Preoperative Care

A comprehensive patient assessment is essential, focusing on potential risk factors like malnutrition, immunocompromised status, and infection risks (e.g., MRSA). Preoperative laboratory tests such as complete blood count, metabolic panel, urinalysis and coagulation profile should be performed. Consider nasal swabs for MRSA/MSSA for high-risk patients^30,140 and treat infections preoperatively^141,142.

Planned Pump Location

Proper evaluation of the patient’s anatomy is crucial, especially for abdominal wall placement, which is generally preferred over the buttock in patients with cachexia or ongoing weight loss.

Preoperative Imaging

Imaging of the thoracolumbar spine is necessary to assess spinal access, tumor involvement, and the location of the conus medullaris.

Post-surgery care includes continuous monitoring, wound care, and ensuring that the intrathecal infusion rate is appropriately managed. Patients should be mobilized within 6 hours post-surgery unless complications arise.

Disease-Related Assessment

When end-of-life is near, it may not be appropriate to undergo surgical implantation and its management. Candidates should ideally have a life expectancy of at least 3 months, but physician judgment of risk-benefit should be used.

Disease Burden and Physical Status

Understanding the extent of disease and choosing a catheter tip location that maximizes analgesic efficacy is critical. Regional pain may benefit from a local anesthetic-based regimen, or with more diffuse pain hydrophilic opioids and/or ziconotide-based solutions. Physical factors like cachexia or poor nutritional status can predict poor surgical outcomes¹⁵⁰.

Device Management and Follow-up Care

The implanting team must ensure that patients or caregivers can manage pump refills and follow-up appointments. If the patient is likely to enter hospice care, the impact on medication and refill costs should be considered.

Consensus Point 11: Multiple factors have to be weighed in deciding to initiate IDD in patients with advanced cancer and poor prognosis, including the availability of pump refills at the hospice facility of choice for the patient.

Therapy-Related Assessment

Optimal platelet and neutrophil counts are necessary before and after surgery to minimize bleeding and infection risks¹⁵¹. A cautious approach should be taken for platelet counts below 80,000/µL or neutrophil counts below 500/µL¹⁵².

Some cancer therapies can impact wound healing and bleeding risks^{153,154,155,156,157,158,159}. Oncologist consultation is recommended to weigh risks versus benefits of discontinuing therapy perioperatively.

The pump should not be placed in recently radiated areas or areas planned for radiation if possible, but pumps exposed to radiation did not show an increased risk of failure in a recent review^160.

IDD should be avoided when prolonged myelosuppression is expected after bone marrow transplantation.

Consensus Point 12: The PACC recommends that the implanting physician should be aware of concurrent antineoplastic therapies and mitigate the associated risks of infection, bleeding, and impaired wound healing. USPSTF Grade A; Level of certainty moderate; Quality of evidence 1-B.

Systemic opioids are frequently used in cancer pain patients. IDD can facilitate rapid cessation of systemic opioids, especially when high doses are required. Studies show that safe transition to IT therapy can occur even in patients with significant opioid tolerance²⁰.

The phenomenon of opioid-induced hyperalgesia (increased sensitivity to pain) can complicate the assessment of pain control and may necessitate rapid transitions and dose adjustments when starting IT therapy.

A review of 275 cancer pain IT pumps describes a structured protocol followed to rapidly initiate IT therapy while simultaneously discontinuing systemic opioids, achieving a cessation of systemic opioids in 96% of patients overnight²⁰.

Past or active substance abuse should not automatically disqualify cancer patients from receiving IDD. IDD may be more beneficial for controlling pain while reducing the risk of abuse and overdose¹⁹.

Consensus Point 13: The PACC concurs that the presence of past or even active substance abuse is not a contraindication for IDD in those with cancer pain or other end-of-life indications. Proper counseling and education should be used in the process of selection and management.

USPSTF Grade B; Level of certainty low; Quality of evidence II.