Ukuhoxiswa kwePump ye-Intrathecal Baclofen vs Overdose: Ukulunywa, Ukuqina Kwe-Rebound, kanye ne-Hyperthermia¶

Ipompo ye-intrathecal baclofen (ITB) efakiwe (njenge-Medtronic SynchroMed II noma i-SynchroMed III system) ihambisa imithamo ye-microgram ye-baclofen ye-liquid ngqo ku-cerebrospinal fluid (CSF) ezungeze umgogodla ukuze kulawulwe ukuphefumula okukhulu okuvela ku-cerebral palsy, i-multiple sclerosis, ukulimala komgogodla, ukulimala komgogodla, noma ukulimala komgogodla. Ngenxa yokuthi ukulethwa kwe-intrathecal kugxilisa imithi kuma-receptors e-GABA-B yomgogodla ngezikhathi eziyi-100 amandla amaphilisi agwinywe, noma yikuphi ukuphazamiseka okungazelelwe kokugeleza kwepompo (kusuka endaweni engenalutho, ukuqokwa kokugcwalisa okuphuthelwe, i-pump rotor emisiwe, ibhethri eliphelile, noma i-kinked / i-catheter yomgogodla) kubangela i-baclofe*2 intrathe amahora amaningi. Ngokuphambene, iphutha lokuhlela noma umjovo wephaketheni ngesikhathi sokugcwalisa kungabangela **i-acute intrathecal baclofen overdose **, okuholela ekukhuphukeni kwe-flaccidity, ukuboshwa kokuphefumula, kanye ne-coma. Uma isiguli esinepompo ye-baclofen efakiwe siqala ukulunywa kungazelelwe okungachazeki, ukuqina kwezicubu ezinobudlova, ukushisa okuphezulu, noma ukozela okungavamile, shayela indawo yangakini. izinombolo eziphuthumayo ngokushesha. Ngezimo eziphuthumayo ezihlobene nezinzwa ne-thermal, thintana I-serotonin syndrome kanye ne-neuroleptic malignant syndrome, i-autonomic dysreflexia ekulimaleni komgogodla, futhi ukulimala kwezinso ezinzima kanye ne-rhabdomyolysis.

Ukuhoxiswa kwe-acute intrathecal baclofen kuvame ukutholwa kabi eminyangweni ephuthumayo njenge-bacterial meningitis, sepsis, neuroleptic malignant syndrome, noma i-autonomic dysreflexia. Ukuqaphela uphawu lwesixwayiso sangaphambi kwesikhathi sakudala (**ukulunywa okuvamile okujwayelekile ngaphandle kokuqubuka **), ukulalela ukukhala kwe-alamu yangaphakathi yephampu, ukunikeza i-baclofen yomlomo yokuhlenga kanye ne-benzodiazepines uma isiguli singagwinya ngokuphepha, nokuphuthuma esibhedlela esikwazi ukuphenywa ngephampu eziphuthumayo kanye nokubuyiselwa kwe-CSF ye-lumbar kusindisa izimpilo.

Yenza lokhu manje¶

1. Shayela inombolo yakho yasendaweni yezimo eziphuthumayo ngokushesha. Shayela u-911 e-United States nase-Canada, 112 ku-European Union yonkana, 999 e-United Kingdom, 000 e-Australia, noma uthintane nohlu lwethu lwemibhalo lwe izinombolo eziphuthumayo. Tshela i-dispatcher ngokucacile: "Izimo eziphuthumayo zephampu ye-baclofen efakwe ngaphakathi kwe-intrathecal: ukuhoxiswa kwe-baclofen okunamandla okusolwayo (noma ukweqisa ngokweqile) okudinga ukuthuthwa esibhedlela ngokushesha."
2. Nquma ngokushesha ukuthi isiguli SIYAHOXA (siqinile, siyanyakaza, siyashisa, siluma) noma ESIDLULA KAKHULU (ukuxhuga, ukozela, ukuphefumula kancane, ukubanda).
3. Izimpawu zokuhoxa: Ukuluma komzimba wonke (pruritus) nokungekho ukuqubuka kwesikhumba, ukubuya kwemisipha enodlame nokuqina okufana nebhodi, amaqhubu, inhliziyo egijimayo, umfutho wegazi ophakeme, ukuyaluza noma ukubona izinto ezingekho, kanye nomkhuhlane okhuphuka ngokushesha (ngokuvamile ongaphezu kuka-40 kuya ku-41 degrees Celsius [104 kuya ku-105.8 degrees Fahrenheit]).
4. Izimpawu zokudlula umthamo: ukozela okwedlulele (somnolence) ukuqhubekela ku-coma, imisipha ye-floppy "rag-doll" (flaccid hypotonia), ukulahlekelwa imisipha ejulile ye-tendon, inkulumo engahlangani kahle, ukuconsa amathe, ukuphefumula kancane (respiratory depression), umfutho wegazi ophansi, nokushaya kwenhliziyo kancane.
5. Uma isiguli ESOKUHOXA futhi siphaphame ngokugcwele futhi sikwazi ukugwinya ngokuphepha, sinikeze umthamo waso ophuthumayo womlomo wokutakula i-baclofen (kanye ne-diazepam/lorazepam enqunyiwe) ngokushesha. Ungalokothi unikeze noma yini ngomlomo uma isiguli sozela, sibamba ngamandla, noma sinemifinya yokugwinya. Nakuba i-baclofen yomlomo iyodwa ** ayikwazi ** ukumisa ngokugcwele ukuhoxiswa okukhulu kwe-intrathecal ngoba yeqa umgoqo wegazi-ubuchopho kancane kakhulu, inikeze umthamo womlomo ophezulu ngokushesha kanye ne-benzodiazepine enqunyiwe (diazepam noma lorazepam) uthenga isikhathi esibucayi ngesikhathi ethutha esibhedlela.
6. Uma isiguli sinomkhuhlane omkhulu kanye nokugedla kwemisipha okunamandla (Ukuhoxa), qala ukupholisa ngaphandle futhi usivikele ekulimaleni. Khumula izingubo zokulala nezingubo ezisindayo, gcoba ama-ice pack asongwe ngamathawula aswakeme entanyeni, emakhwapheni, nasezinqeni, esikhumbeni esimanziswe yifeni, kanye nesihlalo sabakhubazekile esinamasondo noma izinsimbi zombhede zingabangeli ubudlova noma ama-bed rails. i-rhabdomyolysis. Ungalokothi ubambe isiguli esinobuhlungu obukhulu obuphindisela emuva, njengoba ukulwa nemikhawulo kusheshisa ukuwohloka kwemisipha kanye ne-hyperthermia.
7. Uma isiguli SINGEDLULA KAKHULU (sixhuga, singavuki, noma siphefumula kancane), sisekele indlela yaso yokuphefumula futhi silungiselele ukunikeza ukuphefumula kokuhlenga. Gingqela isiguli esiqulekile ohlangothini lwaso ukuze silulame ukuze ugweme ukuminyanisa amathe noma ukuhlanza, tshekisa ikhanda ngobumnene ukuze ugcine indlela yokuphefumula ivulekile, futhi uqale ukuphefumula kokuhlenga noma I-CPR yabantu abadala uma ukuphefumula kuma noma kwehla ngaphansi kokuphefumula okungu-8 ngomzuzu.
8. Thola Ikhadi Lokukhomba Ledivayisi Egxilile lesiguli futhi ulethe umhleli wezinhlelo zesiguli sangaphandle (uma sinikeziwe) esibhedlela. Odokotela bezimo eziphuthumayo nodokotela abahlinza izinzwa badinga ukwazi imodeli yephampu ngqo (ngokuvamile i-Medtronic SynchroMed II noma i-III efakwe ngaphansi kwesikhumba sesisu), ukugcwala kwezidakamizwa ngaphakathi kwechibi (isibonelo, 2cm/50mL) vs. umthamo wansuku zonke, kanye nosuku lokugcwalisa kokugcina.

