Ukuhoxiswa kwePump ye-Intrathecal yeBaclofen vs Overdose: Ukurhawuzelela, ukuBuyela kwakhona kweSpasticity, kunye neHyperthermia¶

Ipompo ye-baclofen (i-ITB) efakwe kwi-intrathecal (efana ne-Medtronic SynchroMed II okanye inkqubo ye-SynchroMed III) ihambisa iidosi ze-microgram ze-baclofen yamanzi ngokuthe ngqo kwi-cerebrospinal fluid (CSF) ejikeleze intambo yomgogodla ukulawula i-spasticity enzima kwi-cerebral palsy, i-multiple sclerosis, ukulimala komgogodla, ukulimala komgogodla, ukulimala komgogodla. Ngenxa yokuba ukuhanjiswa kwe-intrathecal kugxininise iyeza kwi-spinal GABA-B i-receptors ngamaxesha e-100 amandla eepilisi eziginyiweyo, nakuphi na ukuphazamiseka ngokukhawuleza kwempompo (ukusuka kwindawo engenanto, ukutyunjwa okuphosiweyo, ukutyunjwa kwe-refill, i-stalled rotor, ibhetri ephelile, okanye i-kinked / disconnected spinal catheter) ibangela ukuba i-syndrome ye-baclofe* i-acute ihoxiswe kwiiyure ze-2. Ngakolunye uhlangothi, impazamo yeprogram okanye i-pocket injection ngexesha lokuzaliswa kwakhona kunokubangela ** i-acute intrathecal baclofen overdose **, ekhokelela ekunyukeni kwe-flaccidity, ukubanjwa kokuphefumula, kunye ne-coma. Ukuba isigulana esifakwe impompo ye-baclofen efakelweyo senza ukurhawuzelelwa komzimba wonke okungachazwanga, ukuqina kwezihlunu ezinobundlobongela, umkhuhlane ophezulu, okanye ukozela okungaqhelekanga, fowunela indawo ohlala kuyo. amanani kaxakeka ngoko nangoko. Malunga neemeko ezingxamisekileyo ze-neurological and thermal, qhagamshelana i-serotonin syndrome kunye ne-neuroleptic malignant syndrome, i-autonomic dysreflexia kukulimala kwentambo yomgogodla, kwaye ukwenzakala okukhulu kwezintso kunye nerhabdomyolysis.

Ukuhoxiswa kwe-acute intrathecal baclofen kudla ngokungahambi kakuhle kumasebe angxamisekileyo njenge-bacterial meningitis, sepsis, neuroleptic malignant syndrome, okanye i-autonomic dysreflexia. Ukuqaphela isibonakaliso sokuqala sesilumkiso sokuqala (** ukurhawuzelela okugqithisileyo ngaphandle kwerhashalala **), ukumamela i-alamu ye-acoustic alarm yangaphakathi yempompo, ukunika i-baclofen yomlomo kunye ne-benzodiazepines ukuba isigulane sinokuginya ngokukhuselekileyo, kunye nokubalekela esibhedlele esikwazi ukuxilonga impompo ngokukhawuleza kunye nokubuyiselwa kwe-CSF ye-lumbar kusindisa ubomi.

