Management of severe delirium with dexmedetomidine in a palliative care patient—a case report

Dexmedetomidine is used as an adjunct to anaesthesia or as a stand-alone agent for conscious sedation. It is a potent α2-adrenergic receptor agonist, with a fast onset of action and peak effects in 30 minutes to 1 hour after application, depending on the route of administration. It is metabolized in the liver and excreted in urine as a glucuronide. It potentiates analgesia and is effective in opioid sparing. Clinical trials show its efficacy in the treatment of Intensive Care Unit (ICU) delirium with an effect comparable to antipsychotics and benzodiazepines. It has also been used at the Eye Clinic of the University Medical Centre Ljubljana to sedate patients undergoing intraocular surgery. It proved to be an excellent alternative to other sedatives and analgesics, such as midazolam and remifentanil. The aim of this paper is to review the pharmacokinetics and pharmacodynamics of dexmedetomidine and to investigate its potential use in the palliative care population, particularly in the management of delirium. This area of application is still largely unexplored and opens up a new field of application. At the Institute of Oncology (IO) Ljubljana, we have used it with success in several palliative patients with delirium, when all other modalities were failing. At the IO Ljubljana, anaesthesiologists are involved in the palliative management of patients, especially in pain management, but also in sedation and delirium treatment. Given its favourable pharmacokinetic and pharmacodynamic effects, dexmedetomidine could be used more frequently and perhaps alternative and less complex routes of administration, such as intranasal administration, could be explored. In this paper, we present a case of a palliative care patient in whom dexmedetomidine was used successfully.

Sedation; Delirium; Palliative care; Dying patient

[1] Mo Y, Zimmermann AE. Role of dexmedetomidine for the prevention and treatment of delirium in intensive care unit patients. Annals of Pharmacotherapy. 2013; 47: 869–876.

[2] Greiss M, Ghobrial BB, Elmageed WMA, Elfawy DA, Mostafa RH. Dexmedetomidine versus fentanyl on stress response and pain control in adult patients undergoing laparoscopic surgery. Signa Vitae. 2022; 18: 116–124.

[3] Thomas B, Lo WA, Nangati Z, Barclay G. Dexmedetomidine for hyperactive delirium at the end of life: an open-label single arm pilot study with dose escalation in adult patients admitted to an inpatient palliative care unit. Palliative Medicine. 2021; 35: 729–737.

[4] Prommer E. Dexmedetomidine: does it have potential in palliative medicine? American Journal of Hospice and Palliative Medicine 2010; 28: 276–283.

[5] Keating GM. Dexmedetomidine: a review of its use for sedation in the intensive care setting. Drugs. 2015; 75: 1119–1130.

[6] Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P. Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clinical Pharmacokinetics. 2017; 56: 893–913.

[7] Gaertner J, Fusi-Schmidhauser T. Dexmedetomidine: a magic bullet on its way into palliative care—a narrative review and practice recommendations. Annals of Palliative Medicine. 2022; 11: 1491–1504.

[8] Coursin DB, Coursin DB, Maccioli GA. Dexmedetomidine. Current Opinion in Critical Care. 2001; 7: 221–226.

[9] Mantz J, Josserand J, Hamada S. Dexmedetomidine: new insights. European Journal of Anaesthesiology. 2011; 28: 3–6.

[10] Potočnik I, Andjelkovič-Juvan L, Hostnik A, Markovič-Božič J. Remifentanil target-controlled infusion with intranasal dexmedetomidine for vitreoretinal procedures: a randomized controlled trial. Croatian Medical Journal. 2021; 62: 233–240.

[11] Maltoni M, Scarpi E, Rosati M, Derni S, Fabbri L, Martini F, et al. Palliative sedation in end-of-life care and survival: a systematic review. Journal of Clinical Oncology. 2012; 30: 1378–1383.

[12] Grassi L, Caraceni A, Mitchell AJ, Nanni MG, Berardi MA, Caruso R, et al. Management of delirium in palliative care: a review. Current Psychiatry Reports. 2015; 17: 13.

[13] Bush SH, Tierney S, Lawlor PG. Clinical assessment and management of delirium in the palliative care setting. Drugs. 2017; 77: 1623–1643.

[14] Mondardini MC, Amigoni A, Cortellazzi P, Di Palma A, Navarra C, Picardo SG, et al. Intranasal dexmedetomidine: update of current knowledge. Minerva Anestesiologica. 2019; 85: 1334–1345.