Chemical Sedation Research Articles

Racial, Ethnic, and Age-Related Disparities in Sedation and Restraint Use for Older Adults in the Emergency Department

ObjectivesOlder adults may present to the emergency department (ED) with agitation, a symptom often resulting in chemical sedation and physical restraint use which carry significant risks and side effects for the geriatric population. To date, limited literature describes the patterns of differential restraint use in this population. Design, setting, participants, and measurementsThis retrospective cross-sectional study used electronic health records data from ED visits by older adults (age ≥65 years) ranging 2015–2022 across nine hospital sites in a regional hospital network. Logistic regression models were estimated to determine the association between patient-level characteristics and the primary outcomes of chemical sedation and physical restraint. ResultsAmong 872,587 ED visits during the study period, 11,875 (1.4%) and 32,658 (3.7%) encounters involved the use of chemical sedation and physical restraints respectively. The populations aged 75-84, 85-94, 95+ years had increasingly higher odds of chemical sedation [adjusted odds ratios (AORs) 1.35 (95% CI 1.29–1.42); 1.82 (1.73–1.91); 2.35 (2.15–2.57) respectively] as well as physical restraint compared to the 65-74 group [AOR 1.31 (1.27–1.34); 1.55 (1.50–1.60); 1.69 (1.59–1.79)]. Compared to the White Non-Hispanic group, the Black Non-Hispanic and Hispanic/Latinx groups had significantly higher odds of chemical sedation [AOR 1.26 (1.18–1.35); AOR 1.22 (1.15–1.29)] and physical restraint [AOR 1.12 (95% CI 1.07–1.16); 1.22 (1.18–1.26)]. ConclusionApproximately one in 20 ED visits among older adults resulted in chemical sedation or physical restraint use. Minoritized group status was associated with increasing use of chemical sedation and physical restraint, particularly among the oldest old. These results may indicate the need for further research in agitation management for historically marginalized populations in older adults.

1990 Acute Sedation Prescribing in the Older Person

Abstract Introduction Anti-psychotics and benzodiazepines are commonly prescribed for older people. They are usually indicated in the short term for delirium and agitation. There are known risks associated with these drugs in the older population including functional decline, increased falls risk and overall mortality. Moreover, chemical sedation is a form of restraint and deprives patients of their liberty. Sedative prescribing should be protocol driven and preceded by non-pharmacological intervention. However, these prescriptions are often initiated prematurely and evade review, continuing in the long-term. Method Our QI team aimed to reduce prescribing of new sedating drugs by 60% in patients using an MDT approach. Our strategies focused on increasing awareness and utilisation of existing protocols, to improve non-pharmacological management of delirium. This was achieved through the strategic delivery of teaching sessions for nursing, pharmacy and medical staff. Further, we utilised force function techniques and management charts to encourage review of these prescriptions. We gathered our data on a weekly basis over a five-month period by reviewing all prescribed medicines for patients on an older people’s ward. Results We exceeded our initial aim achieving a reduction of 82% in the prescribing of new lorazepam and haloperidol. We also attained a significant and sustained uptake of over 95% in the use of the delirium protocol. Where a review sticker was used, 80% led to discontinuation of the target prescription. Although these improvements were focused on one ward, the wider changes and improvements were observed throughout the hospital. Conclusion The significant reduction in sedative prescribing demonstrates the need and potential for improving the quality and safety of this aspect of patient care. The wider success of this project highlights the importance of addressing human factors to drive and sustain change. Improving the understanding of MDT members is integral to changing behaviours and improving patient safety.

Psychosis in acute methamphetamine intoxication is usually self-limiting and can be managed in the emergency department: A retrospective series.