Isihlahla sesinqumo: intrathecal baclofen futha triage eziphuthumayo¶

flowchart TD
    A["Isiguli Esifakwe I-Intrathecal Baclofen (ITB) Pump"] --> B{"Hlola ithoni yemisipha, ukuqaphela, ne-alamu yephampu"}
    B -->|"Ukulunywa ngaphandle kokuqubuka, ama-spasms aqinile, imfiva, i-tachycardia, noma ukukhala kwe-alamu"| C["I-ACUTE ITB WITHDRAWAL SYNDROME (Ukudiliva ngaphansi / ukwehluleka kwe-catheter)"]
    C --> D{"Ingabe isiguli siphapheme futhi siyakwazi ukugwinya ngokuphepha?"}
    D -->|"Yebo"| E["Nikeza i-baclofen yomlomo yokutakula enqunyiwe + yomlomo/i-rectal benzodiazepine ngokushesha"]
    D -->|"Cha (ukozela, ukubamba, noma ukuklinywa)"| F["Gcina ngokuqinile i-NPO; nikeza i-rectal/intranasal rescue benzodiazepine uma kushiwo"]
    E --> G["Zipholise isiguli ngenkuthalo ngamaphakethe eqhwa entanyeni/i-axillae/groin bese ushayela i-EMS manje"]
    F --> G
    B -->|"Imisipha exegayo/exhugayo, ukozela kakhulu, ukuphefumula kancane, noma ukuwa ngemva kokugcwalisa"| H["I-ACUTE ITB OVERDOSE (Ukugcwaliswa kwephakethe, iphutha lokuhlela, noma i-bolus)"]
    H --> I["Vula indlela yokuphefumula, beka esimweni sokululama eseceleni, qapha ukuphefumula eduze"]
    I --> J["Qala ukuphefumula kokuhlenga/i-CPR uma ukuphefumula kuhamba kancane noma kuma; shayela i-EMS ngokushesha"]
    B -->|"Ububomvu, ukuvuvukala, isikhwama esiwuketshezi, noma ubomvu phezu kwepompo yesisu noma ukusikwa emuva"| K["I-PUMP POCKET INFECTION NOMA CSF HYGROMA: Ungafisi ekhaya; hamba ku-ER"]

Indlela i-intrathecal baclofen system isebenza ngayo nokuthi kungani ihluleka¶

Uhlelo lwe-baclofen lwe-intrathecal luqukethe izingxenye ezimbili ezifakiwe:

1. Iphampu yediski ehlelekayo: Ichibi elilingana ne-titanium hockey-puck elilingana nephampu ye-peristaltic enamandla ngebhethri (cishe amasentimitha angu-8.5 [amayintshi angu-3.3] ububanzi namasentimitha angu-2 [0.8 amayintshi] awugqinsi) afakwe ngokuhlinzwa ngaphansi kwamafutha angaphansi kwesisu esingaphansi. Isikhungo sephampu sinerabha ye-silicone ezivalayo i-reservoir refill septum, futhi unqenqema lwepompo lunembobo encane yokufinyelela ye-catheter (CAP)* eholela ngqo ku-catheter yomgogodla idlula indlela yepompo.
2. I-intrathecal catheter: I-silicone ezacile, eguquguqukayo noma ishubhu le-polyurethane elixhunywe eceleni kwepompo elidonsa ngaphansi kwesikhumba lizungeze ihlangothi ukuya emhlane ophansi (lumbar spine), ingena emgudwini womgogodla ngokusebenzisa i-dura mater, bese ixhuma phezulu ngaphakathi ku-cerebrospinal fluid (subarachnoid space) emthonjeni wesifuba noma womlomo wesibeletho.

