II. Background
- Baclofen is used to reduce severe spasticity (e.g. spinal cord injury, Cerebral Palsy, Multiple Sclerosis)
- Oral Baclofen poorly penetrates blood brain barrier, and requires intolerable oral doses to offer effect
- Instead, intrathecal Baclofen has fewer side effects and may be used at low dose
III. Dosing
- Baclofen 50-100 mcg/day via Intrathecal Pump (up to 900 mcg) and slowly titrate to effect
- Small dose modifications can have significant effects on patient findings (due to direct CSF drug delivery)
IV. Causes: Baclofen Withdrawal
- Empty medical reservoir
- Mistakes in Baclofen Pump programming
- Pump battery failure
- Catheter malfunction (kinked, migrated)
V. Findings: Baclofen Withdrawal
- Baclofen Withdrawal may be severe and life threatening
- Timing of withdrawal
- Onset within 48-96 hours of stopping intrathecal Baclofen (may have onset within 12 hours)
- Mild to moderate
- Spasticity returns
- Pruritus
- Anxiety
- Disorientation
- Severe
- Hyperthermia
- Tachycardia
- Myoclonus
- Seizures
- Coma
- Hallucinations, Delirium, Delusions or paranoia (related to Norepinephrine and Dopamine release)
- Baclofen Withdrawal results in hemodynamic instability, Seizures
- May present with signs similar to Sepsis
- May present with Tachycardia, Tachypnea, fever and confusion (all consistent with Sepsis)
- However, in contrast with Sepsis, Baclofen Withdrawal presents with Hypertension
VI. Differential Diagnosis: Baclofen Withdrawal
VII. Labs: Baclofen Withdrawal
VIII. Imaging
- Abdominal AP and lateral
- Evaluate for catheter migration
- Catheterogram
- May be needed to identify catheter problems
IX. Management: Baclofen Withdrawal
- Urgently consult neurosurgery
- General supportive measures
- Replace Baclofen
- Other measures: GABA-A Agents (prevent Seizures, control spasticity)
- Benzodiazepines
- Propofol infusion may also counter withdrawal effects
- Initiate early before significant withdrawal, hemodynamic instability
- Other agents that have been used in case reports effectively (but inadequate evidence)
X. Complications: Baclofen Withdrawal
XI. Prevention: Baclofen Withdrawal
- Do not stop Baclofen abruptly (taper over weeks)
XII. References
- Mishler and Lovecchio (2017) Crit Dec Emerg Med 31(11): 15-20
- Orman and Swaminathan in Herbert (2017) EM:Rap 17(1): 1
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Concepts | Medical Device (T074) |
English | Baclofen Infusion Implantable Pumps |