There is little recent published data characterising acute psychosis associated with methamphetamine intoxication. We aim to describe the clinical features of psychosis, management of acute behavioural disturbance and disposition of patients with psychosis associated with acute methamphetamine intoxication. This is a retrospective review of patients presenting with acute (use within 24 h) methamphetamine intoxication, with features of psychosis (presence of delusions, hallucinations or formal thought disorder), to an ED over 4 months in 2020. All presentations were extracted from a toxicology unit database and each medical record reviewed. Demographics, past mental health diagnoses, clinical features and disposition were extracted. There were 287 presentations of methamphetamine intoxication over the period. Of these 287 presentations, 205 (71%) had features of acute psychosis, occurring in 171 patients (111 males [65%], median age 36, range 16-57 years). Paranoid delusion occurred in 134 of 205 (65%) presentations and was the most common feature of psychosis. Chemical sedation was given to 194 (95%), with 143 (70%) receiving parenteral sedation to manage acute behavioural disturbance. Complete resolution of psychotic symptoms occurred in 170 of 205 (83%) of exposures. There were 9 of 205 (4%) presentations that resulted in a mental health admission. Most presentations - 200 of 205 (98%) - were managed within the ED, primarily the short-stay unit. The median length of stay was 15 h (interquartile range 11-20 h). In this series of patients presenting to ED with acute methamphetamine intoxication, psychosis appeared to occur commonly and was mostly short-lived, resolving within 24 h in the majority of patients.

A retrospective cohort study of pre-hospital agitation management by advanced paramedic practitioners in critical care.

Pre-hospital clinicians can expect to encounter patients with agitation, including acute behavioural disturbance (ABD). These situations carry significant risk for patients and emergency medical services. Advanced paramedics within the London Ambulance Service (LAS) are frequently tasked to these incidents. At present, little evidence exists regarding clinical decision-making and management of this patient group. We sought to explore the demographics of patients presenting with potential ABD and quantify the degree of agitation, physical restraint, effectiveness of chemical sedation and any associated complications. A retrospective analysis of pre-hospital clinical records for patients coded with ABD and attended by LAS advanced paramedics between 1 October 2019 and 30 September 2020. Sedation assessment tool (SAT) scores were used as the primary outcome measure. A total of 237 patient records were identified. Of the patients, 147 (62%) were physically restrained and 104 (44%) were chemically sedated. Sedation was more commonly administered where patients were exposed to physical restraint. High SAT scores were associated with the administration of sedative agents and at higher doses. Of patients undergoing sedation, 89 (85%) had a SAT score reduction of 2 points or a final score ≤ 0. The mean SAT score reduction was 2.72. Three cases of minor injury were reported following physical restraint. Advanced paramedics undertook sedation in less than half the cohort, suggesting that other strategies such as communication and positioning were utilised. Most patients were managed into a state between being restless and rousable, largely negating the need for ongoing physical restraint during hospital transfer. Appropriately trained advanced paramedics can utilise sedation safely and effectively in selected cases.

Intravenous Haloperidol Has a Limited Role in the Modern Emergency Department

Haloperidol is a butyrophenone-class antipsychotic agent with more than 6 decades of clinical use across most disciplines of medicine. In the emergency department (ED), haloperidol is commonly used to facilitate chemical sedation of acutely agitated patients, ameliorate symptoms of nausea and vomiting, reduce hallucinations and delirium associated with ethanol withdrawal, and more. Only the intramuscular (IM) route is Food and Drug Administration (FDA)-approved for parenteral use, but the same formulation has been used intravenously (IV) for many years.