Yenza oku ngoku¶

1. Fowunela inombolo yakho yexesha likaxakeka ngokukhawuleza. Cofa u-911 eUnited States naseKhanada, 112 kulo lonke elase-European Union, 999 e-United Kingdom, 000 e-Australia, okanye ujonge uluhlu lwethu lweenkcukacha amanani kaxakeka. Tshela i-dispatcher ngokucacileyo: * "I-intrathecal baclofen pump engxamisekileyo efakwe kwi-intrathecal: ukurhanelwa ukuhoxiswa kwe-baclofen ebukhali (okanye i-overdose) efuna ukuthuthwa esibhedlele ngokukhawuleza."*
2. Qinisekisa ngokukhawuleza ukuba isigulana SOKUNXA (riqinile, ukuxhuzula, ukutshisa, ukurhawuzelelwa) okanye UKUGQIBELA (ukuqhwalela, ukozela, ukuphefumla kancinci, ukubanda).
3. Iimpawu zokurhoxa: Ukurhawuzelelwa ngumzimba wonke (pruritus) kunye nokungabikho kwerhashalala kulusu, ukubuya kwerhashalala ezindlongondlongo zezihlunu kunye nokuqina okufana nebhodi, i-goosebumps, intliziyo ebalekayo, uxinzelelo lwegazi oluphezulu, ukungcangcazela okanye ukubona izinto ezingekhoyo, kunye nomkhuhlane onyuka ngokukhawuleza (odla ngokugqitha kuma-40 ukuya kuma-41 ngokukaCelsius [104 ukuya kwi-105.8 ngokukaFahrenheit]).
4. Iimpawu zokusebenzisa idosi egqithisileyo: Ukozela okugqithisileyo (somnolence) uqhubela phambili ukuya kwikoma, izihlunu zefloppy "rag-doll" (flaccid hypotonia), ukulahleka kwe-tendon reflexes, intetho engacacanga, ukuntywila, ukuphefumla kancinci (respiratory depression), uxinzelelo lwegazi oluphantsi, kunye nokubetha kwentliziyo kancinane.
5. Ukuba isigulana sikwi-HOXA kwaye sivukile ngokupheleleyo kwaye siyakwazi ukuginya ngokukhuselekileyo, sinike idosi yabo emiselweyo yomlomo yongxamiseko ye-baclofen yokuhlangula (kunye ne-diazepam/lorazepam emiselweyo) ngokukhawuleza. Ungaze unike nantoni na ngomlomo ukuba isigulana siyozela, sibambe ngokukhutheleyo, okanye sinemibhobho yokuginya. Ngelixa i-baclofen yomlomo yodwa ** ayikwazi ** ukuyeka ngokupheleleyo ukuhoxiswa okukhulu kwe-intrathecal ngenxa yokuba iwela umqobo wegazi-ingqondo ngokukhawuleza, inika umthamo womlomo ophezulu ngokukhawuleza kunye ne-benzodiazepine emiselweyo.diazepam okanye lorazepam) uthenga ixesha elibalulekileyo ngelixa uthutha esibhedlele.
6. Ukuba isigulana sinomkhuhlane omkhulu kunye nezihlunu ezinobundlobongela (Ukurhoxa), qalisa ukupholisa ngaphandle kwaye uzikhusele ekwenzakaleni. Khulula iingubo kunye nempahla enzima, thambisa iipakethi zomkhenkce ezisongelwe ngeetawuli ezifumileyo entanyeni, emakhwapheni, nakwithanga, ulusu olumanziswe yifeni, kunye nesitulo esinamavili esinamavili okanye iintsimbi zebhedi zingabangeli ubundlobongela okanye iintsimbi zebhedi. irhabdomyolysis. **Ungaze usithintele ngokwasemzimbeni isigulana esine-spasticity ephindiweyo ephindiweyo **, njengoko ukulwa ngokuchasene nezithintelo kukhawulezisa ukuphuka kwemisipha kunye ne-hyperthermia.
7. Ukuba isigulana sikwi-OVERDOSE (siyaqhwalela, singavuki, okanye siphefumla kancinane), sixhase indlela yaso yokuphefumla kwaye silungiselele ukuphefumla ukusihlangula. Gingqela isigulana esingekho zingqondweni kwicala laso xa sichachayo ukuze sithintele ukuminxeka ngamathe okanye ukuhlanza, tyekisa intloko ngobunono ukuze ugcine umzila womoya uvulekile, kwaye uqalise ukuhlangula ukuphefumla okanye ukuphefumla. CPR yabantu abadala ukuba ukuphefumla kuyeka okanye kwehla ngaphantsi kwe-8 yokuphefumla ngomzuzu.
8. ** Fumana iKhadi lokuSazisela iSixhobo esiFakelweyo sesigulane kwaye uzise umdwelisi wesigulane wangaphandle (ukuba wabelwe) esibhedlele.** Oogqirha bexesha likaxakeka kunye nee-neurosurgeons kufuneka bazi imodeli yempompo echanekileyo (ngokuqhelekileyo i-Medtronic SynchroMed II okanye i-III efakwe phantsi kwesikhumba sesisu), ukuxinwa kweziyobisi ngaphakathi kwendawo yokugcina amanzi (umzekelo, i-2cg / 50mL. idosi yemihla ngemihla, kunye nomhla wokuzaliswa kwakhona kokugqibela.

Umthi wesigqibo: i-intrathecal baclofen pump emergency triage¶

flowchart TD
    A["Isigulana esinePump ye-Intrathecal Baclofen (ITB) eFakelweyo"] --> B{"Jonga ithoni yezihlunu, ukuphaphama, kunye ne-alam yempompo"}
    B -->|"Ukurhawuzelelwa ngaphandle kwerhashalala, ukuqaqanjelwa okuqinileyo, umkhuhlane, i-tachycardia, okanye i-alarm beeping"| C["ACUTE ITB WITHDRAWAL SYNDROME (Ukuhanjiswa ngaphantsi / ukusilela kweCatheter)"]
    C --> D{"Ngaba isigulana sithe qwa yaye siyakwazi ukuginya ngokukhuselekileyo?"}
    D -->|"Ewe"| E["Nika i-baclofen yomlomo yokuhlangula emiselweyo + ngomlomo/i-rectal benzodiazepine ngoko nangoko"]
    D -->|"Hayi (ukozela, ukubamba, okanye ukuminxa)"| F["Gcina ngokungqongqo iNPO; nika i-rectal/intranasal rescue benzodiazepine ukuba iyalelwe"]
    E --> G["Isigulane esipholileyo ngokusebenzayo kunye neepakethe ze-ice entanyeni / i-axillae / i-groin kwaye ubize i-EMS ngoku"]
    F --> G
    B -->|"Izihlunu ezithambileyo/eziqhwalelayo, ukozela kakhulu, ukuphefumla kancinci, okanye ukuwa emva kokuzaliswa kwakhona"| H["I-ACUTE ITB OVERDOSE (Ukuzaliswa kwepokotho, impazamo yokucwangcisa, okanye i-bolus)"]
    H --> I["Vula indlela yomoya, beka kwindawo yokuchacha esecaleni, jonga ukuphefumla ngokusondeleyo"]
    I --> J["Qala ukuphefumla ukuhlangula/CPR ukuba ukuphefumla kuyacotha okanye kuyeka; fowunela EMS ngoko nangoko"]
    B -->|"Ububomvu, ukudumba, isingxobo solwelo, okanye ubofu phezu kwempompo yesisu okanye ukusika umva"| K["I-POKETHI YE-PUMP OKANYE I-CSF HYGROMA: UNGAnqweneli ekhaya; yiya kuER"]

Indlela inkqubo ye-baclofen ye-intrathecal isebenza ngayo kwaye kutheni ingaphumeleli¶

Inkqubo ye-baclofen ye-intrathecal inamacandelo amabini ahlonyelweyo:

1. Impompo yempompo disk ekwaziyo ukucwangciswa: Indawo engqukuva yehoki-puck enobungakanani bereservoir kunye nepompo yeperistaltic esebenza ngebhetri (malunga ne-8.5 yeesentimitha [3.3 intshi] ububanzi kunye neesentimitha ezi-2 [0.8 i-intshi] ubukhulu) efakwe ngotyando phantsi kwamafutha angaphantsi kwesikhumba emazantsi esisu. Umbindi wempompo unerabha ye-silicone yokuzitywina i-reservoir refill septum, kwaye isiphelo sempompo sinencinci i-catheter access port (CAP) ekhokelela ngqo kwi-catheter yomgogodla edlula indlela yempompo.
2. Icatheter ye-intrathecal: Isilicone ebhityileyo, ebhetyebhetye okanye ityhubhu yepolyurethane eqhagamshelwe ecaleni lempompo ejikela ngaphantsi kwecala elijikeleze icala ukuya kumqolo ongezantsi (lumbar spine), ingena kumjelo womgogodla nge-dura mater, kunye nemisonto ukuya phezulu ngaphakathi kwe-cerebrospinal fluid (subarachnoid space) kwi-thoracic okanye intambo yomgogodla wesibeleko.

