Cardiac arrest due to baclofen withdrawal syndrome

Abstract

SUMMARYA 41-year-old man presented with postcervical traumatic complete quadriparesis under intrathecal baclofen therapy (ITB) for refractory spasticity. Less than 24 h after having his baclofen pump substituted, he develops hyperthermia, seizures, cognitive depression, acute hypoxaemic respiratory failure and cardiovascular instability leading to mechanical ventilation and vasopressor support. He was transferred to an intensive care unit with diagnosis of community-acquired pneumonia leading to septic shock. He evolved with progressive clinical worsening and multisystem organ failure and cardiac arrest in nonshockable rhythm ( pulseless electrical activity)-4 min resuscitation with return of spontaneous circulation. Considering the possible diagnosis of baclofen withdrawal syndrome and, in suspicion of ITB delivery disruption, the catheter system was surgically explored and a leaking tubule attachment was found. Despite aggressive cardiovascular, respiratory and renal support therapy, clinical improvement occurred only after restoration of intrathecal drug delivery. He was discharged from the hospital after 56 days, having returned to baseline status. BACKGROUND

Baclofen therapeutics, toxicity, and withdrawal: A narrative review

“…Baclofen withdrawal can occur in patients taking both oral baclofen and ITB. 74 – 76 , 78 – 80 , 82 , 84 , 91 , 92 Patients typically experience withdrawal symptoms within hours to days following drug interruption, often close to their scheduled prescription refill dates or because of malfunctions in their ITB delivery systems. 81 , 85 A high index of suspicion is required to diagnose baclofen withdrawal given the nonspecific nature of presentation and degree of symptom overlap with other clinical entities.…”

Infectious Complications of Intrathecal Drug Administration Systems for Spasticity and Chronic Pain: 145 Patients From a Tertiary Care Center

“…Abrupt discontinuation of intrathecal baclofen, regardless of the cause, has previously resulted in high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity, which in rare cases, has advanced to rhabdomiolysis, multiple organ‐system failure, and death, although the incidence has not been established yet . In none of the patients who had the pump removed and oral baclofen started, were identified symptoms suggestive of baclofen withdrawal syndrome.…”

Sympathomimetic Toxidromes and Other Pharmacological Causes of Acute Hypertension

“…Similar to alpha 2 agonist intrathecal pumps, intrathecal baclofen pump malfunction can lead to life-threatening overdose and withdrawal states. In withdrawal, hypertension, tachycardia, stress cardiomyopathy, diaphoresis, spasticity, dystonia, seizures, fever, anxiety, delirium, rhabdomyolysis, DIC and death are reported [46][47][48][49]50…”