Violence in intensive care: a point prevalence study

Introduction: Violence in the intensive care unit (ICU) is poorly characterised and its incidence is largely extrapolated from studies in the emergency department. Policy requirements vary between jurisdictions and have not been formally evaluated. Methods: A multisite, single-time point observational study was conducted across Australasian ICUs which focused on the incidence of violence in the previous 24 hours, the characteristics of patients displaying violent behaviour, the perceived contributors, and the management strategies implemented. Unit policies were surveyed across a range of domains relevant to violence management. Results: Data were available for 627 patients admitted to 44 ICUs on one of 2 days in June 2019. Four per cent (25/627) displayed at least one episode of violent behaviour in the previous 24 hours. Violent behaviour was more likely in individuals after a greater length of stay in hospital (incidence, 2%, 4% and 7% for day 0-2, 3-7 and > 7 days respectively; P = 0.01) and in the ICU (2%, 4% and 9% for day 0-2, 3-7 and > 7 of ICU stay respectively; P < 0.01). The most common perceived contributors to violence were confusion (64%), physical illness (40%), and psychiatric illness (34%). Management with chemical sedation (72%) and physical restraint (28%) was commonly required. Clinicians assessed an additional 53 patients (53/627, 9%) as at risk of displaying violence in the next 24 hours. Of the 44 participating ICUs, 30 (68%) had a documented violence procedure. Conclusion: Violence in the ICU was common and frequently required intervention. In this study, one-third of ICUs did not have formal violence procedures, and in those with violence procedures, considerable variation was observed.

Acute Opioid Withdrawal Following Intramuscular Administration of Naloxone 1.6 mg: A Prospective Out-Of-Hospital Series

Large doses of intramuscular (IM) naloxone are commonly used in out-of-hospital settings to reverse opioid toxicity; however, they are used less commonly in hospitals because of concerns about opioid withdrawal, particularly agitation. We aimed to determine the frequency of severe agitation following a single 1.6 mg IM naloxone dose. We undertook a prospective study of adult (>15 years) patients treated by an Australian state ambulance service with 1.6 mg IM administration of naloxone for respiratory depression (respiratory rate <11 breaths/min and/or oxygen saturation <93% in room air) caused by presumed opioid poisoning. The primary outcome was the proportion of presentations with severe agitation (Sedation Assessment Tool score >1) within 1 hour of naloxone administration. Secondary outcomes were the proportion of presentations with acute opioid withdrawal (tachycardia [pulse rate >100 beats/min], hypertension [systolic >140 mm Hg], vomiting, agitation, seizure, myocardial infarction, arrhythmia, or pulmonary edema), and reversal of respiratory depression (respiratory rate >10 breaths/min and saturation >92% or Glasgow Coma Scale score 15). From October 2019 to July 2021, there were 197 presentations in 171 patients, with a median age of 41 years (range, 18 to 80 years); of the total patients, 119 were men (70%). The most common opioids were heroin (131 [66%]), oxycodone (14 [7%]), and morphine (11 [6%]). Severe agitation occurred in 14 (7% [95% confidence interval {CI} 4% to 12%]) presentations. Opioid withdrawal occurred in 76 presentations (39% [95% CI 32% to 46%]), most commonly in the form of tachycardia (18%), mild agitation/anxiety (18%) and hypertension (14%). Three presentations (1.5%) received chemical sedation for severe agitation within 1 hour of naloxone administration. A single 1.6 mg dose of naloxone reversed respiratory depression in 192 (97% [95% CI: 94% to 99%]) presentations. Severe agitation was uncommon following the administration of 1.6 mg IM naloxone and rarely required chemical sedation.

COMPARATIVE STUDY ON THE IMPACT OF DIFFERENT IMMOBILIZATION METHODS ON MUSCLE INTEGRITY AND STRESS INDICATORS IN BROOK TROUT (SALVELINUS FONTINALIS).

Chemical sedation of fish is often used during scientific research to reduce stress and risk of injury. Electric fish handling gloves (EFHG) have been proposed as a no-residue alternative to chemical immobilization. However, the impact of handling fish with EFHG on their physiology remains relatively poorly studied. Stress markers (plasma cortisol and lactate) and the impact on muscular integrity (plasma creatine kinase and histopathology of skeletal muscles) were assessed in brook trout (Salvelinus fontinalis) subjected to one of three immobilization methods (manual restraint, EFHG [10-16 mV], and buffered 60 mg/L tricaine methanesulfonate [MS-222] immersion anesthesia) for 1- and 5-min restraints. Plasma lactate levels were significantly higher 2 h postrestraint for all experimental groups (+242%; P < 0.001), but the magnitude of these increases was significantly lower in the MS-222 groups (P ≤ 0.0002). Plasma creatine kinase concentrations significantly increased 2 h postrestraint for the EFHG groups (+92%, P ≤ 0.0061), and this increase was significantly higher than in the MS-222 group for the 1-min restraint (P = 0.0031). Although there was no significant difference between the restraining methods tested at all time points for plasma cortisol, the EFHG and manual restraint groups showed a linear and statistically significant increase after the initial 5-min restraint, whereas all other groups presented an expected bell-shaped profile with a plasma peak 1 h after the initial restraint. One fish in the manual restraint group died during the 5-min restraint, and two fish from the EFHG group were euthanized at the end of this protocol because of buoyancy anomalies. All other fish from the 5-min restraint group developed cutaneous saprolegniasis 3 wk after the experiments. The evaluation of the safety of EFHG in brook trout showed similar impacts on the variables tested compared with manual restraint for 1- and 5-min immobilizations.

