High-Dose Continuous Propofol for Refractory Hyperactive Delirium: A Case Report

Abstract

Background

Delirium is a frequent and distressing complication in advanced cancer, often multifactorial and refractory to standard agents. Palliative sedation may be required when symptoms remain uncontrolled, and propofol is an emerging option in this context.

Case Presentation

We describe a 61-year-old woman with Stage IV lung adenocarcinoma admitted to a hospice-type palliative care (PC) unit. She had multiple comorbidities and a history of polysubstance use, including long-term methadone and benzodiazepines. On Day 7, she developed hyperactive delirium unresponsive to escalating neuroleptics, benzodiazepines, and barbiturates, consistent with “pharmacoresistant” delirium.

Management/Intervention

After multidisciplinary review and discussion with her son, proportional PS was initiated using continuous intravenous propofol infusion. The infusion began at 60 mg/h (1.5 mg/kg/h) and gradually titrated to 320 mg/h (≈8 mg/kg/h). Concurrently, transdermal fentanyl was increased to 300 µg/h for analgesia. Sedation depth was monitored with the “Consciousness Scale for PC,” with goals set at Levels 1–3 to allow intermittent interaction.

Outcomes

Adequate sedation was achieved within 10 min and maintained for 25 days until death, without respiratory or hemodynamic compromise. No adverse effects or signs of propofol infusion syndrome were observed, despite doses exceeding conventional thresholds.

Conclusion

This case highlights the feasibility and safety of high-dose, long-term propofol infusion for refractory delirium in advanced cancer. While not routine, propofol may serve as a rescue agent when standard regimens fail, provided decisions are ethically grounded, monitoring is rigorous, and family involvement is prioritized.