Table 3. Literature overview of cases with severe symptoms of CNS-depressant overdose after the concomitant use of ITB and opioids.

Ref	Weight (kg)	Age (y)	Diagnoses	Intervention	Baclofen	Intraoperative CNS depressants	Postoperative CNS depressants	Outcome
Anderson et al, 2002 25	22.5	9	CP	Baclofen pump implantation	ITB start: end of surgery Concentration: 2,000 µL/mL Infusion rate: 100 µg/d Possible max inadvertent bolus during surgery: 460 µg	IV sufentanil or fentanyl	IV Morphine	GCS: 6 1.9 h after start of baclofen pump dead space purge; 1.5 h after morphine administration. Needed supplementary oxygen (OS: 94%). Full recovery after 14 h.
	13.6	7	CP	Baclofen pump implantation	ITB start: end of surgery Concentration: 1,000 µL/mL Infusion rate: 100–125 µg/d Possible max inadvertent bolus during surgery: 230 µg	IV sufentanil or fentanyl	IV morphine, IV dimenhydrinate 1.1 mg/kg	GCS: 7 3.8 h after start of baclofen pump dead space purge; 3.6 h after morphine administration; 50 min after dimenhydrinate administration. Full recovery after 1.8 h.
	15.0	5	CP	Baclofen pump implantation	ITB start: end of surgery Concentration: 1,000 µL/mL Infusion rate: 125 µg/d Possible max inadvertent bolus during surgery: 230 µg	IV sufentanil or fentanyl	IV morphine	GCS: 6 1.8 h after start of baclofen pump dead space purge; 1.5 h after morphine administration. Baclofen infusion rate reduced to 100 µg/d. Full recovery after 15 min.
	29.5	12	CP	Baclofen pump implantation	ITB start: end of surgery Concentration: 1,000 µL/mL Infusion rate: 100–125 µg/d Possible max inadvertent bolus during surgery: 230 µg	IV sufentanil or fentanyl	IV morphine	GCS: 6 2 h after start of baclofen pump dead space purge; 1.7 h after morphine administration. Needed supplementary oxygen. Baclofen infusion was stopped. Full recovery after 7.5 h.
	20.4	7	CP	Baclofen pump implantation	ITB start: end of surgery Concentration: 1,000 µL/mL Infusion rate: 100 µg/d. Possible max inadvertent bolus during surgery: 230 µg	IV morphine		GCS: 7 upon arrival in PACU and 1.5 h after intra-OP morphine administration. Woke up after 2 h for 30 min. Again GCS 7. Needed supplementary oxygen (OS: 97% on 4 L/min oxygen). Full recovery after 2 h.
Rizzo et al, 2019 21	30.7 ± 9.6 a	13		Posterior spinal fusion	Stable doses ITB for at least 6 mo	Fentanyl 2 µg/kg, IV ketamine 0.1 mg/kg, IT morphine 20 µg/kg	Bolus morphine 2 mg/mL + ketamine 2 mg/mL (10.60 ± 17.55 µg/kg/h a )	Respiratory depression on postoperative day 0 and 1. Needed supplementary oxygen.
	30.7 ± 9.6 a	17		Posterior spinal fusion	Stable doses ITB for at least 6 mo	CI sufentanil 2 µg/kg/h, bolus sufentanil (range 0.1–0.2 µg/kg), IV ketamine 0.1 mg/kg	Bolus morphine 2 mg/mL + ketamine 2 mg/mL (10.60 ± 17.55 µg/kg/h a )	Respiratory depression on postoperative day 0 and 1, naloxone for respiratory depression treatment, needed supplementary oxygen.
	30.7 ± 9.6 a	13		Posterior spinal fusion	Stable doses ITB for at least 6 mo	CI sufentanil 2 µg/kg/h, bolus sufentanil (range 0.1–0.2 µg/kg), IV ketamine 0.1 mg/kg	Bolus morphine 2 mg/mL + ketamine 2 mg/mL (10.60 ± 17.55 µg/kg/h a )	Respiratory depression on postoperative day 0, 1, and 2, naloxone for respiratory depression treatment, needed supplementary oxygen.
	30.7 ± 9.6 a	15		Posterior spinal fusion	Stable doses ITB for at least 6 mo	CI sufentanil 2 µg/kg/h, bolus sufentanil (range 0.1–0.2 µg/kg), IV ketamine 0.1 mg/kg, IT morphine 20 µg/kg	Bolus morphine 2 mg/mL + ketamine 2 mg/mL (10.60 ± 17.55 µg/kg/h a )	Respiratory depression on postoperative day 0, naloxone for respiratory depression treatment, needed supplementary oxygen.

Abbreviations: CI, continues infusion; CP, cerebral palsy; GCS, Glasgow Coma Scale; IT, intrathecal; ITB, intrathecal baclofen; IV, intravenous; OS, oxygen saturation; PACU, postanesthesia care unit.

^aThe mean weight/opioid consumption of the 13 children on ITB therapy included in this study.