladder, she's not improving. So, she's actually, the ER doctor says, look, we feel like she needs to be admitted, but we talked to the hospitalist, and they're really not comfortable with admitting her because they don't know anything about intrathecal baclofen patients. She's really looking bad. She's febrile. She's tachycardic. We need to get her transferred. I said, no problem. So, she transfers over to my facility. So, she's going from that outside facility to our hospital. She's gonna be admitted to the neurosurgery team and to me. So, she comes straight over and comes to the ICU. So, by the time we get her, it's late Saturday evening into early Sunday morning. So, she comes to our facility. We admit her to the ICU. She's under PM&R neurosurgery. So, in my practice, so I told you I'm private practice, and I have neurosurgery partners that implant pumps, but of course, they were not the ones on call that weekend. It was the one other neurosurgeon who does not do any pumps and is not part of my practice. However, all the residents are on call are very familiar and do all the pump surgeries with my partners. So, I have residents who know about pumps, but the attending, he says, I have no idea. You just tell me what we need to do and we will do it, but he has no idea what's going on. So, first, I just interrogate again, confirm everything, make sure there's no motor stalls happening, there's no alarms, nothing like that. So, I called the implanting surgeon and he said, tell me about the case, tell me about that catheter, how did things look when you re-implanted, and he said, look, so the catheter looked great before we removed the old pump. We reconnected to the new pump. I did a cap access. There was beautiful flow. Everything looked wonderful. Called the Medtronic rep. I said, can you confirm with me the kit number? Did we put in the right concentration of drug? All of these things. She confirmed all of that. We know that we had the right drug in there. We know that we had good flow, according to the surgeon and the surgery team, when they did that pump replacement with the catheter. So, now, we're looking at, we know everything was done right, what do we do now? She's looking really bad. So, she's in the ICU. She is clinically decompensating. If you needed a video that showed you acute baclofen withdrawal, this is what she looks like. So, the neurosurgery resident's eyes are this big, and he says, I'm gonna have to intubate her. We have to protect her airway. I'm getting very concerned. So, I'm feeling like we need to do dye studies. We need to look and make sure that we have flow and things, and they said, we're just gonna take her to the OR. We're putting her under general anesthesia. We can do everything that you need to do to work up in the OR, and that's where we feel most comfortable with her. So, I get to scrub in on Sunday, which is fun. So, she's, I mean, she is febrile. She is tachypneic. Her whole body clone is shaking out of the ICU bed. So, we get her into the OR, general anesthesia, decide to evaluate everything. So, first thing we do, catheter access port. Beautiful flow of CSF. So, the residents are like, what do I do? Do I put it back in? No, please don't push it back in. But they were like, well, we could culture it. Sure, let's culture it. That sounds great, even though that's not our concern. So, then we do a dye study. Everything looks beautiful. It flows great. So, then I said, well, even though we confirmed that we put the right concentration of drug in, let's take that drug out, and let's get a whole new brand new kid and put drug in again. So, we do that, and we got the right, I mean, almost hardly any volume had gone out. It's only a couple of days, but we get the right volume. So, what do we do now? So, the attending, who knows nothing about pumps, says, what do you want me to do? You want me to open her? I have no reason to say we need to move on with surgery at this point. I've found nothing that tells me we have an issue. So, we decide at this point, we're gonna continue to monitor her. We're not, and we have no reason to move forward, like I said. So, then we prep to transfer her back off of the OR table, and she has passed a massive bowel movement. And when she goes back and wakes up in recovery, she's normal. So, what did I do wrong? I did a lot wrong. So, they told me they got a KUB, and there was some stool, but, you know, she had a bowel movement a couple days ago, and that's her normal pattern. So, I should have said, give her an enema anyway. Let's get a bowel movement. We need to really, really, so, like, and we all up here, and we're saying, we need to think of those other causes of spasticity, but we need to, like, really, really make sure that those other causes are not there. We could have solved a lot of problems and prevented a hospital transfer and an OR visit if we'd have given her an enema. The other thing I learned. So, now, Mom, they've been through this traumatic situation where, you know, transferred hospitals, ICU, OR, everything, she's great now, but I don't want this to happen again in seven years, which, by the way, this case was eight years ago, so she's had a pump replacement since. So, I talked to Mom at that first clinic visit, and I said, we need to have some plans. When we're moving forward, we know that anesthesia slows her gut more than it already is slow. We need to have plans. We're gonna have a clean bowel before. We're gonna do a bowel prep beforehand. We're gonna have everything prepared and ready to go. I also presented this case, so there were three neurosurgery residents on call that weekend, so those three knew exactly what was going on, but I presented this case for a couple of years ongoing to the neurosurgery residents so that they were aware of, so we all know what that baclofen withdrawal was looking like, but to be aware how just those