In this section
Definition of terms
Assessment-pre pump implantation
Baclofen is a GABA ß-agonist and is thought to diminish spasticity
primarily by acting at a spinal cord level. It has muscle relaxing properties
and is administered to reduce spasticity or dystonia. Patient groups
receiving Intrathecal Baclofen (ITB) may include:
Baclofen can be administered orally or intrathecally. Intrathecal
baclofen (ITB) has a much greater effect with significantly reduced doses as
opposed to oral baclofen that crosses the blood brain barrier poorly.
Long term intrathecal baclofen therapy is administered via a surgically
implanted programmable pump that continuously infuses baclofen into the
intrathecal space. Patients on ITB have reported reduced pain associated
with spasticity, improved positioning, speech, quality of sleep and quality of
The aim of the guideline is to outline the management of the
implantation of an ITB pump, and ongoing care for patients requiring ITB
therapy for all clinicians at RCH.
Signs and Symptoms
Overdose may occur when:
Overdose may appear insidiously or suddenly.
Withdrawal symptoms may be experienced when:
If withdrawal is suspected but observations are within acceptable
limits and the patient is not clinically compromised Contact Developmental Medicine Consultant or Rehabilitation Consultant (depending on patient's primary team) on call, via switch.
May occur due to:
Infection may occur due to:
may occur due to:
Obtain and document a thorough patient history and baseline
Assessment of child with an ITB pump who
presents to emergency
The "Elective Replacement Interval" (ERI) on every pump program report indicates the length, in months, of life left in the ITB pump. This ERI indicates how long is left until the ERI alarm occurs. Once the ERI alarm has occurred there is no guarantee of remaining battery life in the pump; although it may be up to 3 months before the pump expires.
Elective pump replacement is the time to consider continuation of Baclofen therapy. In many instances this is apparent, however in some clinical situations the paediatrician may elect to try withdrawal of Baclofen to help with this decision.
In some centres, it is common practice to trial weaning of ITB therapy
(slow decrease in dose) prior to pump replacement due to ERI. Trial of weaning is
done to assess the ongoing need for ITB therapy. All children who require an
elective pump replacement due to ERI should be considered for weaning of ITB
therapy. Trial of weaning is to be done at the discretion of the ITB
paediatrician managing the child’s care, taking into consideration the opinion
of the family and the child.
When the ERI has 3-6 months remaining (approximately) the consultant paediatrician who manages the child’s ITB therapy makes a written referral to the child’s Neurosurgeon indicating the ERI alarm date. The neurosurgeon will arrange to review the patient, as an outpatient, in a timely manner. If there are any concerns regarding the hardware integrity or the effectiveness of delivery then a discussion between the paediatrician and the surgeon is recommended
Elective pump replacement is also an opportunity to change the intrathecal catheter if this is indicated and or revise pump positioning and or scars. Surgical assessment therefore includes assessment of the catheter position, the pump position and the scars. A pump series of X-rays is recommended as it allows assessment of the implanted hardware and reduces the incidence of surprise findings at replacement. The catheter height may be a point of discussion with the treating paediatrician if there has been significant growth of the child. In patients with the older catheters (radio opaque catheters) an X-ray may show disruptions in the system, however these are frequently occult. It is recommended that at the time of the pump replacement the existing catheter be tested for patency if it is not going to be replaced. As catheter failure and Baclofen withdrawal can be occult, the treating surgeon should discuss with the family and paediatrician how a surprise finding of a non-functioning system would be managed (e.g. explant of system or revision of system and reprogramming to a starting dose). It is the surgeon’s responsibility to organise the X-rays, surgical booking and consent when the child is seen in clinic, and to assess the X-rays pre-operatively. When the patient is booked for theatre the hardware needs to be ordered from Medtronic and the booking discussed with the paediatric team who will need to be available for the re-programming at implantation.
A child with an ITB pump insitu may present to the Emergency department
for a number of reasons, many of those reasons will not be related to ITB therapy.
The following steps are recommended in the initial assessment of the child who
is clinically stable but showing signs of lack of efficacy of intrathecal
When support for Medtronic
Neuromodulation products is required, please follow the instructions below:
Please note: Medtronic Neuromodulation does not provide a 24 hour
support service in Australia
Intrathecal Baclofen Evidence Table
Please remember to read the disclaimer.
development of this nursing guideline was coordinated by Sacha Petersen, Clinical Nurse Consultant, Developmental Medicine,
and approved by the Nursing Clinical Effectiveness Committee. Updated November 2015.