Izimbangela ezivamile zokuhluleka kwe-catheter (kungani u-70% wokwehluleka uthule)¶

Ngenkathi ikhompuyutha yepompo ye-titanium yakhelwe ukuthi ihlale iminyaka engu-6.5 kuya kwengu-7 ngaphambi kokushintshwa kwebhethri okukhethekile, i-catheter yomgogodla ethambile ingaphansi kwezinkulungwane zokugoba, ukusonteka, nokunwebeka njalo lapho isiguli sisuka embhedeni siya esihlalweni sabakhubazekile, sigoba phambili, noma sikhula sibe side ngesikhathi sobusha. Izinkinga ze-catheter zemishini zihlanganisa:

• I-catheter kinking noma i-occlusion: Igoba elibukhali lapho i-catheter iphuma khona kusixhumi sepompo esingena-sutureless esiswini noma lapho ijika khona nge-thoracolumbar fascia ngemuva.
• Ukuphuka kwe-catheter noma ukugunda: Ukucindezelwa kweshubhu le-catheter phakathi kwezinqubo ezimbili ze-spinous noma amathambo e-lamina ngemuva, ukuhlwitha i-catheter phakathi ukuze imithi ivuze emisipha ye-paraspinal (subcutaneous CSF hygroma).
• Ukukhishwa kwe-catheter / ukufuduka ngaphandle kwe-intrathecal space: Isihloko se-catheter siphuma sihlehle ngembobo emaphakathi siye emafutheni e-epidural noma izicubu ezingaphansi kwesikhumba, ngokuvamile ngemva kokwelashwa ngokomzimba okunamandla, ukuwa esihlalweni sabakhubazekile, ukuhlinzwa kokuhlanganiswa komgogodla, noma ukukhula okungazelelwe kwengane.
• I-Intrathecal catheter-tip granuloma: Ukuvuvukala kwenqwaba yama-macrophage kanye nezicubu ezibaziyo ezakha eduze kwesihloko se-catheter ngaphakathi komsele womgogodla (okuvame kakhulu ngamaphampu e-intrathecal morphine noma e-hydromorphone, kodwa ngezikhathi ezithile kubikwa nge-baclofen ephezulu yokugxila), evimbela ukuhlakazeka kwezidakamizwa futhi ingacindezela, ibangele umgogodla omusha.

Ukutheleleka kwephampu ephaketheni, i-meningitis, nokuvuza kwe-CSF ye-lumbar ("pseudomeningocele")¶

Izimo eziphuthumayo ezimbili zendawo yokuhlinzwa zingenzeka phakathi kwamaviki angu-2 kuya kwangu-8 okuqala ngemva kokufakelwa kwepompo, ukushintshwa kwebhethri, noma ukugcwaliswa kabusha kwe-percutaneous:

1. Ukutheleleka ephaketheni lepompo kanye ne-meningitis yebhaktheriya ekhuphukayo: Uma ubomvu, ukufudumala, ukuvuvuka kwesisu, ukugeleza kwe-purulent, noma ukuwohloka kwesilonda (imithungo evula ukuveza insimbi ye-titanium) kuvela ephaketheni lepompo lesisu noma inxeba elingezansi emhlane, amagciwane (Staphylococcus aureus) noma i-Staphylococcus aureus ngaphandle kwe-epidermicus ngaphandle kwe-trackmicus ngqo ithubhu ku-dura ku-cerebrospinal fluid, okubangela ukugcwala i-bacterial meningitis (umkhuhlane, intamo eqinile, i-photophobia, ukudideka) kanye nokwehluleka kwephampu. Ungalokothi uzame ukukhipha noma ukukhama uketshezi ephaketheni lepompo elivuvukele ekhaya; iya ngokushesha egumbini lezimo eziphuthumayo ukuze uthole amasiko egazi, ukuhlaziya i-CSF, kanye ne-intravenous vancomycin plus cefepime/ceftriaxone.
2. Ukuvuza kwe-Lumbar CSF kanye ne-subcutaneous hygroma: Uma uketshezi lwe-cerebrospinal luvuza eduze kwendawo yokubhoboza emhlane ophansi, lungadala iqhubu elithambile, elivotekayo ngaphansi kwesikhumba sangemuva (pseudomeningocele) futhi kubangele i-classic ikhanda lokubhoboza ngemva kwesikhathi eside (ikhanda elibuhlungu eliba buhlungu kakhulu lapho uhlezi uqonde futhi libe ngcono phakathi nemizuzu ilele yacaba, ehambisana nokucanuzela kwenhliziyo nokuqina kwentamo).

I-100-to-1 potency ratio phakathi kwe-intrathecal ne-baclofen yomlomo¶

I-Baclofen iyi-analog yesakhiwo se-gamma-aminobutyric acid (GABA), i-neurotransmitter eyinhloko evimbela isimiso sezinzwa somuntu. Ibophezela ngokukhetha i-presynaptic ne-postsynaptic GABA-B receptors ophondweni lwe-dorsal yomgogodla, ivimbela ukungena kwe-calcium futhi imise ukukhululwa kwama-neurotransmitters ajabulisayo (i-glutamate ne-aspartate) eqhuba ukufinyela kwemisipha ye-spastic.