Oomatshini abaqhelekileyo oonobangela bokungaphumeleli kwecatheter (kutheni i-70% yokusilela ithule)¶

Ngelixa ikhompyuter yepompo ye-titanium yenzelwe ukuba ihlale iminyaka eyi-6.5 ukuya kwe-7 ngaphambi kokutshintshwa kwebhetri ekhethiweyo, i-catheter ethambileyo yomqolo iphantsi kwamawaka okugoba, ukujija, kunye nokolula amandla ngalo lonke ixesha isigulana sisuka ebhedini ukuya kwisitulo esinamavili, sigoba phambili, okanye sikhula mde ngexesha lokufikisa. Iingxaki zecatheter zoomatshini ziquka:

• I-Catheter kinking okanye i-occlusion: Iigophe ezibukhali apho i-catheter iphuma kwimpompo yesiqhagamshelanisi esingena-sutureless kwisisu okanye apho ijikela kwi-thoracolumbar fascia kumqolo ongezantsi.
• Ukuqhekeka kwecatheter okanye ukucheba: Uxinzelelo lwetyhubhu yecatheter phakathi kweenkqubo ezimbini ze-spinous okanye i-lamina amathambo kumqolo ongezantsi, ukukrazula i-catheter phakathi ukuze iyeza livuze kwizihlunu ze-paraspinal (subcutaneous CSF hygroma).
• Ukukhutshwa kwecatheter / ukufuduka ngaphandle kwendawo yangaphakathi: Incam yecatheter ityibilika ngasemva iphumele kumngxunya we-epidural okanye kwi-subcutaneous tissue, rhoqo emva konyango olunamandla lomzimba, ukuwa kwisitulo esinamavili, utyando lokudityaniswa komnqonqo, okanye ukukhula ngesiquphe komntwana.
• **I-Intrathecal catheter-tip granuloma: ** Ubunzima obuvuthayo be-macrophages kunye nezicubu ezibomvu ezenza ngeenxa zonke kwincam yecatheter ngaphakathi kwi-spinal canal (ixhaphake kakhulu kunye ne-intrathecal morphine okanye iipompo ze-hydromorphone, kodwa ngamanye amaxesha kuxelwe nge-baclofen ephezulu yoxinaniso), ethintela ukusasazeka kweziyobisi kwaye inokubangela ukukhubazeka okanye ukunyanzeliswa komlenze omtsha.

Usulelo lwepokotho yempompo, i-meningitis, kunye nokuvuza kwe-lumbar CSF ("pseudomeningocele")¶

Iimeko ezingxamisekileyo ezimbini kwindawo yotyando zinokuthi zenzeke kwiiveki ezi-2 ukuya kwezisi-8 emva kokufakelwa kwempompo, ukutshintshwa kwebhetri, okanye ukuphinda kufakwe i-percutaneous:

1. Ukosuleleka kwipokotho yepokotho kunye nokunyuka kwemeningitis yebhaktiriya: Ukuba bubomvu, ubushushu, ukudumba, ukubhobhoza kwamanzi, okanye ukubola kwenxeba (imithungo evula ukuveza isinyithi setitanium) kukhula phezu kwepokotho yempompo yesisu okanye umqolo ongezantsi, ibhaktiriya (Staphylococcus aureus okanye iStaphylococcus aureus okanye eStaphylococcus aureus* ngaphandle kwe-epidermicocter ngqo ityhubhu ephumela kulwelo lwe-cerebrospinal fluid, ebangela i-fulminant bacterial meningitis (umkhuhlane, ukuqina kwentamo, i-photophobia, ukudideka) ecaleni kokusilela kwempompo. Ungaze uzame ukukhupha okanye ukukhama ulwelo oluphuma kwipokotho yempompo edumbileyo ekhaya; yiya ngoko nangoko kwigumbi likaxakeka leenkcubeko zegazi, uhlalutyo lwe-CSF, kunye ne-intravenous vancomycin kunye ne-cefepime/ceftriaxone.
2. Ukuvuza kweLumbar CSF kunye ne-subcutaneous hygroma: Ukuba ulwelo lwe-cerebrospinal luphuma lujikeleze indawo yokuhlatywa kwe-dural kumqolo ongezantsi, lunokwenza iqhuqhuva elithambileyo, elinokuvotelwa phantsi kolusu lwangasemva.pseudomeningocele) kwaye kubangele i-classic ** i-post-dural puncture headache ** (intloko ebuhlungu ebuhlungu kakhulu xa ihleli kakuhle kwaye iphucula kwimizuzu elele phantsi ngokupheleleyo, ihamba kunye nesicaphucaphu kunye nokuqina kwentamo).

Umlinganiselo we-100-to-1 wamandla phakathi kwe-intrathecal kunye ne-baclofen yomlomo¶

I-Baclofen yi-analog yesakhiwo ** i-gamma-aminobutyric acid (GABA) **, inkqubo ye-nervous central system ye-primary inhibitory neurotransmitter. Ibophelela ngokukhethekileyo ** i-presynaptic kunye ne-postsynaptic i-GABA-B i-receptors ** kwi-dorsal horn of the spinal cord, ivimbela ukungena kwe-calcium kunye nokuyeka ukukhutshwa kwe-neurotransmitters evuselelayo (i-glutamate kunye ne-aspartate) eqhuba i-spastic muscle contraction.

