A novel cause of intrathecal baclofen overdosage: lessons to be learnt

Clin Rehabil. 2008 Feb;22(2):188-90. doi: 10.1177/0269215507081962.


Case presentation: 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.

Conclusion: We hope that by reporting this incident the risk of this potentially fatal error re-occurring is minimized.

Publication types

  • Case Reports

MeSH terms

  • Baclofen / administration & dosage
  • Baclofen / poisoning*
  • Drug Overdose
  • Drug Therapy, Computer-Assisted
  • Female
  • GABA Agonists / administration & dosage
  • GABA Agonists / poisoning*
  • Humans
  • Infusion Pumps, Implantable / adverse effects*
  • Injections, Spinal / adverse effects*
  • Injections, Spinal / instrumentation
  • Medication Errors / instrumentation*
  • Middle Aged


  • GABA Agonists
  • Baclofen