Racial disparities in the management of emergency department patients presenting with psychiatric disorders

PurposeEmergency departments (ED) provide critical resources including stabilization, diagnosis of underlying medical precipitants and transfer to psychiatric hospitals for mental health emergencies. Our objective was to examine the association of race and/or ethnicity and the administration of chemcial sedation using a nationally representative sample of ED visits for psychiatric disorders. MethodsWe analyzed data from 2008 to 2018 through the National Hospital Ambulatory Medical Survey database, a national probability survey based on ED chart abstraction. All ED visits for psychiatric disorders were included. Our primary outcome variable was receipt of chemical sedation among patients presenting with a complaint related to a psychiatric condition. We defined receipt of chemical sedation by the receipt of a first or second-generation antipsychotic or ketamine that was given in the ED. Our secondary outcome was receipt of psychiatric treatment defined as admission to a mental health and/or detox unit at the same hospital or transfer to a psychiatric facility. We used logistic regression models and used marginal effects to report the average adjusted probability in outcomes for different patient characteristics. ResultsNationally after weighting, 76,200,000 of 1,480,102,130 total ED visits (5.1%, 95% CI 4.9%–5.4%) were designated to be for treatment of a psychiatric disorder. When controlling for patient age, sex, initial pulse, presence of chronic medical conditions, geographic region, EMS arrival and nightshift arrival, among patients presenting with psychiatric disorders, Black race was associated with a 2.2% point (95% CI 0.8–3.7, P < .01) greater probability of receiving chemical sedation than non-Hispanic (NH) white race and/or ethnicity (3.0%) and this difference remained significant when accounting for admission or transfer to psychiatric facilities. However, when accounting for the percent of hospital population that was Black (P < .01), individual patient race was no longer associated with a significant increase in receipt of chemical sedation. There was no significant association between race and/or ethnicity and admission or transfer to psychiatric facilities. ConclusionNationally, Black patients presenting to the ED are more likely to receive chemical sedation than NH-white patients for psychiatric complaints, and this appears to be because hospitals serving a high proportion of Black patients use more chemical sedation, suggesting structural racism is a potential root cause.

Patient Outcomes Following Ketamine Administration for Acute Agitation with a Decreased Dosing Protocol in the Prehospital Setting.