noxious stimuli can really, really mimic baclofen withdrawal. She had her pump replacement again, by the way, just about six months ago, and we did all the bowel prep and everything was great, and of course, post-op day two, she's having increased spasms again, and Mom brought her in to outside. So, you know, and we know she's done this once before, so we're suspecting there's some kind of noxious stimuli going on. She did, Mom gave her another enema at home, had a bowel movement, wasn't getting better, brought her into an outside ED. They cathed her, she wasn't retaining a ton. She did have a dirty urine, so they were thinking urinary tract infection. Put her on an antibiotic. She still didn't get better. Came back in to, came to our ED, so we evaluated it and evaluated the pump and everything. They changed up the antibiotic. Went to, went home, couple days later, still not getting better. Turns out it was strep pharyngitis. Right, but so always be aware of the other things that can really mimic baclofen withdrawal. So when you don't have a team of other physicians that are listening and telling you we gotta look for other things and focus only on the pump, you can miss a lot. Thank you. We have a few minutes. We'll take a vote. Do I give them their badges? I want to thank each one of you personally. They showed up in my little Zoom meetings when I'm like, I want to make sure we really have great cases and we have different things to talk about and we don't overlap. So thank you very much. If people have questions, I'm happy to bring the mic to you or you can come here and we're up here to answer. case. So are you prophylactically giving stool softeners to all your back fluid pump patients? Yes, okay, so I'm not necessarily prophylactic, so I'm asking the questions more about what's your normal bowel program, what's your normal pattern. We need to make sure that we're moving and doing things regularly and not backed up before we get into surgery because anesthesia can really slow those things. All right just a question for the panel since we're talking about different like diagnostic modalities and your troubleshooting process In the cases of like, you know proximal and trap like entrapment of your catheter or a sort of leak near the insertion site Is there any sort of role in ultrasound and looking at these? instances I mean the only Utility I see is that it could help you confirm that you're in the catheter access port. You have better localization It'll help you see a seroma really hard to Absolutely confirm catheter continuity under ultrasound. You might see it But then if it dives deeper you you're not sure if you're if you're doing it so it's mostly for localization of a of a cap or reservoir or if you're doing a seroma aspirate that you could actually See the needle going into the serum of fluid and pulling it out That's the only reasons that I could think of I think if you're just having a little bit of leakage at the catheter, you're not gonna be able to pick up that volume It's too small to see an ultrasound. I have an ultrasound in my clinic and I Learned today about this beta transfer and that you're testing it from the side part I actually have not been doing that. I use beta transfer in all the time however if I use my ultrasound and I see fluid around the pump because there shouldn't be fluid around the pump and Sometimes you can palpate it but sometimes you're surprised so if I have somebody I think there might be a problem I'll just put an ultrasound look around the catheter And if I see an area of fluid there or on top of the pump, I'll aspirate that send it for beta transfer And and it should come back Negative positive negative and if it comes back positive then you have a problem Afternoon well, this question is for all of you or so while you're trying to To find what's going on and you're giving them back of an oral to relieve the symptoms Has it been confusing for you? I mean with the back of an oral sometimes they get better And so then you cannot see if your ball is working or not. So how do you? Work around that or has or maybe it hasn't been a problem because they back with an oral It's never enough to get them in a good place. I Consider the oral therapy as a mitigating strategy temporizing strategy I've not ever seen someone who's had withdrawal that the oral baclofen is enough to get them to Baseline or even close I've got a couple things. First of all, that's awesome that there was collegiality with going to the OR because that doesn't happen anymore in medicine So that's really cool. I have a concern in no case at all. Did anybody talk about the for scopic dye study? It went CAP to CT myelogram. So when I do it, they're one in the same my CT my cap study is my fluoroscope study I just do it right there And I check behind the pump. I check next to the pump I check first my aspirate of course and then I check where the catheter goes into the into the spine and then I check where my The tip is and then I check to see if it's posterior anterior So I'm doing a very comprehensive for scopic study and I'm wondering Obviously, you know if you send it off to IR and they don't give you any data. That's not helpful but for those who are writing the guidelines like I would hate for that to get deleted from the Guidelines because then I would be practicing outside of the guidelines Unless I'm missing something So there are no guidelines Right there is that there's best practices. It's meant to be Assistant as a guide to help you but it's not a referendum on how the practice should be Completed so that's one Second part for me and my institution in order to maintain fluoro credentials I have to do 40 procedures a year So I don't have fluoro access if you're an interventional pain doctor Maybe you have fluoro access, but I don't so fluoro isn't part of my typical Workup, and I wouldn't have anybody to to help