(637) Baclofen Withdrawal Syndrome in the ICU: A Rare but Potentially Fatal Condition

Introduction: Intrathecal baclofen pump has been used with increasing frequency in patients with severe spasticity. Baclofen withdrawal syndrome is a rare, potentially life-threatening complication caused by an abrupt cessation of intrathecal baclofen. We report a case of severe baclofen withdrawal syndrome and associated management challenges in ICU.

Description: A 61-year-old male with history of Multiple Sclerosis and bilateral lower extremity spasticity on intra thecal baclofen pump, presented with concerns for meningitis. Baclofen pump had to be explanted emergently for source control. Post operatively, the patient was extubated and transferred to ICU for monitoring given the long-term use of baclofen and high risk for baclofen withdrawal syndrome. In the ICU, the patient was started on enteral baclofen 20 mg bid and po lorazepam 1mg bid to prevent withdrawal. His home regimen for chronic pain which included fentanyl patch, gabapentin, methadone, tizanidine, clonazepam was also resumed. Despite this, patient went into severe withdrawal and developed severe spasms in lower extremities, oral twitches, neck spasms, and irritable mood. CT head, procalcitonin, CRP were done to rule out other etiologies and all were unremarkable. Given the concern for progression of baclofen withdrawal, baclofen and lorazepam dose were increased and quetiapine 25 mg bid was added. Eventually, in the following days, the patient became more awake and reported that his spasticity was at baseline. On POD-15, the patient was discharged home with tablet baclofen 20 mg every 6 hours, tizanidine, bupropion and plan for baclofen pump re-implantation in future for recurrent muscle spasms from MS exacerbation.

Discussion: Severe baclofen withdrawal can be potentially life-threatening and high-risk patients should be admitted to the ICU preemptively for close monitoring and treatment. Early institution of oral baclofen and benzodiazepines are the mainstay of treatment. Also, other differentials like sepsis, meningitis, neuroleptic malignant syndrome should be ruled out. With the increasing use of intra-thecal baclofen pumps, it is prudent that intensive care team is aware of the clinical spectrum and management of baclofen withdrawal syndrome.