From the Guidelines
For palliative care patients experiencing respiratory distress, midazolam should be administered at a dose of 2.5-5 mg subcutaneously every 2-4 hours as required, with the option for a subcutaneous infusion via a syringe driver starting with 10 mg over 24 hours if needed frequently 1.
Key Considerations
- The subcutaneous route is preferred for administration, with the option for a subcutaneous infusion via a syringe driver for more frequent dosing.
- The dose may need to be reduced to 5 mg over 24 hours if the patient's estimated glomerular filtration rate (eGFR) is <30 mL per minute 1.
- Midazolam can be used in combination with opioids for comprehensive dyspnea management, addressing both the respiratory drive component and associated anxiety.
Administration and Monitoring
- Midazolam has a rapid onset of action and short duration, making it ideal for acute symptom management.
- Respiratory monitoring is important, although in end-of-life care, the priority is symptom relief.
- Elderly patients or those with liver impairment may require lower doses, and careful monitoring is necessary to avoid adverse effects.
Comparison with Other Guidelines
- Other guidelines, such as those from 2015, recommend similar dosages of midazolam for palliation of dyspnea 1.
- However, the most recent and highest-quality study should be prioritized, which in this case is the 2020 study from the BMJ 1.
From the Research
Midazolam Dosage for Palliative Care
- The dosage of midazolam for palliative care is not explicitly stated in the provided studies, but it is mentioned as one of the most widely used drugs for refractory delirium and existential suffering 2.
- Midazolam is used in combination with other medications, such as opioids and scopolamine, to induce transient sedation in terminally ill patients with respiratory emergencies 3.
Route of Administration for Respiratory Distress
- Intranasal administration of midazolam is mentioned as a beneficial alternative route, particularly in community palliative care, due to its ease of administration, tolerability, and avoidance of needle use 4.
- Subcutaneous administration is also commonly used when oral medications are not tolerated or ineffective 4.
- The choice of route of administration may depend on individual patient needs and circumstances, and should be determined by a multidisciplinary team, including pharmacists or clinical pharmacologists 5.
Management of Respiratory Distress
- Breathlessness is a common and important symptom in palliative care, and its management should involve both non-pharmacological and pharmacological interventions 6.
- Midazolam, in combination with other medications, may be used to manage respiratory distress and agitation in terminally ill patients 3.
- A distress protocol, including midazolam, opioid, and scopolamine, can be effective in inducing transient sedation and managing respiratory emergencies in palliative care 3.