A novel cause of intrathecal baclofen overdosage: lessons to be learnt.
METHODS
A serious intrathecal baclofen overdose occurred in a 45-year-old woman with primary progressive multiple sclerosis following a catheter dye study with concomitant change in baclofen concentration. The pump and catheter were emptied of baclofen 2000 microg/mL, refilled and primed with baclofen 1000 microg/mL. No correction was made for the ;dead space' between the reservoir and catheter access port, which contained baclofen 2000 microg/mL. Failure of the priming bolus to account for the residual baclofen concentration within the dead space resulted in a serious overdose.Action: Amendments are being made to both our local and the Medtronic protocols.


CONCLUSIONS
We hope that by reporting this incident the risk of this potentially fatal error re-occurring is minimized.
Dalton
Catherine
C
National Hospital for Neurology and Neurosurgery, London, UK. Catherine.dalton@uclh.nhs.uk
Keenan
Elizabeth
E
Stevenson
Val
V
D001418:Baclofen / Q000008:administration & dosage / Q000506:poisoning*; D062787:Drug Overdose; D004360:Drug Therapy, Computer-Assisted; D005260:Female; D018755:GABA Agonists / Q000008:administration & dosage / Q000506:poisoning*; D006801:Humans; D015918:Infusion Pumps, Implantable / Q000009:adverse effects*; D007278:Injections, Spinal / Q000009:adverse effects* / Q000295:instrumentation; D008508:Medication Errors / Q000295:instrumentation*; D008875:Middle Aged
D018755:GABA Agonists; D001418:Baclofen