Dexmedetomidine
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Tachyphylaxis: case report An adolescent girl [exact age at onset not stated] developed tachyphylaxis during treatment with dexmedetomidine for refractory cyclic vomiting syndrome. The girl, who had undergone multiple surgeries due to complex congenital heart disease (tetralogy of Fallot, discontinuous and hypoplastic pulmonary arteries with multiple aortopulmonary collaterals) and had refractory cyclic vomiting, was hospitalised to paediatric hospice program in January 2012 (i.e. at the age of 14 years). Before admission, she had received prophylactic and abortifacient medications comprising cyproheptadine, amitriptyline, duloxetine, mirtazapine, topiramate, lansoprazole, ondansetron, promethazine, prochlorperazine, lorazepam, diazepam, scopolamine and diphenhydramine; however, all these medications proved ineffective. After failure of these treatments, she received infusion of dexmedetomidine [initial dosage not stated] for moderate sedation to abort the vomiting cycles. Her cyclic vomiting was successfully managed with dexmedetomidine. Ultimately, dexmedetomidine had become her primary treatment. At current admission, she was diagnosed with an end-stage heart failure. As there were no further palliative surgical options left, she was planned for home care as much as possible. Since previously she had required frequent hospitalisations for cyclic vomiting and the cyclic vomiting episodes were triggered by cardiac catheterisation procedures, a protocol was developed for administration of dexmedetomidine at home. A permanent SC infusion port was placed in July 2012. As per the protocol, she received dexmedetomidine infusion 0.3 µg/kg/hour for 30 minutes and then the rate of infusion was increased to 0.5 µg/kg/hour for 16 hours, followed by a decrease in the infusion rate to 0.3 µg/kg/hour for 3 hours and then stopped. The nurse will provide an unspecified IV fluids bolus, if needed, before starting dexmedetomidine. The nurse also administered lorazepam after establishing access to the port. Following the administration of unspecified IV fluids bolus, unspecified maintenance IV fluids were administered while dexmedetomidine infuses. Using this protocol, she was able to remain home through several cyclic vomiting episodes over the next 18 months. In November 2013, she was again hospitalised for menorrhagia and cyclic vomiting. She received packed RBCs and a dexmedetomidine infusion was administered according to the home protocol. Despite receiving multiple adjuvant antiemetics, including those listed above [not all antiemetics specified], the weaning of dexmedetomidine infusion rate resulted in a worsening vomiting. After 14 days, milrinone was administered in an attempt to improve her cardiac output, with a plan to wean both milrinone and dexmedetomidine when the cyclic vomiting improve. Four days later, with improvement in her symptoms, she requested to be discharged. She was discharged back to hospice care with both milrinone and continuous dexmedetomidine infusion. Although the plan was to wean both dexmedetom
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