Medications of Choice
The medications used for palliative sedation vary, but benzodiazepines and
barbiturates are favored agents. Other medications used include the phenothiazine
chlorpromazine, the butyrophenonehaloperidol, and the anesthetic agent propofol.
Medications and Suggested Doses for Palliative Sedation |
Drug |
Suggested Dose (a) |
| Midazolam |
0.5–5 mg bolus IV/SC, then CII/CSI at 0.5–1 mg/h; usual
maintenance dose, 20–120 mg/d |
| Lorazepam |
0.5–2 mg PO, SL, or SC every 1–2 hours
or
1–5 mg bolus IV/SC, then CII/CSI at 0.5–1 mg/h; usual
maintenance dose, 4–40 mg/d
|
| Chlorpromazine |
10–25 mg PO, IV, or PR every 2–4 hours
|
| Haloperidol |
0.5–5 mg PO or SC every 2–4 hours
or
1–5 mg bolus IV/SC, then CII/CSI at 5 mg/d; usual maintenance dose, 5–15
mg/d |
| Pentobarbital |
60–200 mg PR every 2–4 hours
or
2–3 mg/kg bolus IV, then CII at 1 mg/h; titrate upward to
maintain sedation |
| Phenobarbital |
200 mg IV/SC bolus, then CII/CSI at 600 mg/d; usual maintenance
dose, 600–1,600 mg/d |
| Thiopental |
5–7 mg/kg bolus IV, then CII at 20 mg/h; usual maintenance
dose, 70–180 mg/h |
| Propofol |
10 mg/h as CII; may titrate by 10 mg/h every 15–20 minutes;
bolus of 20–50 mg may be used for emergency sedation |
a Clinicians should consult pharmacy textbooks, pharmacists,
and other knowledgeable professionals for further dosing suggestions.
PO = oral; PR = per rectum; SL = sublingual; IV = intravenous; SC =
subcutaneous; CII
= continuous intravenous infusion; CSI = continuous subcutaneous infusion |
| Source: Rousseau P. Palliative sedation in the
management of refractory symptoms. J Support Oncol. 2004 Mar-Apr;2(2):181-6. |
The choice of an agent is dependent, for the most part, upon clinician
preference as well as institutional policy and formulary restrictions. Also,
in difficult cases, more than one medication may be needed to sedate a patient
adequately. Medications may be administered orally (until the patient is sedated),
sublingually, rectally, intravenously, or subcutaneously, with the route usually
patient and clinician dependent. In addition, since there is no definitive
evidence that unconscious patients do not experience pain, opioid administration
is usually continued once palliative sedation is initiated, although the dose
is usually not increased (Rousseau, 2001).
With respect to dose escalation of sedative medications, no universally accepted
guidelines or protocols exist (Rousseau, 2002; Wein,
2000); however, the dose
of a sedative medication should not be increased unless there is evidence of
inadequate sedation. Unfortunately, there are no validated scales to assess
depth of sedation in terminally ill patients, so many clinicians use direct
visual observation to determine depth of sedation.
However,
* the Ramsay Sedation
Scale (Ramsay,
1974),
* the Intra-Operative
Sedation Scale (Rudkin,
1992),
and
* the Richmond Agitation-Sedation
Scale (Ely,
2003)
have all been utilized, although their validation and corroboration with depth
of sedation in terminal illness are lacking. |
