SEDATION OF AGITATED PATIENTS: WHAT AGENT TO USE?
An agitated patient can be a source of concern not only for the care giver but also for his/ her relatives. Sedation of agitated new patients is often a difficult and dangerous problem that could potentially harm the patient and the care giver.
Patients with unknown histories (or even identities) have been known to present in hospital, usually in the emergency department, in an agitated state often following alcohol and/or drug intoxication or secondary to some undiagnosed psychotic illness. In spite of available guidelines for the management of these patients, there continues to be some controversy over the appropriate use of psychotropic agents.
The common causes in agitated new patients include alcohol intoxication or withdrawal, benzodiazepine intoxication or withdrawal, anti-cholinergic delirium, amphetamine intoxication, often in combination with patients with personality disorders (either anti-social or borderline personality disorders). In these patients, it is imperative that the patient be chemically and if necessary physically restrained and the situation quickly controlled.
The goal of therapy is sedation after 15-20 minutes but controversy rages on over whether intramuscular or intravenous medication is more appropriate in these patients. While initially obtaining an intravenous access may require some effort, usually involving several persons, the major advantage of the intravenous route (i.v) is achievement of rapid and safe sedation and easy titration of the medication to effect. The intramuscular route (i.m) is advocated if the patient needs to be sedated quickly after initial restraint. The major disadvantage of this route is that medicines cannot be titrated and this may lead to over-sedation or under-sedation of patients.
Managing an agitated new patient might be a challenge for the care giver because of decision making on the choice of sedative to administer. In most centers however, a benzodiazepine or a neuroleptic or combination of both is used. Concerns however have been raised about the efficacy and the potential side effects of these agents. Many of the traditional anti-psychotic agents are either non-sedating or have been known to cause extra pyramidal side effects. While parenteral forms of benzodiazepines and traditional antipsychotics remains the quickest agents used to achieve sedation in agitated patients, few control studies have compared the use of these agents.
Recent studies however have shown that Midazolam 5mg i.m appears to have a more sedating effect than Haloperidol 5mg i.m and Lorazepam 2mg i.m. other studies comparing Midazolam with neuroleptics such as Droperidol and Ziprasidone show that Midazolam has a faster onset of sedation than other agents but requires more rescue sedation.
Parenteral forms of Haloperidol and Droperidol are widely used to achieve acute sedation with Droperidol having the greater sedative effect as documented in comparative trials. However, there have been concerns in recent years about the prolongation of QT intervals and TdP by both agents. The use of Olanzapine i.m appears to have gained some popularity in recent years as it has been shown to be useful for patients with established psychiatric diagnoses. However, further research must be undertaken before Olanzepine is rubber-stamped as an agent for use in agitated patients.
Caregivers should as a matter of principle use existing drugs approved by their National FDAs or evaluate those agents that have been approved for parallel indications.
