Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Neuro Rehab II > Baclofen pump trouble shooting > Flashcards

Baclofen pump trouble shooting Flashcards

1
Q

Define spasticity

A

upper motor neuron syndrome characterized by a velocity-dependent increase in muscle tone with exaggerated tendon jerks resulting from hyper-excitability of the stretch reflex

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Two causes of spasticity

A
  1. Damage to areas of the central nervous system which causes changes in the balance of descending pathway.
  2. Interruption in the release of the main inhibitory neurotransmitter, GABA (gamma-amino butyric acid)

Zone of T10 border b/w UMN zone and LMN zone??

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Define spasms vs “muscle spasms”

A

Spasms: spontaneous uncontroled movements which may be due to spasticity or due to other hyperactive spinal reflexes such as dystonia, cramps, rigidity, stiff-man syndrome and metabolic contractures (McArdle’s disease)

Muscle spasms: focal areas of increased muscle activity associated with tenderness in the setting of muscle/nerve injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Define dystonia:
A result of:
May be 4 types

A
  1. A syndrome characterized by sustained muscle contractions resulting in abnormal movements or sustained positions.
  2. result of sustained contraction of both agonist and antagonist muscles
  3. May be focal, multifocal, segmenal, or generalized.
    ie writers cramp: toricolis focal dystonia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

9 associated chronic diseases with spasticity

A
  1. stroke
  2. MS; NMO
  3. Transverse Myelitis
  4. Cervical and thoracic myelopathy
  5. Cerebral palsy
  6. Amyotrophic Lateral sclerosis
  7. Spastic paraparesis
  8. Brain injury (tumors, aneurysms, trauma, anoxic injury)
    9 Spinal cord injury (trauma, infarct, tumor)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Name the 4 advantages of spasticty

A
  1. maintain muscle mass and possibly bone mineral density
  2. reduce dependent edema
  3. reduce risk of deep vein thrombosis
  4. Rigidity from spasticity may assist in transfers and ambulation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Name the 6 disadvantages to spasticity

A
  1. Interference with transfers, ambulation, and activities of daily living
  2. Increased risk of contractures
  3. Increased risk of skin breakdown
  4. compromised seating and mobility
  5. interference with sleep
  6. interference with driving
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the 6 possible precipitating factors of worsening spasticity

A

bladder infection, kidney stone, growth spurts, bowel impaction, ingrown toe nail, appendicitis, etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

five components of physical exam of spasticity patient

A
  1. muscle strength and control
  2. range of motion
  3. tendon reflexes including presence of abnormal reflexes (hoffmans, babinski, triple flexion response)
  4. Clonus
  5. functional evaluation to include ambulation, transfers, ADLs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

_____ most widely used clinical method for assessing severity of spasticity and hypertonus.
Describe:

A

Ashworth Scale

  1. normal tone
  2. slight hypertonus, a “catch” when limb is moved
  3. Mild hypertonus, limb moves easily
  4. moderate hypertonus, passive limb movement difficult
  5. severe hypertonus, limb rigid
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe the modified ashworth scale

A

0 no increase in tone
1. slight increase, manifested by a catch
1+ catch followed by resistance (<50%) ROM
2. increased tone through most ROM
3. Passive ROM difficult
4. Affected parts rigid in flexion or extension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

mechanism of action of GABA

A

inhibitory neurotransmitter (gamma amino butyric acid)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Mechanism of action of Baclofen

A

thought to act as a GABA agonist in the spinal cord, reducing positive input to the alpha motor neuron

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

when would intrathecal baclofen be contraindicated?

Relative contraindication?