Xa isigulane siginya iipilisi ze-baclofen zomlomo (ngokuqhelekileyo i-40 ukuya kwi-80 milligrams [40,000 ukuya kwi-80,000 micrograms] ngosuku), iyeza lithatha kakubi kumqobo wegazi-lobuchopho, linike i-concentration encinci ye-CSF ye-lumbar engaphantsi kwe-12 ukuya kwi-nanogram ye-95 ngelixa i-milliter enzima yobuchopho. Ngokwahlukileyo, impompo ye-intrathecal ifaka nje ** i-300 ukuya kwi-800 micrograms ngosuku ** ngokuthe ngqo kwi-CSF ifezekisa i-lumbar spinal concentrations ** ezine ukuya kwishumi eliphindwe kabini** kunamadosi omlomo aphezulu ngelixa usebenzisa i-1 / 100 isamba semilligram.

Ngenxa yokuba ii-receptors ze-GABA-B ze-spinal inhibitory zihlanjwa ngokuqhubekayo kwi-baclofen egxininisiweyo ye-24 iiyure ngosuku, i-spinal neurons iguqulela nge-*-down-regulating (ukususa) i-GABA-B yabo i-receptors ** kunye nokwandisa uvakalelo lwe-excitatory.

Kwenzeka ntoni ngaphakathi kwintambo yomqolo xa ukuhamba kwempompo kuyeka¶

I-biological half-life of baclofen ngaphakathi kwe-cerebrospinal fluid yomntu kuphela ** 1.5 kwiiyure ze-5 **. Xa impompo yomile okanye i-catheter iyakrazula okanye iqhawule:

• Ngaphakathi ** ezi-4 ukuya kwiiyure ze-8 **, amanqanaba e-baclofen e-CSF ehla ukuya kuthi ga kwiqanda.
• Ukuvinjwa kwe-GABA-B inhibition kunye nokungabikho koxinano oluqhelekileyo lwe-receptor, i-spinal cord ye-alpha kunye ne-gamma motor neurons, i-preganglionic neurons enovelwano, kunye ne-pruriceptive (itch) interneurons iqhuma kwi- ** engachaswanga, ukudubula okuqhubekayo okuvuyisayo **.
• Zonke izihlunu zamathambo kwi-trunk kunye neziphelo zitshixa kwi-tetanic contraction, ivelisa ubushushu obukhulu be-metabolic (thermogenesis ngaphezu kwe-41 degrees Celsius [105.8 degrees Fahrenheit]) kunye nokukrazula imicu ye-muscle (**rhabdomyolysis ), ngelixa inkqubo ye-nervous enovelwano ikhukula igazi le-eutorepinephrine * kunye ne-eutorenheit isaqhwithi).

Ukuqaphela izigaba ezine zokurhoxiswa kwe-baclofen ye-intrathecal¶

Ukuhoxiswa kwe-Intrathecal baclofen kulandela ixesha eliqikelelwayo, elikhula ngokukhawuleza. Ukuqaphela iNqanaba loku-1 ngaphambi kokuba umkhuhlane kunye nokusilela kwamalungu kuqale kubalulekile.

Inqanaba loku-1: Iprodrome yokuqala (iiyure ezi-6 ukuya kwezi-18 emva kokuphazamiseka kokuhamba)¶

• **Ukurhawuzelelwa okugqithisileyo, okuqhelekileyo (neuropathic pruritus) NGAPHANDLE kokubonakala kwesikhumba esibonakalayo, i-hives, okanye ubomvu: ** Le yeyona nto ibonakaliswe kakhulu yokuqala yokuhoxiswa kwe-baclofen ye-intrathecal, eyenzeka kwi-40 ukuya kwi-70 ipesenti yezigulane ngenxa yokuba i-receptors ye-spinal GABA-B ngokuqhelekileyo inqanda i-dorsal-horn itch pathways (GRP / Bhlhb5 interneurons). Iintsapho kunye noogqirha bokhathalelo olungxamisekileyo bahlala beyiphutha le nto ngenxa yokungaphenduli kwaye banike i-antihistamines (diphenhydramine), engenzi nto kwaye ibangele i-delirium.
• Ukubuya kwe-baseline spasticity kunye nokuqina kwezihlunu: Imilenze, iingalo, okanye umboko wesigulana uziva uqina xa ufuduswa okanye unxitywa, uhamba nokuqaqanjelwa rhoqo, i-ankle clonus (ukubetha kweenyawo okunesingqi), kunye nokuxhalaba okungaphumliyo okanye ukuphuthelwa.
• I-Dysesthesia kunye ne-paresthesia: Ukutshotshozela, ukutshisa, okanye "izikhonkwane kunye neenaliti" ukuva eluswini, ukubila (diaphoresis) kunye ne-goosebumps (piloerection).

Inqanaba lesi-2: I-Acute rebound spasticity kunye nesaqhwithi esizimelayo (iiyure ezili-18 ukuya kwezingama-36)¶

• ** Ubundlobongela, ubuhlungu, ukuxhatshazwa kwemisipha eqhubekayo kunye nokuqina: ** I-opisthotonus enzima (i-arching of the back and neck), amadolo avaliweyo kunye nezinqe, kunye ne-rhythmic rhythmic myoclonic jerking of the end.
• Ukungazinzi kwe-Hyperadrenergic autonomic: Ukuphumla kwesantya sentliziyo phakathi kwe--120 kunye ne-170 ukubetha ngomzuzu, ujingi-jikelele kuxinzelelo lwegazi (uxinzelelo lwegazi olumandla olutshintshana ne-hypotension), ukuphefumla ngokukhawuleza (tachypnea), kunye nokubila kumanzi.
• I-core fever eyandayo: Ubushushu bomzimba bunyuka budlule 38.5 ukuya kuma-40.0 degrees celcius (101.3 ukuya kwi-104.0 degrees Fahrenheit) - buqhutywa ngokupheleleyo kukufinyela kwemisipha okungapheliyo kunye ne-hypothalamic dysregulation, hayi usulelo.
• Utshintsho lwengqondo nolwengqondo: Ukuphazamiseka okumandla, i-paranoia, iimbono ezibonwayo neziviwayo, ukuphambana, kunye ne-delirium.

