Response to Fiorani et al.,Chlorpromazine as a Viable Alternative to Midazolam for Palliative Sedation in a Liver Transplant Recipient with HCC

Dear Editor:

Palliative sedation is something offered to patients when symptoms cannot otherwise be controlled. Fiorani et al. presented a case study and reported that midazolam was not effective in providing sedation, and thus required a change to chlorpromazine. ¹

Fiorani reported a starting dose of 10 mg per day. This amount is less than the recommended hourly dose of 1 mg per hour. ² Although the authors reported dose escalation, they did not report the final dose that they used which they concluded was not effective, and thus required a change in medication. It is not clear whether a dose of 20 mg/hour (the dose cited as a point where switching medications would be considered) was reached. ²

Palliative sedation requires aggressive titration to achieve comfort and end suffering. Dosing guidelines are helpful in guiding clinicians in this effort. This patient may have been treated with an appropriate dose of midazolam before the clinician concluded that it was not effective; however, the dosage was not apparent in the information provided.