Correct!
5. All of the above
Note in our case that an enteral dose of 100 mg per day (100,000 mcg per day) was insufficient to treat withdrawal syndrome from 10 mcg per day of intrathecal baclofen – the last intrathecal dose our patient received the week prior to discontinuation of his baclofen pump. The high potency of intrathecal administration cannot easily be replaced, even by the highest allowable enteral doses of the drug. Therefore, the best primary therapy is to immediately restart the baclofen intrathecal pump. This requires technical and pharmacological expertise that many intensivists may not have, and in most cases would require an emergent consult to a neurologist or pain specialist experienced in the management of intrathecal baclofen therapy. High-dose intravenous benzodiazepines may be used as an adjunctive therapy – their effect mediated through GABA-a agonism. High level resuscitative and supportive care is often required until the syndrome can be pharmacologically reversed. The most important take-home point for the intensivist is to recognize the syndrome, and understand the urgency of specific therapy.
Our patient rapidly recovered after intrathecal baclofen was reinitiated, with immediate resolution of fever and muscle rigidity, clearing of encephalopathy, and resolution of multisystem organ failure, including cardiomyopathy over 10 days. He was eventually discharged home without sequelae.
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