do that procedure Right, and that's my concern for those that don't have fluoro that are managing most of the back open pumps That that becomes the standard of care and that those of us that have fluoro become a well You guys aren't practicing within standard of care anymore that it should go to CT myelogram. Not fluoro as Dr. Farad said These were and the wording was very specific we did not put standard of care or minimum requirements in those Descriptors for exactly those reasons better to have fluoro that have nothing at all I still think CT myelogram adds some aspects that you probably are not going to pick up on every fluoro dye study But you're not wrong, and I wouldn't criticize you for using it And then the last question was Christian's very first case. What did you do to manage that patient? Did you retrial them? Which one the very first case with the catheter break oh You know what that one important thing is I started weaning him down I mean, I'd figure he's not getting anything, but I still weaned him down He's sitting right now at minimal rate He wants to try not to have to have a pump if he can so I'm letting him kind of sit there But at the end of the day he's probably gonna end up with a new pumping catheter Thanks Does Anyone else sometimes wonder like okay, so where's the drug going right? That's what I get asked all the time, okay So if my pump isn't delivering my medicine like where is it going and sometimes I have to be like I don't know it goes Where the leak is? Like it's going somewhere right, but you're not overdosing because it's not intrathecal anymore, but I get asked that question a lot I'm in an institution. That's a community-based You know public safety net hospital and we see pumps But it's infrequent and not really managed in-house and so they're often admitted to either a family medicine Team or a hospitalist team that would like some help with trying to figure out Overdosing or underdosing as we're troubleshooting the pump right and you're wonderful cases. Thank you so much for this presentation But they also allude to like the process and the iterative nature of Troubleshooting and that sometimes that can take time like multiple days even so my question is what are your parameters for when you would recommend? admitting to the ICU even for monitoring Because people can have different patterns and we recently had a patient that was Hemodynamically stable, but that I felt like needed more continuous Monitoring while we were trying to figure out what was was going on with the pump. So just curious about your ICU monitoring criteria. I Think it depends on a number of things and I want everyone's opinion. I mean We're talking just baclofens in the pump because that certainly changes if you need a telemetry yeah, so this is a patient that had to fill two days prior and Overnight no one was sure what was going on So they monitored and I'm the only person that has privileges at our site. So I came in in the morning and We started making some phone calls and we were pretty sure that he was overdosed and he was becoming increasingly somnolent But he still had really bad tone and so between me and neurology it clinically it was not sort of a Gross pattern where you were really sure which which direction it was going and we did figure out with the Outside provider that there had been a typo in the programming for the concentration of the fill That the concentration was 2,400 and they had typed in 1,400. So they were getting overdosed with with their rate And so we're able to to reprogram and that to that point they were in the emergency department But then the question of sort of waiting out And like the frequency of monitoring in the ICU versus our our neuro unit because their blood pressure and their heart rate were Okay, but they were still abundant So and the patient did well, I'll just say that but you know again like you have these high-risk Infrequent events at our institutions that it's and I'm in a place that's very interested in like how should we do this better? next time and that continuous quality improvement, but to me the monitoring is just high enough to Justify at least initial ICU care I think the key part for me and I and you said it right after I thought it was two days after they saw a Physician they had an encounter. So I've had two times in my career where that has happened One was an outside provider who was using intrathecal Dilaudid At a high dose the patient's dose was regularly two milligrams per day and they had Inadvertently typed in their concentration, which was ten milligrams per day And then they went left town and went skiing in Utah and he showed up in my emergency room So I'm like, wow, that's getting admitted The other time was a patient where I was busy my regular nurse wasn't there the patient had 500 micrograms per ml and I put in 2,000 and I didn't catch it until I was doing my notes at 5 o'clock that night So at least I caught it before it could infuse its way But that could have easily been a problem a couple days from now that would have been all in my doing So my titer I'm much more sensitive when somebody has just meant managed to mess with the pump I'd probably even go stronger. I think anyone would suspect it ITB overdose or withdraw their ICU level care until proven. Otherwise, I think we have this opportunity to basically make that is Recommendation and we need to just not talk about it Patients go south so fast. Yeah, I mean there there are deaths reported. Yeah Yeah, I mean spinal cord injured patients can get dysreflexic at a moment's notice that can easily be overlooked If it's if they're starting to overdose in the situation that the res is described It's not going to get better right away. Your CSF concentration is going to take five hours to overturn They need to be the ICU. Yeah, thank you. I the argument that I make that a hospitalist