Quand le midazolam ne suffit plus. Mise au point et protocoles de Limoges

Midazolam is the main pharmacological agent for sedation in palliative care. But in 13 to 17% of cases, the result is considered unsatisfactory and it must be combined with or replaced by another agent. In addition to midazolam, French and international guidelines mention other benzodiazepines, neuroleptics, barbiturates, propofol, ketamine, sodium oxybate, and, more recently, dexmedetomidine as possible agents for sedation, though this is more of a consensus among experts than evidence-based medicine. The goal of this minireview is to give a detailed overview of why midazolam may fail, to emphasize the importance of a clinical evaluation of the sedative process and to review the practical interest of different therapeutic alternatives from the shared experience of anaesthetists and critical care physicians. Finally, we present the guidelines followed in Limoges in such cases.