From the Guidelines
Refilling an intrathecal pump in a patient with active sepsis is generally not recommended due to the significant risk of introducing pathogens into the central nervous system. The procedure should be postponed until the sepsis is adequately treated and resolved, with documented negative blood cultures and clinical improvement. In urgent situations where pain management is critical and cannot be achieved through alternative routes (such as oral, intravenous, or transdermal medications), a careful risk-benefit assessment should be performed by a multidisciplinary team including infectious disease specialists. If refill is deemed absolutely necessary, it should be performed under strict aseptic technique with prophylactic antibiotics, as suggested by guidelines for managing sepsis and septic shock 1. The rationale for this caution is that sepsis represents a systemic inflammatory response to infection with circulating bacteria in the bloodstream, and any invasive procedure during this state increases the risk of seeding the central nervous system with pathogens, potentially causing meningitis or a pump pocket infection. These complications can be life-threatening and may require pump removal, making prevention through deferral of non-emergency procedures the safest approach. Key considerations in managing sepsis include prompt identification and treatment of the source of infection, as well as careful fluid resuscitation and the use of vasopressors as needed 1. However, the primary concern with refilling an intrathecal pump in a septic patient is the risk of introducing infection into the central nervous system, which outweighs other considerations. Therefore, postponing the refill until the sepsis is resolved is the recommended course of action, unless a multidisciplinary team determines that the benefits of immediate refill outweigh the risks, in which case strict aseptic technique and prophylactic antibiotics should be used 1.
From the Research
Refilling an Intrathecal Pump in an Actively Septic Patient
- The decision to refill an intrathecal pump in a patient with active sepsis should be made with caution, considering the risk of infection and the potential consequences of discontinuing intrathecal baclofen therapy 2, 3, 4.
- Studies have shown that in some cases, it is possible to treat infections related to intrathecal pump refilling without removing the pump, by administering antibiotics through the pump, together with the baclofen 2, 3, 5.
- The use of intrareservoir antibiotics, such as vancomycin or teicoplanin, has been reported to be effective in sterilizing the pump reservoir and tubes, and treating infections that develop during the use of these systems 2, 3, 4, 5.
- However, the optimal treatment strategy for intrathecal baclofen pump-associated CNS infection and meningitis is usually removal of the pump, followed by systemic antibiotics for treatment of local and CNS infection 4.
- In selected cases where surgical explantation is deemed not feasible, radical debridement and intrareservoir baclofen-vancomycin co-infusion may provide an additional option for pump salvage and retention, while eradicating CNS infection and maintaining optimal control of spasticity and dystonia 4.
- There is no direct evidence to suggest that an intrathecal pump can be safely refilled in an actively septic patient, but the above studies suggest that it may be possible to manage infections related to pump refilling without removing the pump, in certain cases 2, 3, 4, 5.