title: Intensive symptom control of opioid-refractory dyspnea in congestive heart failure: Role of milrinone in the palliative care unit.
abstract: OBJECTIVE
  We describe an exemplary case of congestive heart failure (CHF) symptoms controlled with milrinone. We also analyze the benefits and risks of milrinone administration in an unmonitored setting.
  
  
  METHODS
  We describe the case of a patient with refractory leukemia and end-stage CHF who developed severe dyspnea after discontinuation of milrinone. At that point, despite starting opioids, she had been severely dyspneic and anxious, requiring admission to the palliative care unit (PCU) for symptom control. After negotiation with hospital administrators, milrinone was administered in an unmonitored setting such as the PCU. A multidisciplinary team approach was also provided.
  
  
  RESULTS
  Milrinone produced a dramatic improvement in the patient's symptom scores and performance status. The patient was eventually discharged to home hospice on a milrinone infusion with excellent symptom control.
  
  
  CONCLUSIONS
  This case suggests that milrinone may be of benefit for short-term inpatient administration for dyspnea management, even in unmonitored settings and consequently during hospice in do-not-resuscitate (DNR) patients. This strategy may reduce costs and readmissions to the hospital related to end-stage CHF.
authors.affiliation: Department of Emergency Medicine,The University of Texas MD Anderson Cancer Center,Houston,Texas.
authors.forename: Julio
authors.initials: J
authors.lastname: Silvestre
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine,The University of Texas MD Anderson Cancer Center,Houston.Texas.
authors.forename: Maria
authors.initials: M
authors.lastname: Montoya
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine,The University of Texas MD Anderson Cancer Center,Houston.Texas.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bruera
authors.affiliation: Department of Emergency Medicine and Department of Palliative Medicine,The University of Texas MD Anderson Cancer Center,Houston,Texas.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Elsayem
mesh_terms: D000701:Analgesics, Opioid / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use; D004417:Dyspnea / Q000188:drug therapy*; D005260:Female; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D007938:Leukemia / Q000150:complications / Q000188:drug therapy; D008875:Middle Aged; D020105:Milrinone / Q000008:administration & dosage / Q000494:pharmacology* / Q000627:therapeutic use*; D010166:Palliative Care / Q000379:methods*; D019141:Respiratory System Agents / Q000008:administration & dosage / Q000494:pharmacology* / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D019141:Respiratory System Agents; D020105:Milrinone
keywords: Congestive heart failure; Milrinone; Opioid-refractory dyspnea; Palliative care