Agitated behaviors are frequently encountered in the prehospital setting and require emergent treatment to prevent harm to patients and prehospital personnel. Chemical sedation with ketamine works faster than traditional pharmacologic agents, though it has a higher incidence of adverse events, including intubation. Outcomes following varying initial doses of prehospital intramuscular (IM) ketamine use have been incompletely described. To determine whether using a lower dose IM ketamine protocol for agitation is associated with more favorable outcomes. This study was a pre-/post-intervention retrospective chart review of prehospital care reports (PCRs). Adult patients who received chemical sedation in the form of IM ketamine for agitated behaviors were included. Patients were divided into two cohorts based on the standard IM ketamine dose of 4mg/kg and the lower IM dose of 3mg/kg with the option for an additional 1mg/kg if required. Primary outcomes included intubation and hospital admission. Secondary outcomes included emergency department (ED) length of stay, additional chemical or physical restraints, assaults on prehospital or ED employees, and documented adverse events. The standard dose cohort consisted of 211 patients. The lower dose cohort consisted of 81 patients, 17 of whom received supplemental ketamine administration. Demographics did not significantly differ between the cohorts (mean age 35.14 versus 35.65 years; P = .484; and 67.8% versus 65.4% male; P = .89). Lower dose subjects were administered a lower ketamine dose (mean 3.24mg/kg) compared to the standard dose cohort (mean 3.51mg/kg). There was no statistically significant difference between the cohorts in intubation rate (14.2% versus 18.5%; P = .455), ED length of stay (14.31 versus 14.88 hours; P = .118), need for additional restraint and sedation (P = .787), or admission rate (26.1% versus 25.9%; P = .677). In the lower dose cohort, 41.2% (7/17) of patients who received supplemental ketamine doses were intubated, a higher rate than the patients in this cohort who did not receive supplemental ketamine (8/64, 12.5%; P <.01). Access to effective, fast-acting chemical sedation is paramount for prehospital providers. No significant outcomes differences existed when a lower dose IM ketamine protocol was implemented for prehospital chemical sedation. Patients who received a second dose of ketamine had a significant increase in intubation rate. A lower dose protocol may be considered for an agitation protocol to limit the amount of medication administered to a population of high-risk patients.

Agitated Psychiatric Patient.

This scenario was developed to educate emergency medicine residents about the diagnosis and management of the agitated psychiatric patient. The prevalence of agitation among patients in the emergency department is increasing, with an estimated 1.7 million events occurring annually in the United States.1 There are various methodologies for de-escalation, including verbal and chemical de-escalation and physical restraints. Chemical and/or physical restraints are sometimes necessary to ensure patient and staff safety when verbal de-escalation is ineffective, particularly since agitation is the leading cause of hospital staff injuries.2 Chemical restraints have been shown to be less physically traumatizing to patients.3 4 Adverse events associated with physical restraints include persistent psychological distress, blunt chest trauma, aspiration, respiratory depression, and asphyxiation leading to cardiac arrest.5 In regards to chemical restraints, adverse event reporting has been heterogeneous among studies, but the most consistent reported events involve respiratory compromise such as desaturation, airway obstruction, and respiratory depression.3 A study measuring QTc (corrected QT interval) after high-dose intramuscular ziprasidone or haloperidol did not demonstrate any QTc longer than 480 msec.6 Other events linked to chemical restraints include uncommon cardiovascular events and extrapyramidal side effects from medications.3 The main classes of medications utilized for chemical restraint include first-generation antipsychotics (eg, haloperidol and droperidol), second-generation antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone), benzodiazipenes (eg, lorazepam and midazolam), and N-methyl-D-aspartic acid (NMDA) receptor antagonists (eg, ketamine).7,8 It is important to exclude other medical causes of agitation, consider the differential diagnoses, and then select a medication that is tailored to address underlying etiologies while remaining cognizant of the side effect profiles of these chemical agents.Educational Objectives: At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history and physical examination on the agitated psychiatric patient. 2) Develop a differential for the agitated psychiatric patient, including primary psychiatric conditions and other organic pathologies. 3) Discuss the management of the agitated psychiatric patient, including the different options available for chemical sedation. 4) Prioritize safety of self and staff when caring for an agitated psychiatric patient. This session was conducted using simulation with a standardized patient, followed by a debriefing session and lecture on the presentation, differential diagnosis, and management of the agitated psychiatric patient. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board examination case. The residents are provided a survey at the completion of the debriefing session to rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center. Feedback from the residents was overwhelmingly positive, although many stated that they felt some degree of intimidation or stress from the standardized patient who did not break from their role throughout the scenario.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form9 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. This session received mostly 7 scores (extremely effective/outstanding). This is a physically safe method for reviewing management of the agitated psychiatric patient. There are multiple potential presentations of the agitated psychiatric patient, as well as varying underlying etiologies. These scenarios may be tailored to the needs of the learner, including identifying agitation, pharmacologic review, and de-escalation techniques. Medical simulation, agitated psychiatric patient, chemical sedation, verbal de-escalation, emergency medicine, psychiatry.