They are more likely to have a complication that someone with substernal chest pain And you admit them to I see In six months, we've had two overdoses and they've had to be in the ICU and they go to the ER they're a little bit uptunded and Then they need to be intubated and they're in the ICU and it takes a little while even once you turn that pump all the Way down it it takes a while So, what do you do? Dr. Caldera in that situation? We watched them and they got better. No. Yeah, we I did we did. Yeah, we watched him and they got better You could do that not be afraid to take off that much CSF people can handle it That's if you're if you really believe this is overdose The normal human CSF is 150 cc. So you're taking off 20% of it Hyperhydrate them let there be permissive hypertensive. They'll turn off CSF faster and you'll get through the overdose faster and if you if They're at st. Pig's knuckle that no one knows anything about a pump find a neurosurgeon to put a lumbar drain To the side for absolutely Absolutely So I will say and one of them there was no way we were gonna access that side part We couldn't oh you couldn't couldn't And in the second one, it wasn't for sure Overdose, okay, you know, so what it's not always clear, right? But we did watch them and they were supported and they did get better But yeah, I would have been nice to pull it up Awesome. Thank you all so much. I have two real quick questions one discussion at our institution recently was the use of prophylactic antibiotics post implants just a short course if there was any literature to suggest that that would be Value, I'd love to get your guys's opinion and then secondly for CAP studies. Is there do you have a routine? A frequency of CAP studies. Everything's going. Well, we're doing our refills. No issues. Do you have any? Routine where you do CAP studies. Thank you I don't know that there's a routine. I can only tell you that as a practicing physiatrist I have a way lower threshold to do and I thought I might have I Routinely do them before pump replacement for end of battery life And I've recently just started to do more of them after transition of care If I have any suspicion and what I mean by any suspicion I'm talking about someone that I think is on a pretty high dose That shouldn't need it for the size of their body or their underlying diagnosis And maybe they're getting this high dose and they still are kind of tight So if I have any suspicion I have a much lower threshold to do it So I presented that that a study from dr. Sklasky and I saw him present that and I think 2018 at another conference and that changed the way I practice I then started doing catheter access sports before every elective pump replacement and I find a fair number That are not that I cannot access And it's really important for us because I'm very close with my neurosurgeon He's also works very well together and I can help him prepare for what needs to be done He'll have either enough or time for just a pump replacement or he needs the or time to go and look and see what's going On with the catheter Also, even though I can't pull back from that at that catheter access part. Is it intermittent or what's going on? I need time to wean them down and that gives me a lot of clinical And What's going on clinically as well? Since then every time I have a new patient that came from someone else I absolutely do it because I don't know what was going on before because I didn't get to see their trial I haven't gotten to know them So I do it then and now I'm kind of getting into the practice of doing it every one to two years Because it's a lot of medicine and we are showing that there are times that they that patients do not know even Really reliable patients that they don't know that they're receiving it because pumps don't make your spasticity zero Right, they make it better manageable and sometimes we leave some tone there so they can walk or do cares or these things and so I Mean, we know how to do it. Some of them are more difficult than others such as this patient I was alluding to But I strongly recommend and you'll get better at them the more you do them the better you're gonna get at them too and never Take it out and push it back in Okay, I think that is okay I was just gonna answer the first question yes, so preoperative antibiotics I'd refer you to the 2024 poly analgesic consensus conference that was published in neuromodulation a few months ago Recommendations are to do an MRSA screen and if they are positive treat appropriately I would also recommend in the neurogenic bladder patient to grab a urine culture and Decolonize the bladder. I know we do not normally treat bladder colonization But you're putting in a new device and you want to make sure that they don't see from that It's a little bit of a deviation the incidence of community dwelling individuals with MRSA positive scans approaches 40% so the typical First generation cephalosporins are not going to cover that I Think post-operative antibiotics is too late I think you have to prevent it beforehand the scar tissue around that replacement pump is poorly vascularized If you let something get in there, you're doomed So yeah, it's for me. It's bactrim five days. It's bactriban in the nail beds in the nose five days With screening sorry, okay, if I know that if they're an MRSA carrier and chlorohexidine You know bath and wipes beforehand clean pajamas clean sheets Intraoperative vancomycin does not work while it's helpful in some other spine surgeries does not work in neuromodulation devices Good answers good questions. Okay. All right. We'll have a wonderful evening and thank you for coming You

baclofen pumps

intrathecal troubleshooting

catheter issues

diagnostic tools

case studies

x-rays

beta-2 transferrin

CT myelograms

nuclear medicine scans

withdrawal diagnosis

spasticity management

ICU monitoring