Cardiac Arrest: A Rare Complication of Intrathecal Baclofen Withdrawal.

Abstract

Baclofen, a GABA agonist, is used for the management of spasticity. Intrathecal route is indicated in cases of severe spasticity associated with spinal cord injury. Baclofen withdrawal symptoms can happen after IT pump removal which can present as anxiety, 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, fibular osteomyelitis and chronic sacral ulcers presented with wound dehiscence and exposed baclofen pump which was replaced 4 weeks ago due to the end of the pump's life. After 24-48 h of removal of the baclofen pump, cardiovascular instability in the form of supra ventricular tachycardia 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 ROSC after 3 rounds of CPR. He was subsequently intubated, mechanically ventilated and sedated with midazolam intravenously. Baclofen and clonazepam were started through the 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.