What medication should be given to a patient?

Medication Management for Symptom Control

For patients requiring symptom management during critical illness or end-of-life care, initiate opioids as first-line agents for pain and dyspnea, with morphine 2 mg IV bolus every 15 minutes as needed for opioid-naïve patients, followed by continuous infusion if symptoms persist. 1

Pain and Dyspnea Management

Opioid Therapy (First-Line)

• Start with morphine 2 mg IV bolus (or equianalgesic dose of hydromorphone or fentanyl) for opioid-naïve patients experiencing pain or respiratory distress 1
• Titrate to effect with no specified dose limit, adjusting based on patient size, age, and organ dysfunction 1
• Administer bolus doses every 15 minutes as needed for morphine/hydromorphone, or every 5 minutes for fentanyl 1
• Follow bolus with continuous infusion if breakthrough symptoms occur 1

Dosing Adjustments for Patients on Opioid Infusions

• Give bolus dose equal to 2× the hourly infusion rate for patients already receiving morphine or hydromorphone infusions who develop breakthrough pain or dyspnea 1
• Double the infusion rate if patient requires two bolus doses within one hour 1
• Continue stable opioid doses for patients already comfortable on existing regimens 1

Sedation Management (Second-Line)

Benzodiazepines

• Use sedatives only after pain and dyspnea are controlled with opioids, though combinations may be used concurrently 1
• Start with midazolam 2 mg IV bolus followed by 1 mg/hour infusion for benzodiazepine-naïve patients with agitation 1
• Administer bolus doses every 5 minutes as needed, using 1-2× the hourly infusion rate for breakthrough agitation 1
• Double infusion rate if two boluses required within one hour 1

Alternative Sedatives

• Consider propofol or barbiturates as second-line when benzodiazepines are ineffective or in exceptional circumstances 1
• Propofol is appropriate for patients already stable on propofol infusions or when providers are experienced with its use 1

Gastrointestinal Symptom Management

Nausea and Vomiting

• Administer ondansetron 8 mg IV every 8 hours scheduled 30 minutes prior to each dose of therapy 1
• Add prochlorperazine 10 mg IV every 6 hours PRN or lorazepam 0.5 mg IV every 6 hours PRN for breakthrough symptoms 1

Diarrhea

• Give loperamide 2 mg every 2 hours as needed after ruling out gastrointestinal infection 1
• Escalate to diphenoxylate/atropine two tablets PO every 6 hours PRN for loperamide-refractory diarrhea 1

Gastrointestinal Prophylaxis

• Prescribe pantoprazole 40 mg PO/IV daily or famotidine 20 mg PO/IV twice daily 1
• Avoid steroids for prevention of gastrointestinal symptoms 1

Respiratory Symptom Management

Post-Extubation Stridor

• Use inhaled epinephrine to treat post-extubation stridor in conscious patients 1

Supplemental Oxygen

• Provide supplemental oxygen only for comfort, not routinely 1

Additional Supportive Medications

Antiemetics

• Order antinauseant medications PRN with all opioid prescriptions 1

Dermatologic Symptoms

• Give diphenhydramine 25 mg PO every 6 hours PRN or hydroxyzine 10 mg PO every 6 hours PRN for pruritus 1
• Apply Aveeno or Lubriderm lotion three times daily for skin symptoms 1

Cardiovascular Support

• Administer NS or LR 500 mL IV fluid bolus for hypotension 1
• Replete electrolytes and monitor for arrhythmias continuously 1

Critical Pitfalls to Avoid

• Never use mixed agonist-antagonist opioids (such as nalbuphine or butorphanol) as they may precipitate withdrawal 1
• Do not routinely use anticholinergics, furosemide, or methylprednisolone prophylactically without specific indications 1
• Avoid neuromuscular blocking agents during symptom management; allow effects to wear off prior to withdrawal of life-sustaining measures 1
• Do not prescribe NSAIDs in heart failure patients without specific compelling indications, as they are generally contraindicated 1