Lapho isiguli sigwinya amaphilisi e-baclofen omlomo (ngokuvamile ama-milligrams angu-40 kuya kwangu-80 [ama-microgram angu-40,000 kuya kwangu-80,000] ngosuku), umuthi awumunca kahle umgoqo wegazi-wobuchopho, ukhiphe ukuhlushwa okuncane kwe-CSF ye-lumbar engaphansi kwe-12 kuya ku-95 nanograms ngenkathi i-milliliter enzima yobuchopho ngayinye. Ngokuphambene, ipompo ye-intrathecal ifaka nje 300 kuya ku-800 micrograms ngosuku ngqo ku-CSF ifinyelela ukugxila komgogodla we-lumbar okuphindwe kane kuya kweziyishumi ukuphakama kunemithamo yomlomo ephezulu ngenkathi kusetshenziswa i-1/100^th yenani lesamba se-milligram.

Ngenxa yokuthi ama-receptors e-GABA-B avimbela umgogodla womgogodla ahlanjululwa ngokuqhubekayo ku-baclofen egxilile amahora angu-24 ngosuku, ama-neurons omgogodla azivumelanisa ne-*-down-regulating (ukukhipha) ama-receptors abo e-GABA-B ** nokwandisa ukuzwela okujabulisayo.

Kwenzekani ngaphakathi komgogodla lapho ukugeleza kwepompo kuma¶

I-biological half-life ye-baclofen ngaphakathi koketshezi lwe-cerebrospinal yomuntu kuphela **1.5 amahora angu-5 **. Lapho iphampu yomile noma i-catheter igxuma noma inqamula:

• Phakathi namahora angu-4 kuya kwangu-8*, amazinga e-baclofen e-CSF ehla abheke kuziro.
• Incishwe ukuvinjelwa kwe-GABA-B futhi ayinakho ukuminyana okujwayelekile kwesamukeli, i-alpha ne-gamma motor neurons yomgogodla womgogodla, ama-preganglionic neurons anozwela, nama-pruriceptive (itch) interneurons aqhuma ku okungaphikiswa, ukudubula okujabulisayo okuqhubekayo.
• Yonke imisipha yohlaka esiqwini nasemaphethelweni ivaleleka ekufinyezweni kwe-tetanic, ikhiqize ukushisa okukhulu kwe-metabolic (thermogenesis ngaphezu kuka-41 degrees Celsius [105.8 degrees Fahrenheit]) futhi iklebhule imicu yemisipha (rhabdomyolysis), kuyilapho isimiso sezinzwa esinozwela sikhukhula umgudu wegazi kanye ne-eutorenheit* isivunguvungu **).

Ukuqaphela izigaba ezine zokuhoxiswa kwe-intrathecal baclofen¶

Ukuhoxiswa kwe-baclofen ye-Intrathecal kulandela umugqa wesikhathi obikezelwayo, okhula ngokushesha. Ukubona iSigaba 1 ngaphambi kokuba umkhuhlane kanye nokwehluleka kwezitho kuqale kubalulekile.

Isiteji 1: I-prodrome yangaphambi kwesikhathi (amahora angu-6 kuya kwangu-18 ngemva kokuphazamiseka kokugeleza)¶

• Ukuluma okukhulu, okujwayelekile (neuropathic pruritus) NGAPHANDLE kwanoma yikuphi ukuqubuka kwesikhumba okubonakalayo, ukuqubuka, noma ububomvu: Lona uphawu lokuqala olucacile kakhulu lokuhoxiswa kwe-baclofen e-intrathecal, okwenzeka kumaphesenti angu-40 kuya kwangu-70 eziguli ngenxa yokuthi ama-receptors omgogodla we-GABA-B ngokuvamile avimbela imigudu ye-dorsal-horn itch (GRP/Bhlhb5 interneurons). Imindeni kanye nodokotela abanakekela okuphuthumayo bavame ukwenza iphutha lokhu njengokungezwani komzimba futhi banikeze ama-antihistamines (diphenhydramine), angenzi lutho futhi empeleni enze i-delirium ibe yimbi.
• Ukubuya kwe-baseline spasticity kanye nokucinana kwemisipha: Imilenze, izingalo, noma umboko wesiguli uzizwa uqina lapho sidlulisa noma sigqoka, okuhambisana nokuqhaqhazela okuvamile, i-ankle clonus (ukushaya unyawo okunesigqi), nokukhathazeka okungaphumuli noma ukuqwasha.
• I-Dysesthesia ne-paresthesia: Ukuluma, ukuvutha, noma "izikhonkwane nezinaliti" ukuzwa esikhumbeni, ukujuluka (diaphoresis) kanye nama-goosebumps (piloerection).

Isiteji sesi-2: I-acute rebound spasticity kanye nesiphepho esizimele (amahora angu-18 kuya kwangu-36)¶

• Udlame, olubuhlungu, oluqhubekayo lwemisipha nokuqina: I-opisthotonus eqinile (ukugoba kweqolo nentamo), amadolo akhiyiwe nezinqulu, nokugedla okungapheli kwe-myoclonic enesigqi samaphethelo.
• Ukungazinzi kwe-Hyperadrenergic autonomic: Ukuphumula ukushaya kwenhliziyo phakathi kuka-120 no-170 ukushaya ngomzuzu, ukushintshashintsha komfutho wegazi (i-hypertension enzima eshintshana ne-hypotension), ukuphefumula okusheshayo (tachypnea), nomjuluko omanzi te.
• Imfiva eyinhloko ekhulayo: Izinga lokushisa lomzimba likhuphuka lidlule 38.5 liye ku-40.0 degrees Celsius (101.3 kuya ku-104.0 degrees Fahrenheit) - liqhutshwa ngokuphelele ukufinyela kwemisipha okungapheli kanye nokungasebenzi kahle kwe-hypothalamic, hhayi ukutheleleka.
• Izinguquko zengqondo nezengqondo: Ukuyaluza okukhulu, ukudideka, ukubona izinto ezingekho ezibonwayo nezizwakalayo, ukudideka, nokusangana.

