Subcutaneous Dexmedetomidine for Refractory Symptoms in a Hospice Inpatient Unit

Pain, agitation, and other refractory symptoms occur commonly in palliative patients. Dexmedetomidine has anxiolytic, analgesic, and sedating effects; however, its use remains uncommon in palliative care. In New Zealand, the Hospice Waikato Inpatient Unit has increasingly used dexmedetomidine since 2019 when symptoms are refractory and deep sedation is not desirable due to patient and prognostic factors.

To describe use of subcutaneous dexmedetomidine infusions in the Hospice Waikato Inpatient Unit, noting patient demographics, treatment characteristics, safety factors, and effectiveness.

A retrospective, observational review of clinical records, using descriptive statistics.

Twenty-six infusions in 25 adult patients (≥18 years) were analyzed, of whom 24 (96%) had malignancy. Refractory pain (n=24, 92%) and agitated delirium (n = 13, 50%) were the commonest indications for dexmedetomidine. Median duration was 4 days (interquartile range 2.3-8.8 days). Infusion rates ranged between 0.2 and 1.4 mcg/kg/hr. Side effects occurred in 15 infusions (58%) but none required cessation. Potentiation of opioids, causing sedation, occurred once (4% of infusion events). Hemodynamic monitoring was seldom performed. Median change in Richmond Agitation-Sedation Score (RASS-PAL) over 24 hours was -2 (P = 0.0001) and clinicians perceived dexmedetomidine as effective within 24 hours in 23 cases (88%). Opioid and midazolam requirements often reduced but this effect was less pronounced beyond 24 hours.

Dexmedetomidine subcutaneous infusion appears to be well-tolerated, safe, and effective in managing pain and agitation, while maintaining patients' ability to interact with family. It may avoid the need for palliative sedation therapy (PST) in some cases.