Rapid Tranquillisation By - PowerPoint Presentation

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Rapid Tranquillisation

By MichaelDixon (pharmacist) and Mark Regan (nurse)

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Quick Quiz

1. which is the safest RT medicine to give if someone has COPD?2. if someone needs a medication for violent behaviour but they have known serious cardiac condition what would you use?3. if someone has never had an antipsychotic before would you use IM haloperidol or IM olanzapine for RT?

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Contents

Definition NICE guidanceMedicationInjection sites Physical Health Monitoring– MEWS/Visual A-E

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Definition

“the use of medication to treat disturbed or aggressive patients who need to be calmed”.

We will be discussing the use of medication for acutely disturbed patients.

There are non-drug techniques such as

- de-escalation techniques  

seclusion

- restraint.

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Components of Agitation

Motor and verbal overactivityIrritability → threatening gestures → assaultiveness

Impulsiveness

Overwhelming fear / anxiety

Poor judgement

Personal distress

Rapid fluctuations of mental state

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Psychiatric causes of agitation

Common causes are:PsychosisMania

Delirium

Dementia

Agitated depression

Anxiety

Personality disorder

Akathisia

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Non-pharmacological approaches

Positive and safe care plansPrimary SecondaryTertiary

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Points to consider

How the patient is presenting?Cause of presentation? Use of drugs/alcohol?Physical health of patient

Mental health act/mental capacity act status/advanced statements

Current prescribed medication?

Allergies/adverse reactions to medicines

Treatment options – what has worked well in the past

Note

- best predictor of behaviour/violence is past history – consider this when prescribing

Refer to senior doctor for advice if required

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NICE (1)

MDT approach should be used for risk assessment and managementTake account previous episodes of violence/aggression and what workedThere should be a post RT review and debriefMDT including a pharmacist should review the RT strategy for each patient at least weekly inc target symptoms and drug choice/doses

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NICE (2)

Make sure prn medicines don’t push doses above BNF max. If necessary to increase above BNF seek advice from senior doctors oncall

Always include interval between prn doses when prescribing. Prescribe oral and IM separately.

If writing up IM medicines should specify muscle if possible e.g. gluteal, deltoid

Do not prescribe medicines prn routinely on admission.*

*

Only prescribe time-limited prn on admission if patient very disturbed (

ie

max 3-4 days)

esp

if previous hx of unpredictable escalation of aggressive behaviour

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Children /elderly

Require smaller dosesMore sensitive to side effects of medicationTrust rapid tranquillisation guidelines has flowcharts for <18yrs, 18-65yrs and >65yrs old

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Trust Rapid Tranquillisation Guidance

Oral OptionsLorazepam or promethazineHaloperidol, aripiprazole, risperidone,

quetiapine

, olanzapine

Think what formulation to use – e.g.

tabs,

orodisperisible

or liquid – these ensure compliance not speed

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Oral Options

drugTime to peak Half life

Benzodiazepine/sedative

Lorazepam oral

2hrs

12-16hrs

Promethazine

oral

2-3 hrs

10-19hrs

Antipsychotics

Aripiprazole

oral

3-5hrs

75-146hrs

Haloperidol oral

2-6hrs

24hrs

Olanzapine

oral

5-8 hrs

30hrs

Risperidone oral

1-2hrs

3-20hrs

Quetiapine tablets

1.5hrs

7hrs

Don’t normally use diazepam/clonazepam as long half life so accumulate on repeated dosing

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Trust Rapid Tranquillisation guidance

Moderately unwellIM antipsychotic alone – olanzapine/aripiprazoleIM lorazepam or promethazine alone

