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Garcia Romo E, Pfang B, Valle Borrego B, Lobo Antuña M, Noguera Tejedor A, Rubio Gomez S, Galindo Vazquez V, Prieto Rios B. Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms. J Palliat Med 2024. [PMID: 38973718 DOI: 10.1089/jpm.2023.0672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.
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Affiliation(s)
- Eduardo Garcia Romo
- Palliative Care Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Bernadette Pfang
- Health Research Institute of the Jimenez Diaz Foundation, Madrid, Spain
| | | | | | | | - Silvia Rubio Gomez
- Palliative Care Unit, Beata María Ana de Hermanas Hospitalarias Hospital, Madrid, Spain
| | | | - Blanca Prieto Rios
- Palliative Care Unit, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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Trinka E. Phenobarbital in Status epilepticus - Rediscovery of an effective drug. Epilepsy Behav 2023; 141:109104. [PMID: 36807987 DOI: 10.1016/j.yebeh.2023.109104] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 02/22/2023]
Abstract
Phenobarbital (PB) is one of the oldest Antiseizure Medicines (ASMs), which is in clinical use since 1912. Its value in the treatment of Status epilepticus is currently discussed controversially. Phenobarbital has fallen out of favor in many countries across Europe because of reports of hypotension, arrhythmias, and hypopnea. Phenobarbital has a strong antiseizure effect with remarkably little sedation. It exerts its clinical effects, through the increase of GABE-ergic inhibition and decrease of glutamatergic excitation by inhibition of AMPA receptors. Despite good preclinical evidence, there are remarkably few randomized controlled studies on humans in SE, which suggest, that it is at least as good as lorazepam in first-line treatment in early SE, and significantly better than valproic acid in benzodiazepine-resistant SE. Data from randomized trials and large non-randomized prospective and retrospective studies suggest, that Phenobarbital is well tolerated even if used in very high dose protocols. Thus, despite its decline in its popularity at least in Europe and North America, it should be considered a highly cost-effective treatment for early and established SE, not only in resource-limited settings. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of EpiCARE, Salzburg, Austria; Neuroscience Institute, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria; Institute of Public Health, Medical Decision-Making and HTA, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria.
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Sim J, Goh WY, Wiryasaputra L, Hum AYM, Neo HY, Poi CH. Use of Phenobarbitone for Palliative Sedation in Dyspneic Crises Due to COVID-19 Pneumonia - A Case Series. J Pain Palliat Care Pharmacother 2022; 36:242-248. [PMID: 36005904 DOI: 10.1080/15360288.2022.2113596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Patients who suffer from dyspnea while dying from COVID-19 are treated with opioids and benzodiazepines. In some instances, patients may experience refractory dyspnea at the end of life. Palliative sedation can be prescribed to alleviate such patients' suffering. We describe two patients being treated for severe COVID-19 pneumonia in a tertiary hospital. Both developed intractable dyspneic crises despite high-dose opioids and benzodiazepines. This led to their requirement of palliative sedation in the general ward using subcutaneous phenobarbitone (phenobarbital). We outline clinical considerations for the use of palliative sedation in COVID-19 related dyspnea. In particular, we discuss the evidence for, benefits and limitations of using phenobarbitone for palliative sedation in COVID-19 patients.
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Affiliation(s)
- Jingwei Sim
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Wen Yang Goh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Lynn Wiryasaputra
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Allyn Yin-Mei Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Han Yee Neo
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Choo Hwee Poi
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
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Bodnar J. The Use of Propofol for Continuous Deep Sedation at the End of Life: A Definitive Guide. J Pain Palliat Care Pharmacother 2019; 33:63-81. [DOI: 10.1080/15360288.2019.1667941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- John Bodnar
- John Bodnar, Penn Hospice at Chester County, West Chester, Pennsylvania, USA
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Cytochrome P450 in Palliative Care and Hospice Kits. J Hosp Palliat Nurs 2019; 21:280-285. [DOI: 10.1097/njh.0000000000000524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chen A, Loquias EJ, Roshan R, Levene R, Zelhof R, Hickey T, Cooney GA, Gonzalez F. Safe Use of Subcutaneous Diphenhydramine in the Inpatient Hospice Unit. Am J Hosp Palliat Care 2016; 34:954-957. [PMID: 27625354 DOI: 10.1177/1049909116668160] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Diphenhydramine (DPH) is most commonly used via oral, topical, intramuscular (IM) and intravenous (IV) routes for the palliation of pruritus, treatment of extrapyramidal symptoms, management of parkinsonism and for allergic reactions. However, many hospice patients are unable to take oral medications and/or do not have IV access. Moreover, topical administration has a relatively slow rate of absorption. For this reason, in the hospice setting it is not uncommon for diphenhydramine to be administered via the subcutaneous (SC) route secondary to its ease of access, low infection rates and its low levels of discomfort. In contrast, outside the hospice setting, subcutaneous DPH has not been widely used, primarily because of a handful of case reports published in the 1990's that report skin necrosis following subcutaneous administration of DPH for local anesthesia. Since these early case reports, however, there has been very little in the way of research to examine this further. The aim of this study is to provide objective data concerning the safe use of subcutaneous diphenhydramine, as part of our efforts to improve upon safe practices in our organization. METHODS This is a retrospective review of records from 6 of our inpatient hospice units obtained from our pharmacy database for patients who received at least one subcutaneous injection of diphenhydramine between 2012-2015. Selected patients were then subsequently screened for post-administration skin necrosis, as recorded in our quality assurance database during the same time period. RESULTS A total of 648 diphenhydramine subcutaneous injections were administered in109 individual patients. None of the patients were reported to have an adverse cutaneous reaction. CONCLUSIONS This retrospective review demonstrates that subcutaneous diphenhydramine injection is a safe alternative to oral and other parenteral routes, and may be particularly valuable in terminally ill patients, who are often unable to swallow and are without IV access.
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Affiliation(s)
- Aileen Chen
- 1 University of Miami/JFK Medical Center Palm Beach Regional Graduate Medical Education Consortium, Hospice and Palliative Medicine Program, West Palm Beach, FL, USA
| | - Erwin J Loquias
- 1 University of Miami/JFK Medical Center Palm Beach Regional Graduate Medical Education Consortium, Hospice and Palliative Medicine Program, West Palm Beach, FL, USA
| | - Ramesh Roshan
- 2 Trustbridge Health, West Palm Beach, Florida, FL, USA
| | - Richard Levene
- 1 University of Miami/JFK Medical Center Palm Beach Regional Graduate Medical Education Consortium, Hospice and Palliative Medicine Program, West Palm Beach, FL, USA.,2 Trustbridge Health, West Palm Beach, Florida, FL, USA
| | | | - Terry Hickey
- 2 Trustbridge Health, West Palm Beach, Florida, FL, USA
| | - Gail Austin Cooney
- 1 University of Miami/JFK Medical Center Palm Beach Regional Graduate Medical Education Consortium, Hospice and Palliative Medicine Program, West Palm Beach, FL, USA.,2 Trustbridge Health, West Palm Beach, Florida, FL, USA
| | - Faustino Gonzalez
- 1 University of Miami/JFK Medical Center Palm Beach Regional Graduate Medical Education Consortium, Hospice and Palliative Medicine Program, West Palm Beach, FL, USA.,2 Trustbridge Health, West Palm Beach, Florida, FL, USA
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