ABSTRACT
BACKGROUND: Intrathecal baclofen (ITB) is a proven, effective treatment for refractory spasticity and chronic pain, with applications ranging from spinal cord injury to amyotrophic lateralsclerosis (ALS). Despite its effectiveness, the withdrawal syndrome of intrathecal baclofen can be life-threatening. CASE REPORT: This case describes the treatment of a patient with chronic spasticity related to ALS with an ITB pump infection requiring explant and a prolonged period of antibiotics before reimplantation. A 62-year-old man with ALS-related spasticity maintained on high-dose ITB for 20 years presented to the emergency department with one week of fever, confusion, and localized erythema to the R-side of his abdomen. Laboratories indicated a mild leukocytosis 12.9 K/uL and imaging showed a 2.9-cm fluid collection with fat stranding surrounding the ITB pump. The pack was explanted, and the patient started on intravenous antibiotics. Due to the high baclofen dosage, our pain service recommended PO (per os) baclofen 30 mg every 6 h via gastrostomy and PO diazepam 10 mg every 6 h via gastrostomy. These doses were titrated carefully to avoid oversedation while preventing withdrawal symptoms. On Day 23 postexplant, the patient had the baclofen pump reimplanted and baclofen titrated over three days to his previous dose of ITB. CONCLUSION: This case demonstrates a successful approach to avoiding severe baclofen withdrawal using PO baclofen combined with PO diazepam. The high dose of maintenance ITB (1188.8 mcg/day), the inability to reinsert the patient's intrathecal pump, and the high risk of intubation in a patient with severe neuromuscular dysfunction all made this a challenging case.
Subject(s)
Amyotrophic Lateral Sclerosis , Chronic Pain , Muscle Relaxants, Central , Substance Withdrawal Syndrome , Male , Humans , Middle Aged , Baclofen/therapeutic use , Muscle Relaxants, Central/therapeutic use , Amyotrophic Lateral Sclerosis/complications , Amyotrophic Lateral Sclerosis/drug therapy , Infusion Pumps, Implantable/adverse effects , Muscle Spasticity/drug therapy , Muscle Spasticity/etiology , Diazepam/therapeutic use , Chronic Pain/drug therapy , Injections, SpinalABSTRACT
OBJECTIVES: Since the introduction of point-of-care ultrasound (POCUS) in emergency medicine (EM), the applications, indications, and training for POCUS have grown. POCUS training in EM residency is standard and POCUS fellowships are common. We sought to quantify and characterize changes in POCUS publications over time with a scoping review of the literature METHODS: We conducted a structured keyword search of high impact EM journals according to 2019 journal citation reports and other journals publishing POCUS studies between 2000-2019. Two abstractors recorded whether the publication was POCUS related, the type of publication, and author affiliation by department and country. We included studies with at least one author affiliated with a department of EM. Agreement between abstractors was tested. RESULTS: The number of POCUS-related publications grew from a mean of 8.8 publications/year 2000-2004 to 134.8 publications/year from 2015-2019. The most common publication type was case reports or series (44%). The proportion of publications from outside the United States (US) decreased over time. Between 2000 and 2004 89% of publications came from authors affiliated with US institutions; from 2015-2019 this had decreased to 64%. Agreement between abstractors was excellent (Cohen's k = 0.89) CONCLUSIONS: POCUS publications increased substantially between 2000-2019. The most common type of publication was a case report, which was consistent throughout the study period. Authorship from outside the US increased. Publications yielding high-quality evidence from observational or controlled studies represented a low proportion of the total number of studies.
