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Intrathecal pump (baclofen / drug pump)

An implanted pump delivering a drug - usually baclofen - into the CSF. The emergency that gets missed: abrupt baclofen withdrawal, which looks like sepsis or an autonomic storm and can kill. Suspect the pump.

Adult & paediatricNeurologicalManufacturer instructions for use

Also called: intrathecal pump, baclofen pump, ITB pump, intrathecal baclofen, SynchroMed, pain pump, intrathecal drug delivery, spasticity pump

What it is

An intrathecal pump is a hockey-puck-sized device implanted in the abdominal wall, delivering a drug directly into the CSF through a fine catheter to the spine. The commonest is intrathecal baclofen (ITB) for severe spasticity (cerebral palsy, multiple sclerosis, spinal cord injury); others deliver analgesics (morphine, ziconotide) for intractable pain.

The reason this is a Band E emergency is abrupt baclofen withdrawal. If delivery stops - catheter failure, an empty reservoir, a missed refill, pump failure - the patient crashes into a withdrawal syndrome that is easily mistaken for something else. The labelling is stark: abrupt discontinuation has resulted in sequelae that include high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity, that in rare cases has advanced to rhabdomyolysis, multiple organ-system failure and death. The trap is that it mimics sepsis (and autonomic dysreflexia, and neuroleptic malignant syndrome), so the device gets overlooked while the patient is worked up for infection. Used in adults and children.

How to recognise it

What goes wrong

Abrupt baclofen withdrawal (reads as sepsis)

Rebound spasticity and rigidity, high fever, altered mental status, tachycardia and hypertension - developing over hours to a day or two after delivery stops. It may resemble autonomic dysreflexia, infection (sepsis), malignant hyperthermia, neuroleptic-malignant syndrome.

Red flag
This is the entry's whole point: do not anchor on sepsis and miss the pump. Untreated it progresses to rhabdomyolysis, multi-organ failure and death. Treat it as a withdrawal emergency, get the ITB team now, and give benzodiazepines early while delivery is restored.

Baclofen (or opioid) overdose

Progressive drowsiness, hypotonia, hypotension, respiratory depression and coma - after a refill, a programming/refill error, or inadvertent intrathecal bolus. Seizures can occur.

Red flag
Support airway and breathing (this can need intubation and ventilation), and get the pump interrogated and stopped by the ITB team. For an opioid pump, naloxone treats opioid overdose; there is no reliable antidote for baclofen - supportive care is the mainstay.

Catheter or pump failure / missed refill

A pump alarm, a known overdue refill, or recent surgery/trauma near the device, with returning spasticity - the mechanical cause of withdrawal.

Red flag
A failed catheter or empty reservoir means no drug is reaching the CSF, so withdrawal follows regardless of what the pump display says. The ITB team must interrogate the pump and catheter urgently; the fix is to restore delivery.

Seizures

Seizures in a patient on intrathecal baclofen - reported both in overdose and in withdrawal.

Red flag
Seizures have been reported during overdose and with withdrawal from LIORESAL INTRATHECAL. Treat seizures with benzodiazepines (which also help withdrawal) and address the underlying pump problem.

The first ten minutes

  1. In any pump patient who is unwell, febrile or rigid, think baclofen withdrawal before you settle on sepsis - the two look alike and the device is easy to overlook. Let the tone tell them apart: rigid, febrile and hypertensive points to withdrawal (a benzodiazepine helps); floppy, drowsy and hypotensive points to overdose (support the airway - do not sedate).
  2. For withdrawal, give a GABA-ergic agonist early. While intrathecal delivery is being restored, the label states that GABA-ergic agonist drugs such as oral or enteral baclofen, or oral, enteral, or intravenous benzodiazepines may prevent potentially fatal sequelae - in the ED an IV benzodiazepine is the usual holding treatment.
  3. Do not rely on oral baclofen alone - Oral or enteral baclofen alone should not be relied upon to halt the progression of intrathecal baclofen withdrawal; it is one option alongside a benzodiazepine, never the sole treatment.
  4. For overdose, support airway and breathing and be ready to ventilate; the label's emergency steps are to have the pump team empty the reservoir and, if LP is not contraindicated, remove 30-40 mL of CSF to lower the baclofen concentration - both specialist, time-critical actions (this overdose CSF removal is a different situation from the shunt entry's rule against LP).
  5. Get the pump interrogated by the ITB/pump team urgently - restoring intrathecal baclofen at the previous dose is the definitive treatment; the pump display alone does not exclude a catheter failure.
  6. Treat seizures with benzodiazepines and correct the pump problem.

Do not

Do not label a rigid, febrile pump patient as sepsis and stop there.
Baclofen withdrawal mimics sepsis, autonomic dysreflexia and neuroleptic malignant syndrome, and is rapidly fatal if the pump is overlooked. Treat the withdrawal and involve the ITB team while you also look for infection.
Do not rely on oral baclofen to treat intrathecal withdrawal.
Oral baclofen alone does not reliably halt the syndrome. Benzodiazepines bridge the gap and restoration of intrathecal delivery is definitive.
Do not trust the pump display to exclude a problem.
A catheter break, kink or disconnection stops drug reaching the CSF even when the pump reports normal delivery. The device and catheter must be interrogated by the pump team.
Do not manage overdose without securing the airway.
Intrathecal baclofen overdose causes progressive drowsiness and respiratory depression; the patient may need intubation and ventilation. There is no reliable baclofen antidote - support is the mainstay (naloxone is for an opioid pump).

Who owns it

The intrathecal pump / spasticity (or pain) service owns the device - frequently a regional centre. Tell them the drug and concentration, the last refill/interrogation, the pump model, the clinical picture (withdrawal vs overdose), and what you have given. Involve critical care early for airway or haemodynamic compromise.

Who to call

The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.

Say the device name first
Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
Say what you have already established
Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
Ask who owns it out of hours
Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
The patient's own team is a resource, not an afterthought
Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.

When the device is not the problem

A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.

The NTSP says it out loud
The project's own manual warns that patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy. The same sentence applies to every device in this tool.
Clear the device, then leave it
Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
The anchoring runs both ways
The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.

What the patient will be carrying

Pump patients and carers usually carry a device card naming the drug, dose, pump model, refill date and the implanting centre's emergency number, and are often expert in recognising early withdrawal.

Scope of this page

This page covers recognising and starting emergency treatment of intrathecal pump problems in the ED: abrupt baclofen withdrawal (the sepsis mimic), overdose, catheter/pump failure and seizures. It does not teach pump interrogation, refilling, reprogramming or catheter studies (the pump team's role), nor the full critical-care regimen. A programmable pump can also be affected by MRI, which must be cleared and re-checked with the pump team. Intrathecal pumps are used in adults and children; paediatric care is directed by the child's spasticity/pump team.

Sources