A

when allergy to oral baclofen occurs or if there is active infection.

serious psych issues and non-compliance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

describe the spasticity management ladder (bottom to top) 6 tiers

A
  1. prevent nociception stretching program
  2. Medications (baclofen, dantrolene, diazepam, clonidine, zanaflex) & Physical modalities (muscle cooling, e-stim, vibration)
  3. Motor point block, Nerve or subarachnoid block (when determining b/w spastic or soft tissue contracture can use a block first to determine etiology)
  4. Intrathecal baclofen, selective posterior rhizotomy
  5. Neurectomy, rhizotomy, Tenotomy, Myotomy
  6. Myelotomy, cordectomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Pharmacodynamics of baclofen injection:

  1. Bolus
    - Onset of action is ____ after bolus
    - Peak effect at ____ after dosing
    - Effects may last ____ hours
  2. Continuous
    - Effects are seen at _______ after initiation of continuous infusion.
    - max effec observed in ______
A
    • 0.5 - 1 hour
    • 4 hours
    • 4-8 hours
    • 6-8 hours
    • 24-48 hours
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Which study is best to determine effects of intrathecal baclofen trial and to ensure you catch adverse effects

A

continuous catheter study due to timing of medication. May miss mild complications if bolus is done. Bolus performed most often due to convenience

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Oral dose of baclofen ratio to intrathecal Lumbar concentration
60mg dose: _______ IT lumbar concentration.
Half-life of oral?

A

0.024mcg/mL

3-4 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Intrathecal dose 600 mcg/day dose: _____ IT lumbar concentration of baclofen

A

1.24mcg/mL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Lumbar to cervical concentration of intrathecal baclofen is

A

4:1

Why even higher catheter tips may still show more improvement in LE than UE. Due to gravity.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Intrathecal baclofen half-life is:

Eliminated by:

A

4-5 hours

bulk CSF turnover

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Synchromed EL-implanted prior to ____:

  1. Reservoir size:
  2. needs ____ for programmer for interrogation of pump.
A

2004

  1. 18cc
  2. magnet
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Synchromed II implanted after ____

Reservoir sizes?

A

2004

20 cc and 40cc

24
Q

battery life of ITB pump:

A

approximately 5-7 years

25
Q

Starting dose for screening trial:
onset of action:
Peak effect at:
Monitor response to medication by: (3)

A

50mcg
30 min
4 hours
spasm frequency scores, ashworth score, ROM

26
Q

Determinates of ITB pump catheter placement: (4)

A 
Varies based on 
Location
Severity of spasticity
Pulmonary function; chest wall spasms
cognitive function
27
Q

What are the standard drug concentrations of ITB?

What are the 6 combo meds that can be added?

A

500, 1000, 2000mcg/ml

Bupivicaine, morphine, dilaudid, prialt, clonidine, fentanyl

28
Q

Synchromed II has larger reservoir fill port than EL and a self-sealing septum. Benefits? (2)

What needle must be used? why?

A
  1. prevents drugs from leaking from the pump
  2. Prevents air or other contaminants from entering reservoir

Huber-type needle: packaged with refill kit. Angled tip prevents coring of septum.

29
Q

what is drawback for compound medications?

A

They have a precipatory effect which clogs the catheter over time like atherosclerosis. Also effect the rotors.

30
Q

Catheter access _____ pump.
Use for:
Needle which must be used? Why?

A
  1. Bypasses
  2. Troubleshooting (eg catheter patency test), testing that requires fluid delivered directly to CSF (eg dye study)
  3. only small gauge needles - 24G; prevents larger gauge needles of refill kit from accessing; preventing accidental overdose.
31
Q

22 yo female with history of TBI with L spastic HP with ITB presents to the ED after being found by family in the middle of the night to be lying in own vomit and evidence of urinary incontinence. Noted to be very difficult to arouse and described as “floppy”. Appears to be breathing ok, no fever noted….

Issue?