Synthesis of Intensive Care Nurses' Experiences of Caring for Patients With Delirium

Background: There is a paucity of studies synthesizing intensive care nurses' experiences of taking care of patients with delirium. A better understanding of nurses' experiences provides an opportunity to identify areas that can be strengthened to improve care. Aim: To gain insight into intensive care nurses' experiences of caring for patients with delirium through summarizing the existing qualitative studies in the area. Methods: Databases of Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL) Plus, PubMed, and ProQuest Dissertations &amp; Theses Global were searched for qualitative or mixed-method primary research studies, resulting in 269 records screened for eligibility. A three-stage thematic synthesis was followed. Findings: Nine studies were included in the review. Twelve descriptive themes emerged outlining critical care nurses' experiences in the four aspects of delirium care. For prevention, the common nursing themes were using holistic nursing care to promote nighttime sleep, orientate patients through human interaction, and promote early mobilization. Intensive care nurses' experience of delirium assessment included their perceived utility of screening, their understanding of using a screening tool, and their impression of integrating nursing assessment. In terms of treatment, nurses' experience focused on pharmacological and nonpharmacological methods, as well as their attitude toward the use of physical restraints and chemical sedation. Nurses' overall experience of caring for patients with delirium in intensive care units includedemotional exhaustion, physical fatigue, and the perceived low priority and inconsistency of delirium management. Conclusions: Intensive care nurses' complex experiences of caring for patients with delirium revolved around delirium prevention, assessment, treatment, and the overall process of care. Implications for practice include: multicomponent delirium prevention strategies, integrating the use of screening tools and nursing assessment for delirium detection, focusing on nonpharmacological interventions, and offering on-job support to nurses who care for delirious patients.

Chemical sedation of excited delirium in the pre-hospital setting.

A 30-year-old male presents to emergency medical services profoundly combative with a Richmond Agitation–Sedation Scale of +4 after reported use of intravenous methamphetamines. A preliminary diagnosis of excited delirium syndrome is made based on the history obtained and the decision is made to chemically sedate the patient. While preparing for sedation, you wonder which pharmacological agent will produce the fastest and safest sedation in this patient population.

On the Electroimmobilization of Fishes for Research and Practice: Opportunities, Challenges, and Research Needs

As a result of growing demand for immediate‐release sedatives in fisheries research, electroimmobilization has been receiving increasing attention due to its superior induction and recovery times and practicality, particularly under field conditions. However, a review of electroimmobilization and its role in fisheries science has not been previously conducted. Here we describe and differentiate the various forms of electroimmobilization and attempt to standardize relevant terminology. We review the known efficacy of electroimmobilization of fish and summarize the current available knowledge on this topic while identifying major knowledge gaps. Although more information is needed to determine optimal forms and settings for different species, life history stages, and environmental variables, electroimmobilization is a useful tool for fish handling that equals or surpasses the capabilities of chemical sedatives without exacerbating (and sometimes reducing) the negative consequences associated with chemical sedatives and fish handling practices more generally.

Characteristics and Severity of Agitation Associated With Use of Sedatives and Restraints in the Emergency Department.

