Rapid Intrathecal Baclofen Weaning in an Infected Baclofen Pump Site

Case Diagnosis: Rapid baclofen weaning protocol for a patient with C4 complete spinal cord injury and ventilator-dependence following baclofen pump site infection requiring urgent surgical device removal.

Case Description or Program Description: A 53 year old patient with C4 complete spinal cord injury and ventilator-dependence was admitted to a partner intensive care unit (ICU) for surgical removal of his intrathecal baclofen (ITB) pump after ineffective response to broad-spectrum antibiotics and surgical washout of his pump pocket .
The physiatry team directed a daily 30% reduction in ITB from a starting point of 992 mcg/day. His valium 10mg tid was replaced with oral baclofen 20mg tid, and his tizanidine 4mg tid was increased to 8mg qid. Due to the significant risk of central depression, medication toxicity, and baclofen withdrawal, his clinical monitoring included q4h neurologic exams and q8h liver function monitoring. Additionally, ICU staff were provided with withdrawal parameters for initiating creatinine kinase (CK) lab monitoring and additional antispasmodic supplementation.

Setting: Acute care hospital, ICU

Assessment/Results: Although the patient did experience worsening spasticity, he did not experience worrisome withdrawal symptoms. On day 4 of his wean he was taken to the operating room for pump removal, surgical washout and debridement, and implantation of a new ITB pump. His pre-operative ITB dose was 237 mcg/day; his new pump was set to 200 mcg/day intra-operatively.

Discussion (relevance): There is scant literature describing ITB weaning protocols, with most limited to daily doses < 500 mcg/day. Despite our patient's high starting ITB dose, withdrawal symptoms were avoided with aggressive oral antispasmodic replacement.

Conclusions: This case describes a protocol for rapidly weaning ITB due to infected baclofen pump site. After increasing oral antispasmodic therapies, our patient was able to tolerate a 30% daily dose reduction from 992 mcg/day to 237 mcg/day over four days without significant withdrawal symptoms.