Objective:

NA

Background:

Intrathecal baclofen can be used to treat severe spasticity but poses risk of potential life-threatening complications. We describe the case of a patient with intrathecal baclofen overdose.

Design/Methods:

Case Report

Results:

A 71-year-old female with multiple sclerosis and a long-standing intrathecal pump containing baclofen and clonidine presented with hypothermia, hypotension, bradycardia, and unresponsiveness after a pump re-fill of 10,000 mcg (20mL) baclofen and 1000 mcg clonidine. GCS was 3 on ED arrival and she was emergently intubated. She subsequently went into PEA arrest requiring 10 minutes of CPR before ROSC. CT head was normal. Her neurological examination remained poor with coma, absent brainstem reflexes, absent motor responses, and no breaths over the ventilator set rate. Continuous EEG revealed burst suppression. She then developed generalized tonic-clonic seizures that resolved with levetiracetam. Baclofen toxicity was suspected but pump interrogation showed no obvious malfunction. The infusion rate was lowered on day 3 and turned off on day 4. Her neurologic exam and EEG improved on day 4 and she slowly regained consciousness. On day 5, only 3 mL of fluid was recovered from the pump. By day 6, she was briskly following commands but remained weak (2/5 neck flexion, NIF of -10). Her strength gradually improved and she was extubated on day 8, with eventual discharge to rehab on day 12. 

Conclusions:

Intrathecal baclofen toxicity is a rare but life-threatening adverse event and should be suspected in cases of rapid onset coma particularly following any recent changes or manipulation of the pump.  A high index of suspicion is important as the neurological examination can mimic brain death, leading to premature withdrawal of care, especially in the context of cardiac arrest.