Reference no: EM133951455

Question

Over the next week, Joe's pain worsened despite aggressive pain management. He was clearly suffering greatly and this caused severe distress to his family who could not bear to see him suffer in this manner.??????? Since his pain was unendurable and refractory to all palliative measures, palliative sedation was proposed as a humane and compassionate approach to allay his suffering.

???????After explanation of the procedure, both he and his family readily agreed to deep and continuous palliative sedation. An informed consent document was signed and a note describing the indications and plans for palliative sedation was recorded in the patient's chart.

1. A 4-mg subcutaneous bolus of midazolam was then administered, followed by a continuous subcutaneous infusion of 1.5 mg of midazolam per hour. The Ramsay Sedation Scale was used to monitor depth of sedation, and the dosage of midazolam was titrated upward to maintain a deep level of sedation (a 4-mg bolus every 30-60 minutes, as needed, was used, with the continuous infusion increased by 0.5 mg/h after each bolus).

2. He was sedated within 10 minutes, but after 30 minutes he was still rousable with verbal stimulation and complained of pain. So a second bolus of midazolam was administered and his infusion increased to 2 mg/h.

3. Titration continued over the next few hours until he was deeply sedated, with an eventual dose of 5 mg/h required to maintain deep and continuous sedation.

4. He died 4 days later, sedated, peaceful, and with his family at his bedside.

Incorporating your knowledge of this medication, discuss the process used to titrate the midazolam infusion and ensure adequate sedation.