Baclofen, a gamma-aminobutyric acid(GABA)receptor agonist, is used for the management of spasticity in neuromuscular disorders. Intrathecal(IT) route is indicated in cases of severe spasticity associated with spinal cord injury with side effects profile. Baclofen withdrawal symptoms can happen after IT pump removal which can present as pruritus, anxiety, or severe symptoms like paranoia, psychosis, seizures, hallucinations, severe spasticity and dyskinesia. Cardiac arrest after baclofen withdrawal is rare with only 2 cases in literature so far however in both cases IT-pump was replaced. We present a case of PEA arrest after baclofen IT-pump removal which was managed without replacing.
33-year-old male with history of paraplegia from cervical spinal cord injury (C-6) level, chronic spasticity, metastatic melanoma, adrenal insufficiency, fibular osteomyelitis and chronic non-healing sacral ulcers with multiple debridements presented with wound dehiscence and exposed baclofen pump under neurosurgery services. The Baclofen pump was replaced four weeks ago due to the end of the pump's life. During admission, baclofen pump was removed and after 24-48 hours of removal, cardiovascular instability in the form of supra ventricular tachycardia (SVT) with hypotension and altered mentation was noted. It evolved to progressive clinical worsening with stiffness of body, loss of responsiveness, and up-rolling of eyes. Patient underwent PEA, and CPR was initiated with ROSC after 3 rounds. He was subsequently intubated, mechanically ventilated, admitted to NeuroICU and sedated with midazolam intravenously. Baclofen and clonazepam were started through feeding tube. Over a period of 10 days, midazolam was weaned, and baseline clinical stability was achieved without IT-baclofen pump.
Though rare, cardiac arrest can happen after baclofen withdrawal. High index of clinical suspicion is advised for long term baclofen pump patients after pump explant to prevent withdrawal symptoms and complications. Due to lack of established guidelines for baclofen withdrawal treatment, management approach varies among clinicians.