key: cord-0774288-btufken6
authors: Dario, Alessandro
title: Response to: Managing Intrathecal Drug Delivery Devices in a Global Pandemic
date: 2022-01-03
journal: Neuromodulation
DOI: 10.1111/ner.13308
sha: 87f9a47456f1f2b44d0bcb113ede4d46ad2701ba
doc_id: 774288
cord_uid: btufken6

nan

I read with interest Kim and Deer letter (1) to Neuromodulation about managing intrathecal drug delivery devices during COVID-19 pandemic as the epidemic is not over yet.

Every year at the Neurosurgical Clinic of the ASST Settelaghi, there are about 180 refills which in 90% of cases concern patients treated with baclofen. About 35% of our patients come to the hospital for refill coming from protected health facilities or retirement homes.

The pandemic due to the Coronavirus Disease 2019 (COVID-19) hit Italy hard and especially Lombardy, that in a short time almost reached the saturation of hospital beds in February 2020. The Lombard Regional Government since 8 March 2020 has completely reorganized the regional health service, including the management of the neurosurgery units (2). All neurosurgical operations classified as nonurgent have been suspended as well as the nonurgent outpatient activities. With this order, the Varese hospital had the status of neurosurgical hub in the western part of Lombardy called Insubria. Refill of the pumps was allowed with the use of suitable protection systems.

Indeed intrathecal pump refills are an emergent interventional procedure since even high-dose oral replacement therapy may not be sufficient for baclofen because there is extremely wide variability in conversion ratios with the danger of fatal withdrawal (3, 4) . Ziconotide and morphine do not present this danger, but the increase in pains cannot always be controlled by the routine oral substitution at home. Thus following the regional indications, we divided the patients to refill into two classes: the first consisting of patients COVID-19 negative or a low-risk: this group included patients without respiratory symptoms or fever, from home or with nasopharyngeal swab negative. The refill was performed in a clean room after measurement of the patient's temperature by a doctor and nurse wearing surgical mask, gloves, waterproof gown, surgical cap and with the patient wearing a surgical mask; the device-programming equipment is in a plastic bag. The second class of patients consisting of COVID-19 patients positive or a high-risk patient.

As retirement homes in Lombardy have shown a high incidence of patients with COVID-19 all patients from there were considered positive. The refill was performed in a room designated for use with COVID-19 patients by a doctor and nurse wearing N95 mask,two pairs of gloves, safety goggles, waterproof overalls and shoes and with the patient wearing a surgical mask; the device-programming equipment is in a double plastic bag; immediately after the procedure the patient was discharged home and the room disinfected.

In the epidemic period March to May 2020, we supplied in ambulatory 43 pump patients, 39 of which with baclofen, 2 with morphine, 2 with ziconotide; only five patients were refilled on COVID room; the number of refill procedures was comparable to that of the same period 2019. Two patients, one positive but asymptomatic, who did not come on in hospital the booked data for delay due to logistical problems and with baclofen withdrawal symptoms (increased spasticity and restlessness) were refilled to the COVID area of the emergency room without further complications. One patient with COVID symptomatic pulmonary symptoms did not exhibit baclofen withdrawal symptoms after administration of 100 mg/day of oral baclofen for three weeks after the exhaustion of the intrathecal drug; he was the refilled after COVID-19 healing.

All health-care personnel involved in these procedures are still not infected by COVID-19 after two routine nasopharyngeal swabs.

Our experience shows that even in the epidemic era, the management of baclofen pumps refill is feasible with safety in specialized centers, avoiding dangerous withdrawal syndromes and damage to health-care personnel following the indications of the literature (4, 5) .

I fully agree that each case of refueling is subject to medical judgment (1) and that the existence of indications on pump refill during pandemic can increase the safety of patients and health professionals.

Managing Intrathecal drug delivery devices in a global pandemic

Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises

Recommendations for the Management of Implanted Neurostimulation & Intrathecal Drug Delivery Devices During the COVID-19 Pandemic

Recommendations on chronic pain practice during the COVID-19 Panepidemic