Agitated patients frequently present to emergency departments, but limited evidence exists regarding clinical decisions to use chemical sedatives and physical restraints. We examined attributes and levels of agitation impacting thresholds for sedative and restraint use in the emergency setting. This was a secondary study focusing on agitation characteristics within a prospective observational study of agitated patients in the emergency department at an urban, tertiary referral center. We recorded scores on 3 validated agitation scales: the Agitated Behavior Scale, the Overt Aggression Scale, and the Severity Scale. Consecutive patients requiring security presence or scoring ≥1 on an agitation scale were enrolled during randomized 8-h blocks. Ninety-five agitation events on unique patients were observed. The median age was 42years, and 62.1% were male. Highest frequency triage chief complaints were alcohol/drug use (37.9%) and psychiatric (23.2%). Most events (73.7%) were associated with sedative or restraint use. Factors related to treatment course or interactions with staff were commonly cited (56.8%) as the primary etiology for agitation. A logistic regression model found no association between demographics and odds of sedative/restraint use. Overt Aggression Scale scores were associated with significantly higher odds of sedative use (adjusted odds ratio [AOR] 1.62 [range 1.13-2.32]), while Severity Scale scores had significantly higher odds of restraint use (AOR 1.39 [range 1.12-1.73]) but significantly lower odds of sedative use (AOR 0.79 [range 0.64-0.98]). External factors may be important targets for behavioral techniques in agitation management. Further study of the Severity Scale scale may allow for earlier detection of agitation and identify causal links between agitation severity and use of sedatives and restraints.

Evidence-Based Review and Discussion Points

Evidence-Based Review and Discussion Points

Evaluation of a Portable Electrosedation System for Anesthetizing Mature Channel Catfish

AbstractHybrid catfish (female Channel Catfish Ictalurus punctatus × male Blue Catfish I. furcatus) fry are produced by hormone‐induced spawning of Channel Catfish in hatcheries. Anesthetics are used routinely to reduce handling stress by limiting the activation of the hypothalamic–pituitary–interrenal axis hormones. As a comparison, the present study determined the efficacy of electrosedation using a portable electrosedation system (PES) and its feasibility for possible application in hybrid catfish hatcheries. The PES was evaluated at 100 V and a 25% duty cycle at 30, 60, 90, or 100 Hz to anesthetize mature Channel Catfish to stage IV of sedation. The PES was compared to the chemical sedatives tricaine methanesulfonate (MS‐222; 200 mg/L) and metomidate hydrochloride (Aquacalm; 6 mg/L). The PES at 30 Hz anesthetized Channel Catfish in 4 s, significantly faster than the 120 s needed for MS‐222. However, the mean (±SE) time to recover from anesthesia and mean plasma cortisol response were similar (P &gt; 0.05) with MS‐222 (104 ± 9 s; 35 ng/mL) and the PES (119 ± 15 s; 32 ng/mL). Relative fecundity of fish sedated by the PES and MS‐222 averaged 5,222 and 5,593 eggs/kg of body weight (BW), respectively; percent hatch averaged 46.9% and 50.4%, respectively; and hybrid catfish fry production averaged 1,644 and 1,711 fry/kg BW, respectively. Relative fecundity, percent hatch, and hybrid fry production were not significantly different between the PES and MS‐222 groups (P &gt; 0.05). No internal injuries were noted in any of the fish subjected to electrosedation. The PES at 30 Hz effectively anesthetized female Channel Catfish with a quicker induction time, provided moderate time to recover from anesthesia, and elicited a cortisol response, with no known internal injuries. The results suggest that the PES has the potential to replace MS‐222 usage in hybrid catfish hatcheries. The PES is environmentally safe, does not expire or degrade, and requires no disposal or withdrawal period.

Outcomes of Prehospital Chemical Sedation With Ketamine Versus Haloperidol and Benzodiazepine or Physical Restraint Only