Inqanaba lesi-3: I-Fulminant hyperthermia, isimo se-epilepticus, kunye ne-rhabdomyolysis (iiyure ezingama-36 ukuya kwii-72)¶

• I-hyperpyrexia egqithisileyo: Ubushushu obuphambili budlula 40.5 ukuya ku-42.0 degrees celcius (104.9 ukuya kwi-107.6 degrees Fahrenheit), bukhupha ii-enzyme zeseli kwingqondo yonke, isibindi, kunye nentliziyo.
• I-tonic-clonic seizures ngokubanzi kunye ne-refractory status epilepticus: Ukuhoxiswa kwe-Cortical GABA-B kubangela ukuxhuzula okuqhubekayo okungayekiyo ngaphandle kwe-benzodiazepines ye-intravenous ephezulu, i-propofol, okanye i-barbiturates.
• I-rhabdomyolysis enkulu kunye nomchamo omnyama "we-Coca-Cola": Ukophuka kwezihlunu kukhupha ubuninzi be-creatine kinase (amanqanaba eCK ahlala egqitha kwi-10,000 ukuya kwi-100,000 U/L), i-myoglobin, i-potassium, kunye ne-phosphate egazini, iplaga i-tubules yezintso kunye ne-triggering hyperthrethmiaac*life.

Inqanaba lesi-4: Ukungaphumeleli kwamalungu amaninzi kunye nokuwa kwe-cardiovascular¶

• **I-Coagulation ye-Intravascular Coagulation (DIC) esasazwayo: ** I-clotting ye-systemic engalawulwayo kunye nokuphuma kwegazi okuzenzekelayo kwiintsini, kwiindawo ze-IV, kunye ne-gastrointestinal tract.
• Acute hepatic failure, acute kidney injury, ARDS, kunye nokothuka kwentliziyo.

Ukuqonda iMedtronic SynchroMed impompo evakalayo ialam¶

Implanted Medtronic SynchroMed II kunye ne-III impompo zepompo ziqulathe i-piezoelectric acoustic transducer ekhupha iibeep ezivakalayo onokuthi uve xa umi kufutshane nesigulana okanye ubeka indlebe yakho kufutshane nesisu saso:

Ukwahlula ukurhoxiswa kwe-ITB kwiimeko ezingxamisekileyo¶

Ngenxa yokuba izigulane ezine-cerebral palsy, i-spinal cord, okanye i-multiple sclerosis nazo zixhomekeke kwi-urinary tract sepsis, i-ventriculoperitoneal (VP) shunt infections, i-autonomic dysreflexia, kunye nokuphendula amayeza, oogqirha bexesha likaxakeka basebenzisa ezi mpawu zilandelayo zeklinikhi ukwahlula ukuhoxiswa kwe-baclofen ebukhali:

I-acute intrathecal baclofen overdose: "i-pocket igcwalisa" kunye neempazamo zeprogram¶

Ngelixa ingaqhelekanga kunokurhoxiswa, ** i-acute intrathecal baclofen overdose ** yindlela yomoya ekhawulezayo kunye nokuphefumula okungxamisekileyo. Ukugqithisa ngokweqile kwenzeka kwiindawo ezimbini eziphambili:

1. ** I-Accidental Subcutaneous "I-Pocket Fill" ngexesha lokuzaliswa kwempompo yesiqhelo (Ininzi Yengozi): ** Xa ugqirha egcwalisa impompo rhoqo emva kweenyanga ezi-2 ukuya kwezi-6, afaka inaliti ngesikhumba sesisu kwi-septum ye-silicone ephakathi ukujova i-baclofen egxininisiweyo (enokuthi iqulethe ** i-10,000 ye-micrograms * 200m ye-microgram ye-4-4 ye-microgram ye-4. isirinji - ukuya kumaxesha angama-50 idosi ebulalayo ye-intrathecal). Ukuba inaliti iyatyibilika okanye iphosa i-septum nokuba incinci, inxalenye yaloo thamo inkulu itofwa ngokuthe ngqo kwipokotho yamafutha angaphantsi kwecutaneous ejikeleze impompo. Kwixesha elilandelayo ** i-30 imizuzu ukuya kwiiyure ze-4 **, i-baclofen egxininisiweyo ithatha ngokukhawuleza kwi-systemic bloodstream, ibangela ukugqithiswa kobomi ngokukhawuleza (okulandelwa iintsuku ezixubileyo kamva ** ukuhoxiswa okukhulu ** ngenxa yokuba i-pump reservoir ngokwayo ishiywe ingenanto).
2. Impazamo yocwangciso okanye i-concentration-mismatch: Ukucwangcisa i-2,000 mcg/mL yogxininiso lokuzalisa kwakhona ngokungathi yi-500 mcg/mL, okanye ukubala kakubi i-catheter priming bolus emva kohlaziyo lotyando.

