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Prolonged administration of intrathecal baclofen in a patient with generalized grade 4 tetanus
  1. Michael Aiello1,
  2. Sounak Roy1,
  3. Lyndsey Chitty2,
  4. Brittany Johnson3 and
  5. Matthew Warrick1
  1. 1Anesthesiology, University of Florida College of Medicine, Jacksonville, Florida, USA
  2. 2Anesthesiology, UF Health Jacksonville, Jacksonville, Florida, USA
  3. 3Pharmacy, University of Florida Health, Jacksonville, Florida, USA
  1. Correspondence to Dr Sounak Roy, Anesthesiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA; sounakroy96{at}gmail.com

Abstract

Introduction This case report presents the management of a 62-year-old woman with generalized grade 4 tetanus, focusing on the innovative use of intrathecal baclofen (ITB) therapy. The patient initially presented with a laceration and subsequently developed severe tetanic spasms, necessitating interventions beyond standard tetanus immunoglobulin and antibiotics due to the condition’s progressive and life-threatening nature. The preference for ITB over oral baclofen is highlighted, considering ITB’s enhanced bioavailability in the central nervous system and its efficacy in reducing spinal cord reflexes, which is critical for managing severe spasticity.

On her return to the emergency department with symptoms of tetanus, the patient received ITB following the failure of oral baclofen to control the spasms. ITB administration necessitated a lumbar drain, which was later substituted with a tunneled intrathecal catheter due to the extended requirement for baclofen infusion and the unavailability of suitable infusion pumps. This scenario represented a significant application of a CADD-Solis external pump for continuous ITB infusion.

Transitioning the patient from ITB to oral baclofen was a crucial management step to facilitate discharge and recovery, underscoring the importance of a careful approach to prevent withdrawal symptoms and maintain care continuity. Despite initial complications, including an infection signaled by leucocytosis and confirmed through cerebrospinal fluid culture, the patient was effectively treated and discharged.

Conclusion This report contributes to the sparse literature on prolonged ITB use for generalized grade 4 tetanus treatment, underlining the need for interdisciplinary collaboration for the best patient outcomes. It showcases the potential of ITB in spasticity management, in reducing the need for sedation, and in shortening the duration of mechanical ventilation, advocating for a tailored approach that utilizes a full spectrum of pharmacological and supportive therapies.

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Footnotes

  • Contributors MA was instrumental in the hospital-based management of the patient. MA admitted the patient to the ICU as part of the surgery team, went on to manage the remainder of the care as part of the acute pain management team, extracted case data from the Electronic Medical Records (EMR), and delineated the timeline and specifics of the patient’s treatment and outcomes. SR conducted a comprehensive literature review of previous case reports and treatments for grade 4 tetanus. SR was responsible for assembling the manuscript, developing the discussion and conclusion sections, and acted as the primary correspondent for manuscript submission. LC contributed significantly as the nurse practitioner within the acute pain management team, facilitating the patient’s management, ensuring daily follow-ups, and bridging communication between the acute pain service and the pharmacy for effective medication management. BJ, as the pharmacy manager, played a crucial role in managing medication supplies and dosages, particularly overseeing the administration of the intrathecal baclofen pump and the transition to oral medication. MW, the senior faculty member of the acute pain management service, was key in the procedural aspects of care, including the placement and removal of the intrathecal tunneled catheter. MW also provided oversight and guidance in the drafting of the case report.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.