Sgouros S, Charalambides C, Matsota P, Tsangaris I, Kostopanagiotou G
Department of Neurosurgery, 'Attikon' University Hospital, University of Athens, Athens, Greece.
Pediatr Neurosurg. 2010;46(1):62-5. doi: 10.1159/000315319. Epub 2010 Jun 1.
Intrathecal baclofen therapy using implantable pumps is an established treatment for spasticity. The pumps occasionally experience serious malfunction.
A 12-year-old girl suffering from spastic diplegia was implanted with a Medtronic SynchroMed II pump (Medtronic Inc., Minneapolis, Minn., USA). During a refill at 3 months 19 ml of baclofen were still in the pump. It was assumed that there was a lumbar catheter obstruction and a revision was performed. At 11 months she was receiving 180 microg/day. When she presented for refill, there were again 19 ml of baclofen in the reservoir. The pump was refilled, stopped and restarted at a lower dose. Ten minutes after restart the patient was complaining that she could not move her legs. Within the next 50 min she lapsed into coma, from a presumed baclofen overdose. She was intubated and ventilated. The reservoir was emptied of baclofen and the pump stopped. Seventeen hours after the baclofen overdose, the patient woke up gradually with no new neurological deficits. The pump was removed a week later. Medtronic laboratories examined the pump and reported no technical fault.
The implanted Medtronic SynchroMed II pump suffered an unusual malfunction. It is postulated that the pump had suffered a motor stall, and when it was restarted, it gave an unusually high, potentially lethal, dose to the patient.
Physicians who implant pumps for intrathecal baclofen administration need to be aware that these devices may suffer unheralded catastrophic failure that can lead to potentially lethal overdose administration.
使用植入式泵进行鞘内注射巴氯芬疗法是一种已确立的治疗痉挛的方法。这些泵偶尔会出现严重故障。
一名患有痉挛性双侧瘫的12岁女孩植入了美敦力SynchroMed II泵（美敦力公司，美国明尼苏达州明尼阿波利斯）。在3个月时进行药物补充时，泵内仍有19毫升巴氯芬。推测存在腰段导管阻塞，于是进行了修复手术。11个月时，她每天接受180微克的剂量。当她前来进行药物补充时，储液器中又有19毫升巴氯芬。对泵进行了补充、停止并以较低剂量重新启动。重新启动后十分钟，患者抱怨双腿无法动弹。在接下来的50分钟内，她陷入昏迷，推测是巴氯芬过量所致。她接受了插管和通气治疗。将储液器中的巴氯芬排空并停止了泵。巴氯芬过量17小时后，患者逐渐苏醒，没有出现新的神经功能缺损。一周后取出了泵。美敦力实验室对泵进行了检查，报告没有技术故障。
植入的美敦力SynchroMed II泵出现了异常故障。据推测，该泵出现了电机失速，重新启动时给患者输送了异常高的、可能致命的剂量。
植入用于鞘内注射巴氯芬的泵的医生需要意识到，这些设备可能会出现未被察觉的灾难性故障，从而导致潜在的致命性过量给药。