Iimpawu ze-acute baclofen overdose (ukunyuka kwe-rostral progression)¶

Njengoko i-baclofen engaphezulu isasazeka phezulu (rostrally) ukusuka kwi-CSF ye-lumbar ukuya kwi-brainstem kunye ne-cerebral cortex:

• Imizuzu yokuqala engama-30 ukuya kwengama-90: Ukunyamalala ngequbuliso kuyo yonke ithowuni yesiqhelo yomlenze kunye nesiqu (**i-flaccidity enzulu / hypotonia **), isiyezi, intloko ebuhlungu, isicaphucaphu, kunye nokuvuza okugqithisileyo (*sialorrhea).
• Iyure ezi-1 ukuya kwezi-4: Ukozela okugqithisileyo (somnolence), intetho engacacanga (dysarthriaIntliziyo ecothayo, i-ataxia, hypothermia,bradycardia) kunye noxinzelelo lwegazi oluphantsi (hypotension).
• Ityhefu eqatha: Ubunzulu obungavukiyo **ikoma **, ukulahleka kwe-pupillary light reflexes kunye ne-corneal reflexes (ukulinganisa ukufa kobuchopho), ukuxhuzula okuqhelekileyo (okubangelwa yi-presynaptic GABA-B autoreceptor disinhibition kwi-cortex), kunye ** ukubanjwa kokuphefumla / ukuphefumla **.

Ulawulo olungxamisekileyo lwe-baclofen overdose¶

1. ** Umoya kunye nokuphefumla kuza kuqala: ** Akukho ** akukho nto inokuthenjwa ngokupheleleyo ye-receptor-antagonist antidote ** ye-baclofen overdose (i-physostigmine yayizanywa ngokwembali kunye neziphumo ezingahambelaniyo kunye nemiphumo eyingozi ye-cholinergic efana ne-bradycardia, i-bronchospasm, kunye nokuhlutha; i-flumazenil ayiguquli i-GABA-B i-receptors). Nangona kunjalo, ngokukhawuleza ** i-bag-mask ventilation kunye ne-endotracheal intubation **, ukusinda kwi-baclofen overdose enkulu kusondela kwiipesenti ze-100 emva kokuba iyeza licinywe ngaphezu kwe-24 kwiiyure ze-72.
2. Ukumisa impompo engxamisekileyo esibhedlele kunye ne-CSF drainage: Kwigumbi likaxakeka, oogqirha baxilonge ngokukhawuleza impompo ukuze ** bayeke ukunyuswa (okanye babeke kwinqanaba elincinci)**, bafune ichiza ngaphandle kwempompo yempompo (kwaye ufune nayiphi na iqoqo lolwelo kwipokotho engaphantsi kwe-subcutaneous ukuba kuzaliswa ipokotho), kwaye wenze **i-lumbar puncture nge-Caspiter ye-Aspiter0 ecaleni (okanye i-aspirate ye-3) I-40 mL ye-baclofen-laden cerebrospinal fluid ** (ngamanye amaxesha itshintshisa nge-saline eqhelekileyo engenazintsholongwane).

Izibhedlele zikuphatha njani ukurhoxiswa kwe-ITB xa ufika¶

Ukwazi ukuba isebe likaxakeka kufuneka lenze ntoni kunceda abakhathaleli ukuba bathethe ngokucacileyo kwisigulane xa befika kwisibhedlele soluntu apho abasebenzi banokuthi bangabonakali iimpompo ze-intrathecal:

1. Idosi ephezulu ekhawulezayo ye-GABA-A kunye ne-GABA-B agonism:
2. Ngenxa yokuba i-baclofen yomlomo ayikwazi ukufikelela kwintambo yomgogodla ngokukhawuleza ngokwaneleyo ukuhoxiswa okukhulu, oogqirha bexakeka ngokukhawuleza balawula ** i-benzodiazepines ye-intravenous (lorazepam okanye diazepam I-IV boluses kunye ne-infusions eqhubekayo) **, eyenza ** i-GABA-A i-receptors ** phantsi kwintambo yomgogodla kunye nengqondo, idlula indlela ye-GABA-B engenanto yokuyeka ukuxhuzula, ukukhulula i-tetanic muscle spasms, kunye nokumisa i-hyperthermia.
3. Ukuba isigulane sisakwazi ukuthatha amayeza ngomlomo, i-tube ye-nasogastric, okanye i-gastrostomy (PEG) ityhubhu, i-dose ephezulu ** i-enteral baclofen ** (ngokuqhelekileyo i-10 ukuya kwi-20 mg nganye kwiiyure ze-4 ukuya kwiiyure ze-6) iqaliswe ngaxeshanye, idla ngokuncediswa ngomlomo ** cyproheptadine ** (4 ukuya kwi-8 mgnt nganye, i-6 iiyure ze-6 kunye ne-serotonin i-serotonin i-myoclonus ye-baclofen ukuhoxiswa) okanye **dexmedetomidine / propofol ** infusions kwiyunithi yokunyamekela kakhulu.
4. ** I-Dantrone sodium ** (IV) ingasetyenziselwa njenge-adjunct kwi-rigidity ye-skeletal muscle esongela ubomi kunye ne-hyperthermia ukuba i-benzodiazepines ayanelanga, nangona ukubuyiselwa kwe-GABAergic kuhlala kunyango oluphambili.
5. Ukubuyiselwa ngokukhawuleza kwe-intrathecal baclofen delivery:
6. Ukuba indawo yempompo ihambe ingenanto okanye ime emva kwe-MRI: Ugqirha wotyando, ugqirha wotyando (PM&R specialist), okanye umenzi oqeqeshiweyo oyingcali yezonyango ugocagoca impompo ngewand ye-telemetry kwaye iphinde izalise kwakhona i-motor esecaleni kwebhedi okanye iphinde iqalise injini.
7. ** Ukuba i-catheter i-kinked, ikhutshwe, okanye iphukile kwaye utyando lubambezelekile: ** Ugqirha unokwenza i-bedside ** i-single-shot lumbar puncture injection ye-baclofen ye-preservative-free intrathecal baclofen (ngokuqhelekileyo i-50 ukuya kwii-microgram ze-100) ** okanye ubeke isigxina sesikhashana sangaphandle se-lumbar intrathergic suminant de catheter ukurhoxiswa ngokukhawuleza.
8. Aggressive IV hydration for rhabdomyolysis: Isotonic intravenous fluids (0.9% normal saline) zifakwe ngokukhawuleza ukugcina ukukhutshwa komchamo ophezulu kunye nokukhupha i-myoglobin ngaphandle kwezintso, ngelixa ubeka iliso kwi-serum potassium, i-creatine kinase (CK), kunye neepaneli ze-coagulation nganye kwii-4 kwiiyure ze-6.