Isiteji sesi-3: I-Fulminant hyperthermia, isimo sesithuthwane, kanye ne-rhabdomyolysis (amahora angu-36 kuya kwangu-72)¶

• I-hyperpyrexia eyedlulele: Izinga lokushisa elimaphakathi lidlula 40.5 ukuya ku-42.0 degrees Celsius (104.9 kuya ku-107.6 degrees Fahrenheit), likhipha ama-enzyme eselula ebuchosheni, esibindini nasenhliziyweni.
• Ukuquleka okujwayelekile kwe-tonic-clonic kanye ne-refractory status epilepticus: Ukuhoxiswa kwe-Cortical GABA-B kubangela ukuquleka okuqhubekayo okungayeki ngaphandle kwe-benzodiazepines, i-propofol, noma i-barbiturates enedosi ephezulu.
• I-rhabdomyolysis enkulu kanye nomchamo omnyama we-"Coca-Cola": Ukuwohloka kwemisipha kukhipha amanani amakhulu e-creatine kinase (amazinga e-CK avame ukudlula ku-10,000 kuya ku-100,000 U/L), i-myoglobin, i-potassium, ne-phosphate egazini, kuxhume amashubhu ezinso futhi kubangele ukuphefumula kwenhliziyo*rrhythrethrethreth.

Isigaba 4: Ukwehluleka kwezitho eziningi kanye nokuwa kwenhliziyo¶

• I-Disseminated Intravascular Coagulation (DIC): I-systemic clotting engalawuleki kanye nokopha okuzenzakalelayo okuvela ezinsinini, izindawo ze-IV, kanye nomgudu wamathumbu.
• Ukwehluleka kwesibindi okukhulu, ukulimala kwezinso okukhulu, i-ARDS, nokushaqeka kwenhliziyo.

Ukuqonda ama-alamu azwakalayo epompo ye-Medtronic SynchroMed¶

Amaphampu afakwe i-Medtronic SynchroMed II kanye ne-III aqukethe i-piezoelectric acoustic transducer ekhipha izinsimbi ezizwakalayo ezizwakalayo ongazizwa lapho umi eduze nesiguli noma ubeka indlebe yakho eduze kwesisu saso:

Ukwehlukanisa ukuhoxa kwe-ITB ezimeni eziphuthumayo ezibukeka ngokufanayo¶

Ngenxa yokuthi iziguli ezine-cerebral palsy, ukulimala komgogodla, noma i-multiple sclerosis nazo zivame ukutholakala ku-urinary tract sepsis, i-ventriculoperitoneal (VP) shunt infections, i-autonomic dysreflexia, nokusabela kwemithi, odokotela bezimo eziphuthumayo basebenzisa izici ezilandelayo zomtholampilo ukuze bahlukanise ukuhoxiswa kwe-baclofen okunamandla:

I-acute intrathecal baclofen overdose: "iphakethe ligcwalisa" namaphutha ohlelo¶

Nakuba kungavamile kunokuhoxiswa, i-acute intrathecal baclofen overdose iyindlela ephuthumayo yokuphefumula kanye nokuphefumula. I-overdose ivela ezilungiselelweni ezimbili eziyinhloko:

1. I-"Pocket Fill" Yengozi Engaphansi Ngengozi ngesikhathi sokugcwaliswa kabusha kwepompo (Okuyingozi Kakhulu): Lapho umtholampilo egcwalisa iphampu njalo ngemva kwezinyanga ezi-2 kuya kweziyi-6, ufaka inaliti esikhumbeni sesisu ku-septum ye-silicone emaphakathi ukuze ajove i-baclofen egxilile (engase ibe nesidakamizwa esingu-10,00002000m kuya ku-40m isipetu - kufika izikhathi ezingu-50 umthamo obulalayo we-intrathecal). Uma inaliti ishelela noma igeja i-septum ngisho kancane, ingxenye yalowo mthamo omkhulu ijovwa ngqo ephaketheni lamafutha angaphansi kwesikhumba eduze kwepompo. Esikhathini esilandelayo ** imizuzu engu-30 kuya emahoreni angu-4 **, i-baclofen egxilile imunca ngokushesha egazini lesistimu, ibangele ukudlula ngokweqile okusongela ukuphila (okulandelwa izinsuku eziyindida kamuva ** ukuhoxiswa okukhulu ** ngenxa yokuthi inqolobane yepompo ngokwayo ishiywe ingenalutho).
2. Iphutha lohlelo noma lokugxilisana-okungafani kahle: Ukuhlela ukugxiliswa kokugcwalisa kabusha okungu-2,000 mcg/mL njengokungathi ngu-500 mcg/mL, noma ukubala kabi i-catheter priming bolus ngemva kokubuyekezwa kokuhlinzwa.

