Page 24 - Palliative Care, Trials and COVID-19 Tribulations: First-hand experience shared by the experts at ground zero

If the patient has anxiety, restlessness, and is still distressed, you can add a benzodiazepine
like midazolam or lorazepam. Typically, we use a combination in our infusion of morphine,
10 - 15 mg, and midazolam, 5 - 10 mg over 24 hours.

Happy Hypoxemia

Now, just a word about happy hypoxemia. I think that all of us who manage COVID-19, you
would have seen this phenomenon where SpO and PaO are low, but the patient does not feel
2
2
dyspnoeic. In situations like this, you do not need to start the opioids based on the SpO 2
alone, only treat it if the patient is having dyspnoea.

What we know is that patients who have this happy hypoxemia, they actually at some point,
when the lung gets worse, they will actually feel dyspnoeic. Sometimes that transition can be
very acute and very severe. So, please make sure that you write up subcutaneous Morphine
2.5 mg with Midazolam 2.5 mg PRN to stand by just in case the nurses need to give
something to the patient when they become very breathless or restless all of a sudden.

Delirium and Restlessness

Moving on to delirium and restlessness, which is the second most common problem. You
may see patients with delirium (i) they have got confused speech; (ii) hallucinations; (iii)
reversal sleep patterns and; (iv) trying to get on and off the bed. While restlessness/agitation,
(i) they are moving all around; (ii) they are pulling off their lines and their masks and; (iii)
they are kicking violently on bed.

Figure 15: Restrain patients in bed.