Morr Simon, Heard Christopher M, Li Veetai, Reynolds Renée M
Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, New York, USA.
Neurocrit Care. 2015 Apr;22(2):288-92. doi: 10.1007/s12028-014-0083-8.
Intrathecal baclofen is widely accepted as a treatment option for severe spasticity through its γ-Aminobutyric acid-B (GABAB ) agonist properties. Abrupt cessation can lead to severe and life-threatening withdrawal characterized by altered mental status, autonomic dysreflexia, rigidity, and seizures. This symptomatic presentation is similar to alcohol withdrawal, which is mediated by modification of GABAA expression. Use of the α2-adrenergic agonist dexmedetomidine for the treatment of ethanol withdrawal has been widely reported, raising the question of its potential role in baclofen withdrawal. We present a case of the successful treatment of acute severe baclofen withdrawal with a dexmedetomidine infusion.
A 15-year-old patient with spastic quadriparesis and cerebral palsy underwent unexpected removal of his baclofen pump due to an infection that was encountered during a planned pump revision. Following removal, he was placed on high dose enteral baclofen every 6 h. Despite further benzodiazepine supplementation, he had progressive hemodynamic instability, severe rebound spasticity, and intermittent spontaneous clonus consistent with baclofen withdrawal. A dexmedetomidine infusion was titrated to a peak dose of 16 mcg per hour with successful treatment of withdrawal symptoms.
The patient became normotensive without tachycardia. Tone and agitation improved.
Dexmedetomidine is to our knowledge a previously unreported option for treatment of acute severe baclofen withdrawal. We report a case of safe and efficacious use in a patient with spastic quadriparesis on chronic intrathecal baclofen. Scientifically rigorous comparison with other options remains to be performed.
鞘内注射巴氯芬因其γ-氨基丁酸B（GABAB）激动剂特性，被广泛认为是治疗严重痉挛的一种选择。突然停药会导致严重且危及生命的戒断反应，其特征为精神状态改变、自主神经反射亢进、僵硬和癫痫发作。这种症状表现类似于酒精戒断，后者是由GABAA表达的改变介导的。α2肾上腺素能激动剂右美托咪定用于治疗乙醇戒断的报道已很广泛，这引发了其在巴氯芬戒断中潜在作用的问题。我们报告一例通过输注右美托咪定成功治疗急性严重巴氯芬戒断的病例。
一名15岁患有痉挛性四肢瘫和脑瘫的患者，因计划中的泵修复期间发生感染，意外移除了他的巴氯芬泵。移除后，他每6小时接受高剂量的肠内巴氯芬治疗。尽管进一步补充了苯二氮䓬类药物，但他仍出现进行性血流动力学不稳定、严重的反弹性痉挛，以及与巴氯芬戒断相符的间歇性自发阵挛。右美托咪定输注剂量滴定至每小时16微克的峰值剂量，戒断症状得到成功治疗。
患者血压恢复正常，无心动过速。肌张力和烦躁情绪改善。
据我们所知，右美托咪定是治疗急性严重巴氯芬戒断的一种此前未报道的选择。我们报告了一例在长期鞘内注射巴氯芬的痉挛性四肢瘫患者中安全有效使用的病例。与其他选择进行科学严谨的比较仍有待进行。
