Baclofen withdrawal
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Baclofen withdrawal syndrome: case report A 55-year-old man developed drug withdrawal syndrome manifested as hiccups, jaw clonus, myoclonus, rebound spasticity across all limbs and left arm dystonia after withdrawal of baclofen. The man had a medical history of schizophrenia, spasticity and paraplegia secondary to a spinal cord injury in his late teens. He was admitted for right hip septic arthritis and reinfection of a pressure sore to his buttocks. He was previously admitted for the same pressure sore accompanied by right ischial tuberosity osteitis and complete destruction of his right femoral head. During that hospital stay, he had undergone 5 different operations for surgical debridement of the wounds. On current admission, he received unspecified antibacterials [antibiotics]. Further investigations showed right lung pneumonia with microabscesses. However, his condition deteriorated further. He was noted to have oxacillin-sensitive Staphylococcus aureus infection. At that point, he mentioned his desire to stop ongoing treatments citing poor quality of life due to a worsening of his mobility in the previous years and the multiple admissions that he could not bear anymore. Subsequently, his antibacterials were stopped, and he was admitted to the palliative care ward. He had been receiving oral baclofen 25mg four times a day along with olanzapine, gabapentin, flurazepam and mirtazapine. Subsequently, he started receiving morphine. After 4 days, his underlying infectious process evolved rapidly, and his pain was difficult to manage. Thus, he stated receiving palliative sedation. Baclofen was stopped, and he received his last dose of baclofen at 12:00. He received midazolam, scopolamine hydrobromide, morphine and methotrimeprazine. The initial 14 hours of sedation was uneventful. At 10:00 on day 2, his consciousness level increased, and he developed myoclonus appeared. He was briefly opening his eyes and groaning. Spasticity was noted in his both arms. The dose of methotrimeprazine and midazolam was increased to achieve adequate sedation and muscle relaxation. In the morning of day 3, he woke up without external stimulation, had hiccups, very brief generalised myoclonus every 60–90s, jaw clonus, left arm dystonia and spasticity across all limbs. Despite midazolam treatment, his condition progressed from early morning with an increased intensity. The man was treated with dexmedetomidine with sodium chloride [normal saline], and methotrimeprazine was stopped. The dose of dexmedetomidine increased, and his jaw clonus decreased, generalised myoclonus disappeared, his dystonic left arm relaxed progressively; but spasticity persisted. After further increasing the dose of dexmedetomidine, the spasticity across all limbs completely vanished and he looked completely relaxed. Subsequently, he became unarousable, but was maintained on spontaneous ventilation. For the following 20h, no adjustments was made to his sedative medications due to difficulties in obtaining adequate sedation in the last hours of his life. Eventua
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