A

Went throughou recent refill and concentration change but concentration was not changed on the programmer.

overdose

32
Q

patient symptoms of baclofen overdose (11)

A
  1. drowsiness
  2. lightheadedness
  3. dizziness
  4. vomiting
  5. urinary retention
  6. somnolence
  7. hallucinations
  8. respiratory depression
  9. seizures
  10. rostral progression of hypotonia
  11. loss of consciousness progressing to coma
33
Q

Potential causes of baclofen overdose:

A
  1. dosing error
  2. programming error
  3. injecting catheter access port during refill or during catheter dye study
  4. accidental subcutanous fill
  5. filling catheter with syringe during surgery
  6. use of concomitant drugs - such as illicit or anesthesia paralytics without regarding pump meds
  7. pump malfunction
34
Q

What is the emergency procedure for overdose? (5 steps)

A
  1. Maintain airway, breathing circulation
  2. empty pump reservoir to stop drug flow and record amount withdrawn
  3. administer physostigmine IV if not contraindicated.
  4. If lumbar puncture is not contraindicated, withdraw 30-40ml CSF to reduce baclofen concentration
  5. report incident to medtronic technical services
35
Q

What is the dose of physostigmine IV for baclofen overdose

A

Adult: 1-2mg over 5-10 minutes; repeat doses of 1mg at 30-60min intervals to help maintain adequate respiration and alertness if patient shows a positive response.

Pediatric: 0.02 mg/kg; no more than 0.5mg/minute; repeat at 5-10 minute intervals; maximun dose 2mg

36
Q

32 yo male with history of complete tetraplegic presents to the ED with 2 day complaints of anxiety, itching on arms and increased spasticity. Denies fever, SOA, or rash. issue?

A

Baclofen withdrawal - pump was empty

37
Q

Other potential causes of symptoms presenting as baclofen withdrawal (4)

A
  1. nociception
  2. less drug effect with worsening spasticity
  3. advancement of disease
  4. concomitant illnes: UTI, impacted bowels, URI, ingrown toe nail, new or worse pressure ulcer
38
Q

Signs of baclofen withdrawal/underdose

A
  1. pruritus without a rash
  2. hypotension
  3. parasthesia
  4. fever
  5. altered mental state
  6. exaggerated rebound spasticity and muscle rigidity
  7. may result in death if not treated appropriately
39
Q

Questions to ask if patient presents with signs of withdrawal from ITB.

A
  1. Did the patient miss a refill appointment?
  2. Is pump programmed correctly? - verify dose/concentration
  3. Have refill volumes been accurate? any mention of discrepancy with pump refill?
  4. How does telemetry compared with last programming strips.
  5. Have alarms been triggered? - low reservoir alarm vs end of life battery alarm
40
Q

Synchromed II rotor study

A
  1. interrogate the pump
  2. xray the rotor, it has 2 arms with 2 radiopaque markers and 1 arm with 3 markers. Note the orientation of the arm with the 3 markers.
  3. Program single bolus of .010ml over 1 minute
  4. x-ray the rotor again. The 3 identifier arm should have turned 60 degrees.
  5. make copies of the image for the chart
  6. If the rotor appears stalled, repeat the bolus to verify.
41
Q

After inserting a needle into the catheter access port, it is best to aspirate: _____.
Which syringe? why?

A

1-2 ml to ensure removal of drug from the catheter.

It is better to use a TB or 3ml syringe with slow aspiration. A large syringe or too much pressure could collapse the catheter.

If complete catheter kink, aspiration is impossible. If partial occlusion, aspiration is difficult.

42
Q

emergency procedure for withdrawal of ITB

A
  1. initiate life-sustaining measures, if indicated
  2. immediately contact a physician experienced in ITB therapy.
  3. If an ITB therapy physician is unavailable, consider instituting one or more of the following options, unless otherwise contraindicated.
    - high dose oral or enteral baclofen
    - may consider intrathecal administration of 50mcg bolus dose but risk damage to the catheter per LP
    - Restoration of intrathecal baclofen infusion
    - intravenous BDZ by continous or intermittent infusion, titrating the dosage until the desired therapeutic effect is achieved.
43
Q

ITB implant device considerations:

  1. Avoid LP due to _____
  2. _____ is contraindicated in this population due to stopping and potentially damaging the pump.
  3. May use these 3 modalities
  4. ____ and ___ may cause damage to the pump but should be used if life saving maneurver.
  5. May have an _____ but risk of motor stall due to magnetic field and recommended to have post MRI visit to ensure pump has restarted.
A
  1. risk of puncture of the catheter
  2. lithotripsy
  3. TENS unit, welding, electrical equipment
  4. Defibrillation and electrocautery
  5. MRI
44
Q

What are the two synchromed pump alarms?

