Appendix 2: Table of medications
Medication Initial bolus Maintenance dose
Step 1
Midazolam
Light palliative sedation
2.5 mg SC
1.25 mg IV
Deep palliative sedation
5-10 mg SC
2.5-5 mg IV
Bolus with half of the
starting bolus dosage may
be repeated after 20 min
SC or 5 min IV if
necessary.
It is not uncommon to
give 2 to 3 additional boli
during the first hrs of
palliative sedation.
Use 1 mg/hr (SC and IV) and then adjust as
needed.
Dosage has to be titrated according to effect. It
can be adjusted every 1-2 hrs as required in
conjunction with another bolus.
If risk factors are present (age > 60, weight
< 60 kg, severe kidney or liver function disorder,
very low serum albumin and/or co-medication
that could exacerbate the effect of sedation):
- half the initial dose, and
- longer interval (6-8 hrs) before increasing
maintenance dose.
In the case of doses higher than 10 mg/hr,
consider adding or changing medication.
Alternative
to
midazolam
Lorazepam 1-3 mg SC or IV
When administered by intermittent bolus: 1-3 mg
SC or IV every 2-4 hrs
Or 1-5 mg/hr SC or IV by continuous infusion
Step 2
in
combinatio
n with
midazolam
Levomepromazine
12.5-25 mg SC or IV
When administered by intermittent bolus: 12.525
mg SC or IV every 6-8 hrs
Or 0,5-8 mg/hr SC/IV by continuous infusion.
After 3 days, reduce the dose of
levomepromazine by half to avoid accumulation
of the sedative medication.
If the desired effect is not obtained, the
administration of midazolam and
levomepromazine should be changed to an
alternative medication.
Alternative
to
levomepromazine
Chlorpromazine
12.5 mg in slow IV
infusion over 0.5-1 hr or
12.5 mg IM every 4-12
hrs, or 3-5 mg/hr IV
or 25-100 mg PR every 412
hrs
Usual effective dose:
Parenteral 37.5-150 mg/day,
PR 75-300 mg/day.
Step 3 Propofol
Starting dose: 1 mg/kg/hr IV, increase by 0.5
mg/kg/hr every 30 min. Administration under the
supervision of an anaesthesiologist is advisable.
Intermittent sedation
Benzodiazepines are appropriate for intermittent sedation. Midazolam should
be stopped 30 min (if IV) or 2 hrs (if SC) before the expected awakening of the
patient. To restart palliative sedation, the starting bolus and maintenance dose
are those that were optimal last time.
57