Baclofen Pump

Baclofen Pump

 

Medical technology continues to advance with the goal of improving patient care, but as the march toward the future seems to occur more rapidly each year, it is our challenge to stay abreast of the good and the, potentially, bad for each advancement.  Let us take this opportunity to look at Baclofen Pumps.

 

Baclofen

  • What is it?

    • Baclofen is a derivative of gamma-aminobutyric acid (GABA), the inhibitory neurotransmitter.
    • It is a agonist for the GABA B receptors at the spinal and supra spinal sites.
    • Has anti-spasticity effects.
  • Why it’s used in kids?

    • Most commonly used for treating spasticity related spinal cord disease:
      • Cerebral Palsy
      • Spinal Cord Injury
      • Generalized Dystonia
      • Mutliple Sclerosis
    • Some use for intractable hiccups
  • How it’s Given

    • Oral or IV
    • Topical creams
    • Intrathecal via Implantable Device

 

Baclofen Toxicity

  • Baclofen toxicity has been reported after intrathecal and oral administration (both accidental and intentional).
  • Baclofen crosses the blood-brain barrier.
  • Clinical findings:
    • Muscular hypotonia
    • Areflexia
    • Somnolence
    • Respiratory Depression
    • Bradycardia
    • Hypotension
    • Temperature instability
    • Coma
    • May mimic brain death (Ostermann, 2000)
  • Symptoms can occur rapidly.
  • Diagnosis is clinical, as measuring plasma levels is not always reliable.
  • Treatment

    • Primarily treatment is supportive (IV Fluids, Inotropes, Airway Support)
    • Limit the Baclofen exposure (if a implantable pump is being used, drain the reservoir).
    • Physostigmine
      • There are case reports of it being effective and some advocate for its consideration. (Yeh, 2004)
      • It may cause bradycardia and increased airway secretions.

 

Baclofen Withdrawal

  • Acute withdrawal of Baclofen can lead to severe symptoms and death if not recognized and treated.
  • Clinical Findings: (Yeh, 2004)
    • Itching
    • Dysphoria
    • Rebound Spasticity
    • Audio and Visual Hallucinations
    • Paranoia
    • Seizures
    • Rhabdomyolysis
    • Death
  • Symptoms may start to develop during the course of treating Baclofen Toxicity. (Darbari, 2005)
  • Treatment

    • Supportive Care (ABCs as always)
    • Oral or Enteral Baclofen (Yeh, 2004)
      • Should be initiated at the earliest signs of withdrawal.
      • Be looking for generalized itching or increased spasticity.
    • High dose Benzodiazepines

 

Baclofen Pump

  • Intrathecal delivery allows for a much lower dose (100-1000 fold).
  • Determination of dosage is complex.
  • Mechanics

    • Baclofen Reservoir
      • The pump has a reservoir that is filled with baclofen periodically.
      • The access point for the pump’s reservoir can also be used to extract the medication also.
    • Catheter Access Port
      • Adjacent to the connection of the catheter.
      • The Catheter Access Port can be used to extract remaining baclofen in catheter and CSF if needed.
    • Pump Motor
      • Programmable via bedside computer.
      • Automatically turns off when reservoir is empty.
  • Toxicity may occur as a result of device error or human error.
  • Suggested Approach to Toxicity related to Baclofen Pump. (Yeh, 2004)
    • ABCs and Supportive Care
    • Obtain the device-associated computer to turn off device and assess it (this may take some time to get, so move on to next steps).
    • Obtain the device-specific template guide that, when placed over the device, helps to locate the access sites.
    • Empty the Reservoir to stop the motor (so no more of the Baclofen in the catheter will enter the thecal sac).
    • Withdraw fluid / CSF from the Catheter Access Port (to extract any Baclofen that is still in the catheter or adjacent to it).
    • Consider Physostigmine if not contraindicated.
    • Admit to the ICU.

 

References

Ghosh D1, Mainali G, Khera J, Luciano M. Complications of intrathecal baclofen pumps in children: experience from a tertiary care center. Pediatr Neurosurg. 2013;49(3):138-44. PMID: 24577095. [PubMed] [Read by QxMD]

Caron E1, Morgan R, Wheless JW. An unusual cause of flaccid paralysis and coma: baclofen overdose. J Child Neurol. 2014 Apr;29(4):555-9. PMID: 23481445. [PubMed] [Read by QxMD]

Dickey MP1, Rice M, Kinnett DG, Lambert R, Donauer S, Gerber MA, Staat MA. Infectious complications of intrathecal baclofen pump devices in a pediatric population. Pediatr Infect Dis J. 2013 Jul;32(7):715-22. PMID: 23429557. [PubMed] [Read by QxMD]

Borowski A1, Littleton AG, Borkhuu B, Presedo A, Shah S, Dabney KW, Lyons S, McMannus M, Miller F. Complications of intrathecal baclofen pump therapy in pediatric patients. J Pediatr Orthop. 2010 Jan-Feb;30(1):76-81. PMID: 20032747. [PubMed] [Read by QxMD]

Vender JR1, Hester S, Waller JL, Rekito A, Lee MR. Identification and management of intrathecal baclofen pump complications: a comparison of pediatric and adult patients. J Neurosurg. 2006 Jan;104(1 Suppl):9-15. PMID: 16509474. [PubMed] [Read by QxMD]

Darbari FP1, Melvin JJ, Piatt JH Jr, Adirim TA, Kothare SV. Intrathecal baclofen overdose followed by withdrawal: clinical and EEG features. Pediatr Neurol. 2005 Nov;33(5):373-7. PMID: 16243227. [PubMed] [Read by QxMD]

Yeh RN1, Nypaver MM, Deegan TJ, Ayyangar R. Baclofen toxicity in an 8-year-old with an intrathecal baclofen pump. J Emerg Med. 2004 Feb;26(2):163-7. PMID: 14980337. [PubMed] [Read by QxMD]

Ostermann ME1, Young B, Sibbald WJ, Nicolle MW. Coma mimicking brain death following baclofen overdose. Intensive Care Med. 2000 Aug;26(8):1144-6. PMID: 11030173. [PubMed] [Read by QxMD]

Müller-Schwefe G1, Penn RD. Physostigmine in the treatment of intrathecal baclofen overdose. Report of three cases. J Neurosurg. 1989 Aug;71(2):273-5. PMID: 2746350. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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3 Responses

  1. DONELLA FLORENCE says:

    Great! this is very impressive.

    Usmle Medical Books

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