What is the recommended dosage of Ativan (lorazepam) for seizure management in a comfort care setting?

Lorazepam for Seizure Management in Comfort Care

For seizure management in a comfort care setting, administer lorazepam 4 mg IV slowly (2 mg/min), which may be repeated once after 10-15 minutes if seizures persist, with respiratory support immediately available. 1

Standard Dosing Protocol

The FDA-approved dosing for status epilepticus in adults is straightforward:

• Initial dose: 4 mg IV administered slowly at 2 mg/min 1
• Repeat dose: Additional 4 mg IV may be given after a 10-15 minute observation period if seizures continue or recur 1
• Maximum experience: Limited data exists for doses beyond 8 mg total 1

This dosing is critical—underdosing lorazepam (anything less than 4 mg) significantly increases progression to refractory status epilepticus (87% vs 62%) 2. The Canadian Stroke Best Practice guidelines similarly recommend lorazepam IV as appropriate short-acting medication for new-onset seizures in acute stroke patients 3.

Critical Safety Requirements in Comfort Care

Equipment for airway management must be immediately available before administering lorazepam 1. This is non-negotiable even in comfort care settings:

• Oxygen and airway management equipment must be at bedside 4
• Artificial ventilation equipment should be readily available 1
• Apnea may occur up to 30 minutes after the last dose 4
• Respiratory depression risk increases substantially when combined with opioids or other sedatives commonly used in comfort care 4

Route Considerations for Comfort Care

When IV access is unavailable or undesirable in comfort care:

• IM lorazepam: 0.2 mg/kg (maximum 6 mg per dose) can be used, though therapeutic levels are reached more slowly than IV 5
• Sublingual lorazepam: 0.5-2 mg has shown effectiveness for seizure emergencies in home settings, with 70% of prolonged seizures stopping within 5 minutes 6
• Sublingual administration resulted in no serious adverse events and 31% developed moderate/severe sedation 6

The sublingual route may be particularly appropriate in comfort care when IV access is absent and the goal is symptom control rather than aggressive seizure termination.

Monitoring and Duration

Lorazepam's anticonvulsant effect lasts 15-80 minutes due to rapid redistribution 4, 7. In comfort care:

• Monitor for seizure recurrence for at least 2 hours after administration 5
• Continuous oxygen saturation monitoring is recommended 5
• Do not use flumazenil to reverse sedation in seizure patients, as it will precipitate seizure recurrence 5, 4

Key Differences from Acute Care

Unlike aggressive seizure management, comfort care typically does NOT require:

• Long-acting anticonvulsants (phenytoin/fosphenytoin) following lorazepam 5, 7
• Escalation to phenobarbital or continuous infusions 3
• Prophylactic anticonvulsants for single self-limiting seizures 3

A single self-limiting seizure should not be treated with long-term anticonvulsants 3. The goal in comfort care is symptom relief, not prevention of future seizures.

Comparative Efficacy

Lorazepam demonstrates superior efficacy compared to alternatives:

• Lorazepam controlled overt status epilepticus in 64.9% of patients vs 43.6% for phenytoin alone 8
• Lorazepam has longer anticonvulsant duration than diazepam 7
• Lower risk of respiratory depression compared to diazepam (relative risk 0.72) 7

Practical Algorithm for Comfort Care

1. Ensure respiratory support equipment is at bedside 1
2. Administer lorazepam 4 mg IV slowly over 2 minutes 1
3. If no IV access: Consider sublingual 1-2 mg or IM 0.2 mg/kg (max 6 mg) 5, 6
4. Observe for 10-15 minutes 1
5. If seizures persist: Repeat lorazepam 4 mg IV once 1
6. Monitor oxygen saturation and respiratory status for at least 30 minutes 4
7. Do not escalate to long-acting anticonvulsants unless goals of care change 5