Emergency intravenous sedation of the delirious, medically ill patient

More than 2,000 medically ill patients with delirium have been treated by intravenous administration of a combination of haloperidol and lorazepam. The protocol was developed over 8 years at two major cancer centers in the United States and Canada. The addition of the potent benzodiazepine to the neuroleptic produces rapid and safe symptomatic sedation in emergency conditions and allows the use of lower doses of haloperidol. The combination was first attempted when doses of haloperidol as high as 350 mg failed to provide rapid emergency neurobehavioral control. All patients treated to date had cancer, and all were suffering multisystem organ failure. Hourly doses of each drug as high as 10 mg for as long as 15 days have been shown to be safe and effective in the most critically ill patient with delirium. Patients generally respond to the first one or two doses and, in most cases, less than 100 mg/day of each drug is required. The addition of the opioid hydromorphone makes the combination ideal for the treatment of intractable pain in terminally ill cancer patients. This polypharmacological approach is advocated as the method of choice for emergency sedation of the delirious patient as well as for palliative care.