Drainage or lavage as a salvage manoeuvre after intrathecal drug errors: A systematic review with therapeutic recommendations.

Study Objective: Cerebrospinal fluid (CSF) drainage and lavage are reported to reduce drug exposure after inadvertant intrathecal drug administration errors. This reviews aims to provide recommendations for this salvage technique, with regard to methodology, effectiveness and adverse events.

Design: Systematic review. A search in the databases of Embase, Medline, Web of Science, Cochrane Central Register of Randomized Trials and Google Scholar was performed in 2022.

Study Eligibility Criteria: All reports of individual patient data with CSF drainage or lavage with a percutaneous lumbar access for an intrathecal drug error were included.

Measurements: The primary outcome is the description and count of CSF drainage or lavage, such as times and volume of drainage, volume of replacement and type of replacement fluid. Secondary outcomes are the effects, adverse events and overall outcome.

Main Results: 58 cases were found, of which 24 were paediatric cases. There was a large variance in methodology, with regard to volume t and type of replacement fluid. In 45% of the cases the intrathecal drug removal continued. The effects were specifically reported in 27 cases, all demonstrated drug removal based on drug concentrations in the CSF (n = 20) and clinical signs (n = 7). Adverse effects were sought for in 17 cases and found intracranial haemorrhage in 3 cases. No interventions were required for these adverse events and the only reported long-term sequelae in these three patients was short-term memory impairment up to 6 months after the event (n = 1). The overall outcome depended largely on the causative agent.

Conclusions: This review shows that CSF drainage or lavage leads to intrathecal drug removal, but it is unsure if this intervention leads to improved overall patient outcome. Based on aggregated data from case reports, we provide recommendations that may guide clinicians. The risk-benefit ratio should be weighed on a case-to-case basis.