Izimpawu ze-acute baclofen overdose (ukukhuphuka kwe-rostral)¶

Njengoba i-baclofen eyengeziwe isakazeka phezulu (rostrally) ukusuka ku-CSF ye-lumbar kuya ku-brainstem kanye ne-cerebral cortex:

• Imizuzu yokuqala engama-30 kuye kwengama-90: Ukunyamalala kungazelelwe kwayo yonke ithoni yemisipha yomlenze nesiqu (i-flaccidity ejulile / hypotonia), isiyezi, ikhanda elilula, isicanucanu, nokuconzela amathe ngokweqile (sialorrhea).
• ihora eli-1 kuye kwayi-4: ukozela okwedlulele (somnolence), inkulumo engacacile (dysarthriai-ataxia, hypothermia, ukushaya kwenhliziyo kancane (bradycardianomfutho wegazi ophansi (hypotension).
• Ubuthi obunzima: Okungavuki okujulile ikhoma, ukulahlekelwa ukukhanya kwe-pupillary reflexes kanye ne-corneal reflexes (elingisa ukufa kobuchopho), ukuquleka okujwayelekile (okuyindida okubangelwa ukuvimbela i-presynaptic GABA-B autoreceptor ku-cortex), kanye ukuboshwa kokuphefumula / ukuphuphuma umoya.

Ukuphathwa okuphuthumayo kwe-baclofen overdose¶

1. Umoya nokuphefumula kuza kuqala: Akukho ayikho i-antidote ethize enokwethenjelwa ngokuphelele ye-receptor-antagonist ye-baclofen overdose (i-physostigmine yazanywa ngokomlando ngemiphumela engahambisani nemiphumela eyingozi ye-cholinergic efana ne-bradycardia, i-bronchospasm, nokuquleka; i-flumazenil ayiguquli ama-GABA-B receptors). Nokho, ngokushesha ukungenisa umoya wesikhwama semaski kanye ne-endotracheal intubation, ukusinda ngisho nasekusetshenzisweni ngokweqile kwe-baclofen kusondela kumaphesenti angu-100 uma umuthi ususulile ngaphezu kwamahora angu-24 kuya kwangu-72.
2. Ukumiswa kwephampu yezimo eziphuthumayo esibhedlela kanye nokukhipha amanzi e-CSF: Egunjini lezimo eziphuthumayo, odokotela baphenya ngokushesha iphampu ukuze bamise ukumnika (noma bakubeke ezingeni eliphansi), bakhiphe umuthi endaweni yokugcina amanzi (futhi bafune noma yikuphi ukuqoqwa koketshezi ephaketheni elingaphansi kwesikhumba uma kugcwaliswa iphakethe), futhi benze i-lumbar puncture ngokusebenzisa i-Capter3 eseceleni kwe-Aspire0 40 mL we-baclofen-laden cerebrospinal fluid (ngezinye izikhathi ishintshaniswa nosawoti ovamile ongenayo i-preservative-free).

Izibhedlela zikuphatha kanjani ukuhoxiswa kwe-ITB okukhulu lapho ufika¶

Ukwazi lokho umnyango wezimo eziphuthumayo okudingeka ukwenze kusiza abanakekeli bakhulume ngokucacile esigulini lapho befika esibhedlela somphakathi lapho abasebenzi bengase babone amaphampu e-intrathecal:

1. Idosi ephezulu esheshayo ye-GABA-A ne-GABA-B agonism:
2. Ngenxa yokuthi i-baclofen yomlomo ayikwazi ukufinyelela umgogodla ngokushesha ngokwanele ekuhoxisweni okukhulu, odokotela abaphuthumayo baphatha ngokushesha ** i-benzodiazepines ye-intravenous (lorazepam noma diazepam I-IV boluses kanye nokucwiliswa okuqhubekayo)**, okwenza ama-GABA-A receptors asebenze phansi entanjeni yomgogodla nasebuchosheni, edlula umzila we-GABA-B ongenalutho ukuze amise ukubanjwa, aphumuze ama-tetanic muscle spasms, futhi amise i-hyperthermia.
3. Uma isiguli sisakwazi ukuphuza imithi ngomlomo, i-nasogastric tube, noma i-gastrostomy (PEG) tube, umthamo ophezulu ** i-baclofen yangaphakathi ** (ngokuvamile i-10 kuya ku-20 mg njalo emahoreni angu-4 kuya kwangu-6) iqalwa kanyekanye, ivame ukungezwa ngomlomo ** cyproheptadine ** (4 kuya ku-8 mgnt njalo ngamahora angu-6 kuya ku-8 i-serotonin) i-myoclonus yokuhoxiswa kwe-baclofen) noma **dexmedetomidine / propofol ** infusions endaweni yokunakekelwa okujulile.
4. I-Dantrone sodium (IV) ingase isetshenziswe njengesengezo sokuqina okweqile kwemisipha yamathambo esongela ukuphila kanye ne-hyperthermia uma i-benzodiazepines inganele, nakuba ukubuyisela i-GABAergic kusalokhu kuyikhambi eliyinhloko.
5. Ukubuyiselwa okuphuthumayo kokulethwa kwe-baclofen ye-intrathecal:
6. Uma indawo yephampu ivele iphelelwe nalutho noma ima ngemva kwe-MRI: I-neurosurgeon, physiatrist (PM&R specialist), noma uchwepheshe womtholampilo womkhiqizi oqeqeshiwe uphenya iphampu ngenduku ye-telemetry futhi enze ukugcwalisa kabusha kwechibi eliyinyumba eliseceleni kombhede noma aqalise kabusha injini.
7. **Uma i-catheter inqanyuliwe, inqanyuliwe, noma iphukile futhi ukuhlinzwa kubambezeleka: ** Udokotela angenza umbhede ** umjovo we-lumbar puncture onesibhamu esisodwa se-preservative-free intrathecal baclofen (ngokuvamile i-50 kuya ku-100 micrograms) ** noma abeke isikhashana i-lumbar intrathergic intrathergic injection kuze kube yilapho i-catheter ye-catheter ikhishwa ngokushesha.
8. Aggressive IV hydration for rhabdomyolysis: Isotonic intravenous fluids (0.9% normal saline) afakwa ngokushesha ukuze alondoloze umchamo ophezulu futhi akhiphe i-myoglobin ezinso, kuyilapho eqapha i-serum potassium, i-creatine kinase (CK), nama-coagulation panel njalo emahoreni angu-4 kuya kwangu-6.

