Liverpool Care Pathway - The Execution Of Death

IVADS, including Midazolam, "significantly increased risk of death".






This is Family Practice News –

Although prospective, randomized controlled trials are needed to confirm the findings of this retrospective cohort study, the data should heighten awareness of the potential adverse effects of anesthetic drugs, Dr. Peter W. Kaplan said at the annual meeting of the American Epilepsy Society.

Of 171 adults who presented to University Hospital Basel, Switzerland, with status epilepticus between January 2005 and January 2011, 63 (37%) were treated with intravenous anesthetic drugs (IVADs), including thiopental, midazolam, propofol, and/or high-dose phenobarbital, and 18% of the patients died. After adjustment for status epilepticus duration and severity (based on status epilepticus severity score) and for critical medical conditions, those treated with IVADs had a significantly increased risk of death, compared with those who did not receive IVADs (relative risk = 3.16), said Dr. Kaplan of Johns Hopkins University, Baltimore.

Furthermore, 

Those who received IVADs also had a significantly higher rate of infectious complications (43% vs. 11%). The infections were diagnosed during the course of treatment, and 25 of 27 infections were respiratory infections. The remaining two cases were urinary tract infections.

and

Severe hypotension also occurred more often in the patients who received IVADs.

A Pubmed submission confirms this last finding -

Abstract
A 72-year-old patient received 0.1 mg morphine by the intrathecal route and 2 x 1.5 mg midazolam as adjuvant therapy. Severe respiratory depression and somnolence supervened 3.5 h later, which lasted over the next 24 h and necessitated intubation and mechanical ventilation. Continuous administration of >6 mg naloxone to antagonize the supposed effect of the morphine had no effect. The patient's condition was not normalized until a single dose of 0.3 mg flumazenil was administered. For the time being, especially in the case of elderly patients, we recommend that strict indications are adhered to when intrathecal administration of morphine is considered and that less than 0.1 mg morphine is given. Diazepines should be avoided. Respiration should be monitored for quite some time.

This interaction between Morphine and Midazolam to compound their effects is also of note. This was not picked up on by Baker (Gosport Inquiry), was not considered by Ellershaw (LCP) and was not acknowledged by Neuberger (LCP Review). That is gross oversight and negligence.

Morphine depresses respiratory drive in any case.

Hence, use for symptom management for breathlessness? All nice and tidy and reassuring for the relatives at the bedside...

But fatal if you've been diagnosed as 'dying' and you're not actually dying.

Perception is everything. Those PROMs are all-important to tick the boxes.

There has been outcry in the US in regard to Midazolam being a 'cruel and unusual punishment' and this has been reported in these pages. This is a more recent report in the Guardian –

The European Commission imposed tough restrictions on the export of anaesthetics to US corrections departments in 2011, and amid the squeeze a succession of states has been running out of their primary lethal drugs supplies. As a result, Florida has turned to midazolam hydrochloride, a drug never before used in executions, provoking an outcry that it might be inflicting cruel and unusual punishment on condemned prisoners.

The EU Commission moratorium has so affected application of the ultimate sanction that Correction Boards are now resorting to other protocols including Midazolam to execute death.

Please! Mr. Ellershaw, a letter to the Florida Department of Corrections in regard to the safety and efficacy of Midazolam would, surely, not go amiss.

Further reading -

Liverpool Care Pathway - A "Cruel And Unusual Punishment"?