Iinombolo zengingqi zikaxakeka kunye neeprothokholi ze-arhente¶

• I-United States neKhanada: Fowunela 911. The US Food and Drug Administration (FDA) Black Box Isilumkiso nge-intrathecal baclofen (Lioresal Intrathecal / Gablofen) ugunyazisa ukulaliswa ngokukhawuleza esibhedlele ngenxa yokuhoxiswa okukrokrelwayo, ukugqamisa ukuba i-baclofen yomlomo yodwa ayikwazi ukuthintela ngokuthembekileyo ukuqhubela phambili kwi-rhabdomyolysis, ukungaphumeleli kwamalungu amaninzi kunye nokufa. Oogqirha banokuqhagamshelana ** ne-24 yeyure ye-Medtronic Technical Services Emergency Line (1-800-707-0933 e-US) ** ukukhupha iphepha lenjineli yeklinikhi yendawo kunye nethebhulethi yomdwelisi kwisebe likaxakeka.
• United Kingdom: Fowunela 999. I-NHS yaseNgilani i-Clinical Commissioning Policy ye-Intrathecal Baclofen Therapy kunye ne-NICE Spasticity Guidelines ngqo ukudluliselwa ngokukhawuleza kwi-neurosciences yengingqi okanye kwiziko lokulimala komgogodla, i-IV benzodiazepine titration, kunye ne-interrogation yepompo ephuthumayo.
• ** IManyano yaseYurophu:** Fowunela 112. I-European Academy of Neurology (EAN) kunye ne-European Medicines Agency (EMA) iiprothokholi zigxininisa i-benzodiazepines ye-IV ephezulu, ukupholisa kwangaphandle okusebenzayo, kunye ne-boluses yokuhlangula ye-intrathecal engxamisekileyo nge-lumbar puncture xa ukungaphumeleli kwe-catheter yepompo kubangela ukuhoxiswa okukhulu.
• Ostreliya neNew Zealand: Fowunela 000 e-Australia okanye 111 eNew Zealand. Ulawulo lweeMpahla zoNyango (TGA) kunye ne-ANZCA izilumkiso zokhuseleko lwe-neuromodulation zigunyazisa uvandlakanyo olukhawulezileyo lwesibhedlele kuyo nayiphi na i-alamu yempompo enethoni ezimbini okanye i-pruritus/hypertonia engachazwanga.
• ** I-Indiya kunye ne-Asia-Pacific: ** Fowunela ** 112 ** eIndiya, ** 995 ** eSingapore, ** 119 ** eJapan naseMzantsi Korea, okanye ** 999 ** eMalaysia naseHong Kong. Ngokwamanye amazwe, jonga uluhlu lwethu lwe iinombolo zikaxakeka zamazwe ngamazwe.

Imibuzo edla ngokubuzwa¶

Kutheni ukurhoxa kwe-intrathecal baclofen kubangela ukurhawuzelelwa ngumzimba wonke ngaphandle kwerhashalala?¶

Kwi-dorsal horn ye-spinal cord yomntu, i-interneurons ekhethekileyo yokuthintela isebenzisa i-GABA-B receptors ukugcina i-itch-signaling nerve pathways ithule phantsi kweemeko eziqhelekileyo. Xa isigulane sifumana i-baclofen ye-intrathecal eqhubekayo kwiinyanga okanye iminyaka kwaye ukuhamba kuyeka ngokukhawuleza, ezo receptor zomgogodla we-GABA-B zishiywe zingashukunyiswa ngokupheleleyo, ezibangela ukuba i-spinal itch neurons ivuthe ngokuzenzekelayo kwaye ingayeki. Ngenxa yokuba oku kurhawuzelelwa kuqala ngaphakathi kwintambo yomgogodla kunokuba kukhululwe i-histamine eluswini, akukho mingxunya okanye bubomvu, kwaye i-antihistamines efana ne-diphenhydramine (Benadryl) ayisebenzi.

Ngaba ndinganika iipilisi zomlomo ezongezelelweyo ze-baclofen ekhaya ukuba impompo ye-baclofen yomntwana wam iqala ukukhala okanye iyaphela?¶

Ukuba isigulana sivukile ngokupheleleyo kwaye siyakwazi ukuginya ngokukhuselekileyo, kufuneka unike idosi emiselweyo yohlangulo olungxamisekileyo lwe-baclofen yomlomo ngoko nangoko, kodwa kusafuneka uye ngqo kwisebe likaxakeka. I-baclofen eginyiweyo inqumla umqobo wegazi-ingqondo kakubi kakhulu, ifikelela ngaphantsi kwekhulu le-concentration ye-spinal fluid nge-milligram nganye xa kuthelekiswa nokufakwa kwe-intrathecal. Ukuxhomekeka kwiipilisi ze-baclofen zomlomo wedwa ekhaya kuye kwabangela ukufa okubhaliweyo okubhaliweyo ngenxa yokubanjelwa kwe-refractory, i-41 C (106 F) i-hyperthermia, kunye nokungaphumeleli kwamalungu amaninzi.

