A High-Dose Continuous Haloperidol Infusion Successfully Controlled Intractable Terminal Delirium (748)

Abstract

1.Consider a continuous infusion of haloperidol in cases of intractable terminal delirium.2.Learn the dosing and indication for continuous haloperidol infusion for management of intractable delirium or agitation at the end of life.3.Learn about the safety and tolerability of a continuous haloperidol infusion. Background. Haloperidol infusions have been successfully used to treat delirium in the palliative and critical care setting at dosages up to 600 mg/day. Case description. A 68-year-old female with metastatic hepatobiliary cancer was admitted with altered mental status and severe agitation. Further evaluation revealed probable leptomeningeal carcinomatosis and no reversible causes for her delirium. Her agitation became so severe that 4-point restraints were initiated for safety. The unremitting agitation caused untold amounts of suffering for both the patient and her family who witnessed the struggle. After multiple discussions with the family, the primary goal became relieving the patient's agitation to allow for removal of restraints. Attempts to manage her severe agitation with frequent, intermittent administration of haloperidol up to 4 mg were unsuccessful. A continuous infusion of haloperidol was started at 1 mg/hour, and gradually increased based on response to 7 mg/hour. At this dosage, the patient's agitation was controlled and restraints were safely discontinued. The patient also received a hydromorphone infusion at 1 mg/hour for pain control. When symptoms were well controlled for 24 hours, the haloperidol was decreased to a final rate of 1 mg/hour with no exacerbation of symptoms. EKGs revealed no QT prolongation. The patient was discharged to an inpatient hospice facility on both infusions. She died comfortably 1 week after hospital discharge. Conclusion. A high-dose haloperidol infusion was successfully and safely used to control severe agitation at the end of life. Continuous infusions are less labor intensive than frequent bolus dosing and provide more constant symptom relief. Where inpatient hospice facilities are available, continuous infusions of haloperidol can be considered for intractable agitation and delirium.