Saulino Michael, Anderson David J, Doble Jennifer, Farid Reza, Gul Fatma, Konrad Peter, Boster Aaron L
MossRehab, Elkins Park, PA, USA.
Mid County Orthopaedic Surgery & Sports Medicine, St. Louis, MO, USA.
Neuromodulation. 2016 Aug;19(6):632-41. doi: 10.1111/ner.12467. Epub 2016 Jul 19.
Troubleshooting helps optimize intrathecal baclofen (ITB) therapy in cases of underdose, overdose, and infection.
An expert panel of 21 multidisciplinary physicians currently managing >3200 ITB patients was convened, and using standard methodologies for guideline development, created an organized approach to troubleshooting ITB. They conducted a structured literature search that identified 263 peer-reviewed papers, and used results from an online survey of 42 physicians currently managing at least 25 ITB patients each.
The panel developed two algorithms. The first was for loss-of-efficacy and applies to patients with previously well-controlled hypertonia on a stable dosing regimen who have increased spasticity Evaluation includes a targeted history (onset, duration, course, exacerbating/relieving factors, medications, recent procedures), physical examination (neuromuscular, vital signs, mental status), radiologic/laboratory testing (catheter imaging, noxious stimuli, infection, rising CK levels), and pump telemetry (pump interrogation, reservoir volume). Rapidly progressing hypertonia with autonomic instability or hypotonia and somnolence require emergent care and perhaps hospitalization. The second algorithm was for emergent care and describes treatment of overdose or withdrawal, which requires immediate care in a monitored setting and restoration of ITB delivery. The previous dosing schedule can be used in withdrawal of short duration; 10-20 mg every six hours can be used in longer-duration withdrawal. Supportive care includes maintenance of airway, respiration, and circulation. Seizure prevention should be considered, along with pump reprogramming or interruption, cerebrospinal fluid drainage, and sequential lumbar punctures/drains. Physostigmine and flumazenil are not usually advised. Superficial infections can be treated with oral antibiotics, and deep infections with broad-spectrum IV antibiotics (e.g., cefazolin, clindamycin, vancomycin). Explantation is often required. A new pump can be implanted in a new site under IV antibiotic coverage.
Orderly troubleshooting helps ensure patient safety.
故障排除有助于在鞘内注射巴氯芬（ITB）治疗出现剂量不足、过量及感染的情况下优化治疗效果。
召集了一个由21名多学科医生组成的专家小组，这些医生目前管理着超过3200名ITB患者，并采用制定指南的标准方法，创建了一种有组织的ITB故障排除方法。他们进行了结构化文献检索，共识别出263篇经同行评审的论文，并采用了对42名目前每人至少管理25名ITB患者的医生进行在线调查的结果。
该专家小组制定了两种算法。第一种用于疗效丧失，适用于之前在稳定给药方案下肌张力亢进得到良好控制但痉挛加重的患者。评估包括针对性病史（发作、持续时间、病程、加重/缓解因素、药物、近期操作）、体格检查（神经肌肉、生命体征、精神状态）、放射学/实验室检查（导管成像、有害刺激、感染、肌酸激酶水平升高）以及泵遥测（泵询问、储液器容量）。伴有自主神经不稳定的快速进展性肌张力亢进或肌张力减退及嗜睡需要紧急治疗，可能还需要住院治疗。第二种算法用于紧急治疗，描述了过量或撤药的治疗方法，这需要在监测环境中立即进行治疗并恢复ITB给药。短时间撤药可采用之前的给药方案；长时间撤药可每6小时使用10 - 20毫克。支持性治疗包括维持气道、呼吸和循环。应考虑预防癫痫发作，同时进行泵重新编程或中断、脑脊液引流以及连续腰椎穿刺/引流。通常不建议使用毒扁豆碱和氟马西尼。浅表感染可用口服抗生素治疗，深部感染可用广谱静脉抗生素（如头孢唑林、克林霉素、万古霉素）治疗。通常需要取出装置。可在静脉使用抗生素的情况下在新部位植入新泵。
有序的故障排除有助于确保患者安全。
