Errors involving the infusate may occur if meticulous attention is not paid to the type of system being used, the drug being used, the drug concentration being used, the dead space in the system, and the prescription entered with programmable systems. Errors that occur may result in a life-threatening overdose. Some type of verification of these parameters should be in place at initial filling and at each refill procedure. When more than one drug is placed into the pump, the potential errors in compound dosing require a skilled operator and careful calculation.
Systems containing a side port unfortunately also have the disadvantage of possible direct injection of an overdose volume of drug at high concentration. Medtronic has offered a solution to this problem by producing a side port with a fenestrated screen that will not admit the standard refill needle, thus preventing inadvertent overdose when standard refill technique is attempted. When the side port is used for bolus dosing or troubleshooting, care must be taken to account for whatever concentration and volume of drug exist in the catheters. Forcing fluid through the side port also forces whatever fluid is in the line into the intrathecal space. Proper technique would suggest aspirating the side port to clear the line before injecting. Some physicians, including the author, avoid errors of these types by not implanting pumps with side ports, believing that the advantages of troubleshooting are not outweighed by the risk of overdose.
Treatment of an overdose should begin by immediate removal of CSF, with replacement by preservative-free saline. An intravenous line should be placed and the patient admitted to the intensive care unit with careful monitoring for respiratory depression. Naloxone should be administered for respiratory depression, keeping in mind the possibility of exacerbating the hypertension associated with massive doses of opioids.30 Other signs of overdose such as neurotoxicity and seizure activity should be managed symptomatically.
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