Severely unwell

IM lorazepam + IM haloperidol

IM promethazine + IM haloperidol

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IM RT medicines

All licensed for IM, not particular muscle unlike depots which are either gluteal or deltoidNICE guidance recommends prescribing which muscle is to be used e.g. gluteal, deltoid or other muscleNever give lorazepam and promethazine together, chose 1 of them only as the non-antipsychotic optionIf both prescribed in exceptional circumstances on the medicine chart it should be clearly stated on the prescription which is to be used 1st

line and which is 2

nd

line

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IM options

DrugTime to peak

Half life

Benzodiazepine/sedative

Promethazine injection

2-3 hrs

10-19hrs

Lorazepam injection

60-90 mins

12-16hrs

Antipsychotic

Haloperidol 5mg/ml short acting injection

20-40mins

24hrs

Aripiprazole short acting injection

1hr

75-146hrs

Olanzapine short acting injection

15-45mins

30hrs

Zuclopenthixo

l

acetate (

acuphase

– not classed as RT)

24-36hrs

20 hrs

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RT (1)

Lorazepam alone (1-2mg max 4mg/day, elderly 0.5mg, max 2mg/day)Preferable if already on antipsychotic or cardiac problemsDon’t use with patients with respiratory problems or paradoxical agitation with benzodiazepines.

Peaks 60-90 mins

Recommended by NICE as 1

st

line option

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RT (2)

Promethazine alone (25-50mg, max 100mg/day, elderly 12.5-25mg max 50mg/day)Peaks 2 hrs

Useful if respiratory problems or paradoxical agitation with benzodiazepines

Longer acting than lorazepam

BNF gives daily max of 50mg orally and 100mg IM. Oral not licensed for rapid tranquillisation and we allow up

t

o 100mg/day via oral or IM route.

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RT (3)

Haloperidol (5mg, max 20mg/day orally or 10mg/day IM, elderly 0.5-1mg max oral 5mg/day, IM 3mg/day)IM dose approximately equivalent to 2/3 oral dose

Usual IM dose in adult 5mg, antipsychotic naïve 2.5mg, elderly 0.5-1mg

Always prescribe prn

po

/

im

procyclidine

in case of EPSEs

Requires mandatory ECG if possible e.g. at baseline then if on it regularly after each dose increase SPC – contra-indicates it with other antipsychoticsAvoid if cardiac problems or sensitive to EPSEs

Can repeat dose 60mins

Can use with lorazepam 1mg or promethazine 25-50mg in adults or half dose in elderly

Not used in child and adolescent Rapid tranquillisation protocol

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RT (4)

IM Olanzapine (usual adult dose 5-10mg, elderly 2.5-5mg)Don’t give with benzodiazepines/promethazine within 1hrCant repeat within 2 hours

Max 3 dose or 20mg in 24 hours

Max effect within 15-45 mins

Useful option for antipsychotic naïve patients or people likely to have EPSEs

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RT (5)

IM aripiprazole (usual adult dose 9.75mg -1.3ml, elderly dose 5.25mg -0.7ml)can be used in combination with lorazepam (1-2mg)Do not repeat within 2 hours

Max dose 3 injections or 30mg in 24 hours

halve dose if on certain enzyme inhibitors e.g. fluoxetine or give increased dose if on enzyme inducers e.g. carbamazepine

peaks at 60 mins

Minimal EPSEs or sedation

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RT (5)

Haloperidol (5-10mg) + promethazine (25-50mg) combinationif lorazepam alone hasn’t workedIf patient has respiratory problems

If patient needs an antipsychotic

Max dose of haloperidol

10mg/24hrs

& promethazine

100mg/24hrs

Haloperidol peaks 15-45mins where as promethazine peaks about 2hrs

Prescribe prn

procyclidine

o/imNot good choice if cardiac problems

Good choice if severe agitation/behavioural disturbance

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RT (6)

Haloperidol (5-10mg) + lorazepam (1-2mg) combinationMax of lorazepam 4mg/24 hours & haloperidol 10mg/24 hours

May need lower doses of each drug in combination then if give either alone

Prescribe prn

po

/

im

procyclidine

Not good choice if cardiac

problemsGood choice if severe agitation/behavioural disturbance

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Comparison side effects of Antipsychotics

Sedation

EPSEs

Hypotension

Anticholinergic

Olanzapine

Moderate

Very low/low

Low

Low

Haloperidol

Low

High

Low

Low

Aripiprazole

Low

Low

low

low

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Deviation from RT guidance

It is a guideline and deviation from it can occur with advice from senior medics ie Consultant or Speciality Trainee. Examples of situations where deviation may be considered include:

risk versus benefits analysis supports prescribing

it has not been practically possible to do a physical exam since admission

it has not been to practically possible to do blood investigations since admission

it has not been practical to do an ECG since admission

benefits outweigh risks even in service users naïve to psychotropic medications.