Ukuba impompo ye-baclofen AYIKHO i-beep, ngaba oko kubonisa ukuba isigulane asikho ekuhoxisweni kwe-baclofen?¶

Akukho ngaphezu kweepesenti ze-70 zeemeko ezisongela ubomi ze-baclofen zokuhoxiswa kwe-intrathecal zenzeka ngaphandle kwe-alarm evakalayo evela kumpompo. Ikhomputha yangaphakathi yempompo iyazi kuphela ukuba ibhetri inamandla, nokuba i-timer ye-reservoir ithi i-fluid ihleli, nokuba i-motor rotor iyajika; ayinanzwa ngaphakathi kwityhubhu yecatheter eguquguqukayo eya kumqolo. Ukuba i-catheter iyakrazula, iqhekeze, iqhawule kumbhobho wempompo, okanye iphume kumjelo womqolo ukuya kumanqatha angasemva, impompo iqhubeka incwina ngokuthula ngelixa iyeza eliziro lifikelela kwintambo yomgogodla.

Kutheni oogqirha banika i-lorazepam ene-intravenous okanye i-diazepam (i-Valium) yokuhoxiswa kwe-baclofen xa iziyobisi ezahlukeneyo?¶

I-Baclofen isebenza kwii-receptors ze-GABA-B, eziye zehliswe kakhulu kwaye zingabikho ngexesha lonyango olungapheliyo lwempompo ye-intrathecal. I-Benzodiazepines efana ne-diazepam, i-lorazepam, kunye ne-midazolam ziwela ngokukhawuleza kwinkqubo ye-nervous central xa zinikezelwa nge-intravenously kwaye zivule ii-receptors ze-GABA-A kwi-spinal motor neurons kunye neendlela zobuchopho. Oku kubuyisela i-inhibitory chloride-channel braking kuyo yonke inkqubo ye-nervous ngaphakathi kwemizuzu, ukumisa i-spasms yemisipha enobundlobongela, ukuxhuzula, kunye ne-hyperthermia ngelixa oogqirha belungisa impompo.

Yintoni "i-pocket fill" ngexesha lokuqeshwa kwempompo ye-baclofen, kwaye zeziphi iimpawu ezilumkisayo?¶

Ukuzaliswa kwepokotho kwenzeka xa inaliti yokuzaliswa ngokutsha ityibilika okanye isilela ukungena kwi-silicone septum yempompo, ngengozi igalele iimililitha ze-baclofen yolwelo egxininiswe kakhulu kwizicubu ezithambileyo eziphantsi kwesikhumba sesisu endaweni yetanki ye-titanium. Iimpawu ezilumkisayo ziquka ukudumba okungaqhelekanga okanye ukubetha kwisiza sempompo ngexesha lokuzaliswa kwakhona, kulandelwa phakathi kwemizuzu engama-30 ukuya kwiiyure ze-4 ngokuxinana okunzulu kwemisipha, ukulala kakhulu, ukuthetha okungahambi kakuhle, ukuphefumla okucothayo, kunye ne-coma. Nabani na owozela ngendlela engaqhelekanga okanye aphaphatheke kwiiyure nje ezimbalwa zokuphinda kufakwe impompo udinga i-ambulensi ngoko nangoko.

Imithombo kunye nezikhokelo ezisemthethweni¶

• ** Ulawulo lwe-US lokuTya kunye neDrugs (i-FDA) kunye ne-Medtronic Neuromodulation: ** * Ukuchaza ulwazi kunye ne-Boxed Warning ye-Lioresal Intrathecal / Gablofen (i-Baclofen Injection) kunye ne-SynchroMed II / III IiNkqubo zokuNgeniswa kweNkqubo * (Ukuqaphela kunye nolawulo olungxamisekileyo lwe-intrathecal baclofen-injection kunye nokuhoxiswa kwe-pocketfill ye-intrathecal).
• Ikofu RJ et al. ( Ii-Archives of Physical Medicine and Rehabilitation ): *Ukuhoxiswa ngokukhawuleza kwi-Intrathecal Baclofen: Ukuqatshelwa kunye noLawulo lwe-Syndrome enobungozi boBomi * (I-Pathophysiology ye-spinal GABA-B i-receptor downregulation, i-neuropathic pruritus ngaphandle kwe-rash, i-rhabdom).
• *USaulino M et al. ( I-Neuromodulation: IThekhnoloji kwi-Neural Interface *): ** *Iindlela ezigqwesileyo ze-Intrathecal Baclofen Therapy: Ukuxazulula iingxaki kunye noLawulo lweeNgxaki ze-ITB * (Izikhokelo zePhaneli ye-Consensus malunga nokuxilongwa kokungaphumeleli kwe-catheter, i-Catheter Access Port aspiration, kunye ne-IV benzodiazepine / cyproheptadine).
• ** INkonzo yezeMpilo yeSizwe (i-NHS eNgilani) kunye neZiko leSizwe lezeMpilo kunye noNonophelo oluPhezulu (i-NICE, e-United Kingdom): ** *UMgaqo-nkqubo wokuKhomishina kweKlinikhi: I-Intrathecal Baclofen ye-Spasticity eNcinci kuBantu abadala kunye nabantwana *.
• *Watve SV et al. ( I-Spinal Cord *): ** * Ukulawulwa kwe-Acute Overdose kunye ne-Underdose ye-Intrathecal Baclofen: I-Lumbar Puncture CSF Drainage kunye ne-ICU IiProtocol zeNkxaso zoNyango *.

Izikhokelo ezinxulumeneyo¶

• I-Serotonin syndrome, i-neuroleptic malignant syndrome, kunye nokusebenzisana kweziyobisi
• I-Autonomic dysreflexia kukulimala kwentambo yomgogodla
• I-Status epilepticus, ukuxhuzula ixesha elide, kunye namayeza okuhlangula
• Ukwenzakala okukrakra kwezintso, i-rhabdomyolysis, kunye novavanyo lomchamo omnyama
• Ukusetyenziswa kwe-CPR yabantu abadala kunye ne-AED