Izinombolo zezimo eziphuthumayo zesifunda kanye nezinqubomgomo ze-ejensi¶

• I-United States ne-Canada: Shayela u-911*. I-US Food and Drug Administration (FDA) Black Box Isexwayiso nge-intrathecal baclofen (Lioresal Intrathecal / Gablofen) ugunyaza ukulaliswa esibhedlela esiphuthumayo ngokushesha ngenxa yokuhoxiswa okusolwayo, okugqamisa ukuthi i-baclofen yomlomo iyodwa ayikwazi ukuvimbela ngokuthembekile ukuqhubeka kwe-rhabdomyolysis, ukwehluleka kwezitho eziningi, nokufa. Odokotela bangaphinde baxhumane ne-24-hora ye-Medtronic Technical Services Emergency Line (1-800-707-0933 e-US) ukuze bafake ikhasi unjiniyela wendawo wendawo ngethebhulethi yomklami emnyangweni wezimo eziphuthumayo.
• United Kingdom: Shayela 999. I-NHS England Clinical Commissioning Policies for Intrathecal Baclofen Therapy and NICE Spasticity Guidelines iqondisa ukudluliselwa ngokushesha ku-neuroscience yesifunda noma isikhungo sokulimala komgogodla, i-IV benzodiazepine titration, kanye nokuphenywa kwepompo okuphuthumayo.
• I-European Union: Shayela 112. Izivumelwano ze-European Academy of Neurology (EAN) kanye ne-European Medicines Agency (EMA) zigcizelela umthamo ophezulu we-IV benzodiazepines, ukupholisa kwangaphandle okusebenzayo, nama-boluses okusindisa angaphakathi kwe-intrathecal aphuthumayo ngokubhoboza i-lumbar lapho ukwehluleka kwephampu ye-catheter kubangela ukuhoxiswa okukhulu.
• I-Australia ne-New Zealand: Shayela u-000* e-Australia noma 111 eNew Zealand. I-Therapeutic Goods Administration (TGA) kanye nezixwayiso zokuphepha ze-neuromodulation ze-ANZCA zigunyaza ukuhlolwa okusheshayo kwesibhedlela nganoma iyiphi i-alamu yephampu enethoni ekabili noma i-pruritus/hypertonia engachazeki.
• I-India ne-Asia-Pacific: Shayela u-112* e-India, 995 e-Singapore, 119 e-Japan naseNingizimu Korea, noma 999 e-Malaysia nase-Hong Kong. Kwamanye amazwe, bheka inkomba yethu ye- izinombolo eziphuthumayo zamazwe ngamazwe.

Imibuzo evame ukubuzwa¶

Kungani ukuhoxiswa kwe-baclofen ye-intrathecal kubangela ukuluma komzimba wonke ngaphandle kokuqubuka?¶

Ophondweni lomgogodla womgogodla womuntu, ama-interneuron akhethekile avimbela ama-receptors e-GABA-B ukuze agcine izindlela zenzwa ezibonisa ukulunywa zithule ngaphansi kwezimo ezijwayelekile. Lapho isiguli sithola i-baclofen ye-intrathecal eqhubekayo izinyanga noma iminyaka futhi ukugeleza kuyeka ngokuzumayo, lawo ma-receptors omgogodla we-GABA-B ashiywa engashukunyiswa ngokuphelele, okwenza ama-neuron e-spinal itch avutha ngokuzenzekelayo futhi ngokungakhathali. Ngenxa yokuthi lokhu kulunywa kuvela ngaphakathi komgogodla kunokuphuma kwe-histamine esikhumbeni, azikho izidleke noma ububomvu, futhi ama-antihistamine afana ne-diphenhydramine (Benadryl) awasebenzi.

Ngingavele nginikeze amaphilisi e-baclofen ngomlomo engeziwe ekhaya uma iphampu ye-baclofen yengane yami iqala ukukhala noma iphela?¶

Uma isiguli siphapheme ngokugcwele futhi sikwazi ukugwinya ngokuphepha, kufanele unikeze umthamo waso omisiwe wokuhlenga ophuthumayo we-oral baclofen, kodwa kusafanele uye ngqo emnyangweni wezimo eziphuthumayo. I-baclofen egwinyiwe yeqa umgoqo wegazi nobuchopho kabi kakhulu, ifinyelela ngaphansi kwekhulu lokuhlushwa koketshezi lomgogodla ngemiligremu ngayinye uma kuqhathaniswa nokufakwa ngaphakathi kwe-intrathecal. Ukuthembela kumaphilisi omlomo we-baclofen yedwa ekhaya kuye kwaholela ekufeni okuningi okubhaliwe okuvela ekubanjweni okuphikisayo, i-41 C (106 F) hyperthermia, kanye nokwehluleka kwezitho eziningi.