A
  1. Elective replacement indicator (ERI) or Low Alarm Reservoir - indicates that the pump will stop in approximately 90 days.
    Single tone alarm.
    May be 4-16 seconds apart if low reservoir volume.
    Will sound at a minimum every hour when need of replacement
  2. End of Service (EOS)/Critical alarm - indicates that the pump has stopped because it has reached the end of its service life.
    Two tone alarm.
    Will sound at a minimum of every hour.
45
Q

What should you do if you are having trouble filling the drug reservoir and are having trouble determining if your needle is in the pump at time of refill.

A

take a lateral view of the pump while filling with preservative free normal saline to watch the bellows expand. Bellows collapsed, pump is empty, bellows expanded, pump is full.

46
Q

If you are having trouble aspirating meds from the catheter

A
  1. drug precipitation within the inner lining of the catheter is similar to atherosclerosis. It builds up along the wall of the catheter. Maybe one of the reasons that you cant always aspirate a catheter, it doesn’t necessarily mean that the catheter isn’t functioning. Important to obtain a proper history prior to the pump change out. Reservoirs have been accurate? PT pain/spasticity has been well controlled?
47
Q

What is patient therapy manager?

A

PTM: typically only used in pain patients, allows the patient to give themselves small boluses of med that are pre-designated. Can obtain approval in spasticity patients if WC related. Can be difficult and confusing so requires higher cognitive function to be able to use.

48
Q

High concentration drugs can cause _____ in ITB pumps

A

corrosion within the pump which causes rotor stall

49
Q

______ has caused issues in which the drug makes the internal pump tubing harder so that the rotor doesn’t collapse the tubing enough, therby letting more drug out than what is prescribed.

A

High concentration Fentanyl 3500-5000mcg/ml

50
Q

______ may cause drug precipitation if not maintained in appropriate temperature which can cause rotor stall or blockage of the catheter

A

Bupivicaine >35mg/ml

51
Q

45 yo female with RRMS with LE spasticity s/p ITB wimplant 3 months ago presents iwth worsening LE spasticity. No neurological changes except for increased tone noted in the LE. Cause?

A

Dislodged catheter - more at risk if patient is ambulatory and active; this patient was playing tennis

52
Q

42 yo male with central cord syndrome with severe spasticity s/p ITB. Transferred to inpatient rehab and tolerating ITB titration well for about a week, thereafter no change noted with 20% increase in pump every day as well as 50 mcg dose bolus.

A

withdrawal - defect in catheter.

53
Q

78 yo female with h/o paraplegia with ITB for 7 years with worsening spasticity and found to have a broken catheter, in preparation for surgery dose reduced over time by 50% (400mcg/day) catheter was replaced and patient started at base dose of 400mcg/day and transferred for acute IRF. Within 6 hours the patient found to be sedated, confused and RR of 8… issue?

A

Baclofen medication overdose noted. Pump turned off for 6 hours until return of tone and patient found to be more alert. Pump resumed at 100mcg/day where tone was well controlled.

Less med needed because patient was not getting as much due to defect in the catheter.

54
Q

Occurrence of Adverse events in long-term ITB infusion: 1 year follow up study:

  1. _____ study
  2. Most with SCI (____%) and MS (____%)
  3. 53% of AE due to _______. 29 related to device which was predominantly ____ related. and 18% AE due to ____use itself
A
  1. prospective cohort study - 158 adults;
  2. 42%; 28%
  3. surgical procedure; catheter related; baclofen
55
Q

IBT needed information

A 
medication(s) in the pump
concentration of all meds
daily dosing of all meds
size of pump 
alarm date
ERI

also (two piece catheter? and where tip is placed)

Neuro Rehab II (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions