A prospective study of high dose sedation for rapid tranquilisation of acute behavioural disturbance in an acute mental health unit

Leonie Calver,Geoffrey K Isbister,Vincent Drinkwater

doi:10.1186/1471-244x-13-225

Abstract

BackgroundAcute behavioural disturbance (ABD) is a common problem in psychiatry and both physical restraint and involuntary parenteral sedation are often required to control patients. Although guidelines are available, clinical practice is often guided by experience and there is little agreement on which drugs should be first-line treatment for rapid tranquilisation. This study aimed to investigate sedation for ABD in an acute mental healthcare unit, including the effectiveness and safety of high dose sedation.MethodsA prospective study of parenteral sedation for ABD in mental health patients was conducted from July 2010 to June 2011. Drug administration (type, dose, additional doses), time to sedation, vital signs and adverse effects were recorded. High dose parenteral sedation was defined as greater than the equivalent of 10 mg midazolam, droperidol or haloperidol (alone or in combination), compared to patients receiving 10 mg or less (normal dose). Effective sedation was defined as a fall in the sedation assessment tool score by two or a score of zero or less. Outcomes included frequency of adverse drug effects, time to sedation/tranquilisation and use of additional sedation.ResultsParenteral sedation was given in 171 cases. A single drug was given in 96 (56%), including droperidol (74), midazolam (19) and haloperidol (3). Effective sedation occurred in 157 patients (92%), and the median time to sedation was 20 min (Range: 5 to 100 min). The median time to sedation for 93 patients receiving high dose sedation was 20 min (5-90 min) compared to 20 min (5-100 min; p = 0.92) for 78 patients receiving normal dose sedation. Adverse effects occurred in 16 patients (9%); hypotension (14), oxygen desaturation (1), hypotension and oxygen desaturation (1). There were more adverse effects in the high dose sedation group compared to the normal dose group [11/93 (12%) vs. 5/78 (6%); p = 0.3]. Additional sedation was given in 9 of 171 patients (5%), seven in the high dose and two in the normal dose groups.ConclusionsLarge initial doses of sedative drugs were used for ABD in just over half of cases and additional sedation was uncommon. High dose sedation did not result in more rapid or effective sedation but was associated with more adverse effects.

Highlights

Acute behavioural disturbance (ABD) is a common problem in psychiatry and both physical restraint and involuntary parenteral sedation are often required to control patients
Many prescriptive guidelines are available, clinical practice is often primarily guided by experience as there is little agreement on which drugs should be used as first-line treatment for rapid tranquilisation
This study aimed to investigate the types, doses and frequency of drugs used for sedation of ABD in an acute mental health unit, and the frequency of adverse drug effects

Summary

Introduction

Acute behavioural disturbance (ABD) is a common problem in psychiatry and both physical restraint and involuntary parenteral sedation are often required to control patients. Clinical practice is often guided by experience and there is little agreement on which drugs should be first-line treatment for rapid tranquilisation. Acute behavioural disturbance (ABD) is a common occurrence in the healthcare setting of acute psychiatry [1,2] Both physical restraint and involuntary parenteral sedation are often required to control patients with ABD. Many prescriptive guidelines are available, clinical practice is often primarily guided by experience as there is little agreement on which drugs should be used as first-line treatment for rapid tranquilisation. This is acknowledged by expert clinical opinion [1,11,12]

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