Uma iphampu ye-baclofen INGABE ikhala, ingabe lokho kufakazela ukuthi isiguli asikho ekuhoxisweni kwe-baclofen?¶

Cha. Ngaphezulu kwamaphesenti angu-70 ezimo ezisongela ukuphila zokuhoxiswa kwe-baclofen ze-intrathecal zenzeka ngaphandle kwe-alamu ezwakalayo evela epompo. Ikhompiyutha yangaphakathi yephampu yazi kuphela ukuthi ibhethri linamandla, noma ngabe isibali sikhathi se-reservoir sithi uketshezi luhlala, nokuthi i-motor rotor iyaphenduka; ayinayo inzwa ngaphakathi kweshubhu ye-catheter eguquguqukayo eya emgogodleni. Uma i-catheter igxuma, iqhekeka, inqamuka kumbhobho wepompo, noma iphuma emgudwini womgogodla ingene emafutheni angemuva, iphampu ilokhu ivungama buthule kuyilapho imithi eyiziro ifinyelela entanjeni yomgogodla.

Kungani odokotela benikeza i-lorazepam emithanjeni noma i-diazepam (Valium) yokuhoxiswa kwe-baclofen uma kuyizidakamizwa ezihlukene?¶

I-Baclofen isebenza kuma-GABA-B receptors, ancipha kakhulu futhi aphelelwe amandla ngesikhathi sokwelashwa kwepompo ye-intrathecal engapheli. I-Benzodiazepines efana ne-diazepam, i-lorazepam, ne-midazolam inqamula ngokushesha ohlelweni lwezinzwa olumaphakathi lapho inikezwa ngemithambo futhi ivule ama-GABA-A receptors kuma-neuron omgogodla kanye nezindlela zobuchopho. Lokhu kubuyisela inhibitory chloride-channel braking kusistimu yezinzwa phakathi nemizuzu, kumise ukunyakazisa kwemisipha okunodlame, ukuquleka, kanye nokushisa okukhulu kokushisa ngesikhathi odokotela belungisa iphampu.

Kuyini "ukugcwalisa ephaketheni" ngesikhathi sokuqokwa kokugcwalisa kabusha iphampu ye-baclofen, futhi yiziphi izimpawu eziyisixwayiso?¶

Ukugcwaliswa kwephakethe kwenzeka lapho inaliti yokugcwalisa ishelela noma yehluleka ukungena ku-septum ye-silicone emaphakathi yephampu, ijove ngephutha amamililitha e-baclofen ewuketshezi egxile kakhulu esicutshini samafutha athambile ngaphansi kwesikhumba sesisu esikhundleni sangaphakathi kwethangi le-titanium. Izimpawu eziyisixwayiso zihlanganisa ukuvuvukala okungavamile noma ukuluma phezu kwesayithi lephampu ngesikhathi sokugcwalisa, okulandelwa phakathi kwemizuzu engu-30 kuya emahoreni angu-4 ukuxega okujulile kwemisipha, ukozela okwedlulele, inkulumo engahlelekile, ukuphefumula kancane, kanye nekhoma. Noma ubani owozela ngendlela engavamile noma ophaphayo emahoreni ambalwa ngemva kokugcwalisa iphampu udinga i-ambulensi ngokushesha.

Imithombo neziqondiso ezisemthethweni¶

• I-US Food and Drug Administration (FDA) & ne-Medtronic Neuromodulation: Ichaza Ulwazi Nesexwayiso Sebhokisi Le-Lioresal Intrathecal / Gablofen (I-Baclofen Injection) kanye ne-SynchroMed II/III Programmable Infusion Systems (Ukuqashelwa kanye nokuphathwa okuphuthumayo kwe-intrathecal baclofen-fill ukuhoxiswa kanye nokuhoxiswa kwe-pocket-fill ye-intrathecal).
• **Ikhofi RJ et al. (Izingobo Zomlando Zomuthi Womzimba Nokuvuselelwa ): *Ukuhoxiswa Ngokushesha Ku-Intrathecal Baclofen: Ukuqashelwa Nokuphathwa Kwe-Syndrome Engase Isongela Ukuphila * (I-Pathophysiology yokunciphisa umgogodla we-GABA-B receptor, i-neuropathic pruritus ngaphandle kokuqhuma, i-rhabdom).
• **Saulino M et al. (I-Neuromodulation: Ubuchwepheshe Ku-Neural Interface ): Imikhuba Engcono Kakhulu Yokwelapha I-Intrathecal Baclofen: Ukuxazulula Izinkinga Nokuphatha Izimo Eziphuthumayo ze-ITB (Iziqondiso Zephaneli Yesivumelwano mayelana nokuxilongwa kokuhluleka kwe-catheter, i-Catheter Access Port aspiration, kanye ne-IV benzodiazepine/cyproheptadine yokutakula).
• Isevisi Yezempilo Kazwelonke (NHS England) kanye Nesikhungo Sikazwelonke Sezempilo Nokunakekelwa Okuhle kakhulu (NICE, United Kingdom): Inqubomgomo Yokugunyazwa Kwezokwelapha: I-Intrathecal Baclofen Ye-Spasticity Enzima Kubantu Abadala Nezingane.
• Watve SV et al. (Spinal Cord): *Ukuphathwa Kwe-Acute Overdose kanye Ne-Underdose ye-Intrathecal Baclofen: I-Lumbar Puncture CSF Drainage kanye ne-ICU Supporting Care Protocols *.

Iziqondiso ezihlobene¶

• I-Serotonin syndrome, i-neuroleptic malignant syndrome, nokusebenzisana kwezidakamizwa
• I-Autonomic dysreflexia ekulimaleni komgogodla
• Isimo sokuwa, ukuquleka isikhathi eside, nemithi yokuhlenga
• Ukulimala kwezinso okukhulu, i-rhabdomyolysis, kanye nokuhlolwa komchamo omnyama
• Ukusetshenziswa kwe-CPR yabantu abadala kanye ne-AED