Objective: The goal of this study is to describe complications and outcomes of prehospital ketamine use for agitation as compared to other methods of physical or chemical restraint such as haloperidol plus benzodiazepine or physical restraint only. Methods: We conducted a single-center retrospective review of patient encounters in which restraint was administered in the prehospital setting. At the beginning of our study window, only physical restraint was available to paramedics managing agitated patients but subsequently, haloperidol and benzodiazepines were introduced, followed by ketamine 2 years later. By comparing patients before and after each transition, we divided subjects into 3 cohorts based on restraint type: physical restraint, haloperidol plus benzodiazepine, and ketamine. Demographic data were collected, and outcome measures included intubation rate, need for additional physical or chemical restraint, emergency department (ED) length of stay, need for hospital admission, and employee injury. Results: Of 214 subjects included in the study, 95 patients were administered ketamine, 68 received haloperidol and benzodiazepine, and 51 were physically restrained. Eleven of the patients (11.6%) who received ketamine were intubated. Compared to patients who received haloperidol plus benzodiazepine, patients who received ketamine were more likely to be intubated (odds ratio [OR] = 8.77, 95% confidence interval [CI], 1.10–69.68) and were more likely to require additional chemical restraint when compared to haloperidol/benzodiazepine or physical restraint only (OR =2.94, 95% CI, 1.49–5.80, and OR =2.15, 95% CI, 1.07–4.31, respectively). There were no differences between the 2 chemical sedation groups in terms of ED length of stay or hospital admission rate. Conclusions: This study demonstrates a lower intubation rate in patients administered ketamine than prior literature in association with a lower weight-based dosing regimen. Ketamine use was correlated with a higher frequency of intubation and a greater need for additional chemical restraint when compared with other restraint modalities, though exogenous factors such as provider preference may have impacted this result. There was no difference in ED length of stay or admission rate between the ketamine and haloperidol plus benzodiazepine groups. Further prospective study is needed to determine whether there is a subset of patients for whom ketamine would be beneficial compared to other therapies.

Antipsychotics, Delirium, and Acute Respiratory Distress Syndrome: What Is the Link?

Acute respiratory distress syndrome (ARDS) is an acute inflammatory process that impairs the ability of the lungs to oxygenate and ultimately leads to respiratory failure. Patients who develop ARDS often have prolonged and complicated hospital courses putting them at risk for intensive care unit (ICU) delirium. Patients with ICU delirium often need chemical sedation, mechanical ventilation, prolonged duration of ICU and hospital stays, and they experience long-term cognitive impairment and increased mortality. In a patient with ARDS, ICU delirium further complicates the hospital course and increases the risk of morbidity and mortality. Antipsychotics are prescribed to decrease the severity and duration of ICU delirium, thus potentially decreasing their risk of morbidity and mortality. However, antipsychotics are associated with many adverse effects including respiratory failure. Given the long-term sequelae associated with the development of ICU delirium and the risks associated with antipsychotic use, clinicians must weigh the risks and benefits of antipsychotic use. This review investigates the interrelationship between ARDS, delirium, and antipsychotic use. In addition to discussing relevant studies evaluating antipsychotics for the prevention and treatment of delirium, we investigate safety concerns with the use of antipsychotics, especially as they relate to ARDS. Using the data compiled in this review, clinicians can make an informed decision about the use of antipsychotics for the prevention or treatment of delirium, with special consideration for their patients with ARDS. Future studies are needed to critically evaluate antipsychotic timing, dose, and duration for the prevention and treatment of ICU delirium and specifically evaluate the impact in special populations, particularly patients with ARDS.

A Method to Administer Agents to the Larynx in an Awake Large Animal.

This research note describes an adapted experimental methodology to administer an exogenous agent to the larynx and upper airway of awake animals. The exogenous agent could be a perturbation. In the current study, the agent was isotonic saline. Isotonic saline was selected because it is safe, of similar composition to extracellular fluid, and used in voice studies. The described approach allowed large animals such as pigs to be comfortably restrained without chemical sedation or anesthesia for extended periods while receiving the agent. Six Sinclair pigs were successfully trained with positive reinforcement to voluntarily enter and then be restrained in a Panepinto Sling. Once restrained, the pigs accepted a nose cone that delivered nebulized isotonic saline. This procedure was repeated 3 times per day for 20 days. At the end of the study, the larynx and airway tissues were excised and examined using histology and transmission electron microscopy. Pathology related to the procedure (i.e., nebulized inhaled isotonic saline or stress) was not identified in any examined tissues. This methodology allowed for repeated application of exogenous agents to awake, unstressed animals. This method can be used repeatedly in the laboratory to test various therapeutics for safety, toxicity, and dosage. Future studies will specifically manipulate the type of agent to further our understanding of laryngeal pathobiology.