If deviating from this guideline there must be evidence of a robust attempt at physically monitoring health parameters after administration of medication and Visual A-E as a minimum when physical observations cannot be safely obtained.

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Prescribing in antipsychotic naïve patients (1)

More likely to get side effectsWill respond to lower doses e.g.

Never use

zuclopenthixol

acetate

Drug

Min effective dose

1

st

episode

multiple

Haloperidol

po

2mg

4mg

Olanzapine

po

5mg

7.5mg

Risperidone

po

2mg

3mg

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Prescribing in antipsychotic naïve adult patients (2)

IM Options – olanzapine 5mghaloperidol 2.5mg +/- lorazepam 1mg or promethazine 25mg,

Aripiprazole 5.25mg

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Drugs not recommended

IM chlorpromazine – postural hypotension, painful on injectionIM diazepam – can accumulate/unpredictable erratic absorptionantipsychotics if patient has dementia

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Short acting antipsychotic injections

(rapid tranquillisation):Haloperidol 5mg/ml injection –no muscle specifiedOlanzapine

10mg

injection– no

muscle specified

Lorazepam

4mg/ml

injection– no

muscle specified

Aripiprazole

9.75mg injection– no muscle specifiedPromethazine injection– no muscle specifiedZuclopenthixol acetate (acuphase) gluteal or lateral thigh muscle

Antipsychotic long acting depot injections:

Paliperidone

depot –

deltoid or gluteal

Risperidone

consta

depot – deltoid or gluteal

Olanzapine depot –

gluteal

muscle

Aripiprazole depot –

gluteal

or deltoid muscle

Zuclopenthixol

decanoate

depot – gluteal or lateral thigh muscle

Flupentixol

depot

–

gluteal

or lateral thigh muscle

Haloperidol

decanoate

depot – gluteal muscle

Fluphenazine

depot

–

gluteal muscle

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Alternative sites-

To avoid use of prone restraintInjection Site

The

dorsogluteal

site: the injection is administered into the gluteus maximus muscle in the buttock. The upper outer quadrant of this area must be used to avoid any damage to the sciatic

nerve.

The vastus

lateralis

site: a large muscle in the thigh free from major nerves and vascular structures.

The deltoid site: this site, on the lateral upper aspect of the arm, is used for the administration of smaller volumes of solution.

The ventrogluteal site: the injection is administered into the gluteus medius and maximus muscles of the hip area.

Range of Volume for

effective muscle absorption

1 to 3mls

1 to 3mls

0.5 to 2mls

1 to 3mls

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Physical restraint

Can only be used if there is a legal authority to treat without consent.The use of restraint to administer non-emergency medication should be avoided wherever possible, and should first be discussed with the MDT and documented and justified in patient’s notes.

Wherever possible the use of prone restraint to administer IM medication should be avoided

NG 10 identifies 10 minutes as a prolonged restraint and advises rapid tranquillisation (and/or seclusion) to be considered to bring to an end as soon as possible

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Observation checks

MEWsAfter oral – only if MDT decide its necessaryAfter IM – MEWs obs every 15 mins for 1 hour then every 15mins until ambulatoryReview obs hourly

Document on ward physical health observation charts

Use visual A-E chart if MEWS not possible

IM meds – have obs for at least 1 hour

Datix for everyone who has po/IM rapid tranq

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Post RT debrief

A review should take place within 48hrs of how RT went including nurse & drreview RT prescription for what to use if needed in future and involve service user in decisionWeekly review of “prn” medicines involving medic, nurse and pharmacistDebrief should take place with service user within 48hrs

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Zuclopenthixol acetate (Acuphase)

Not rapid-acting drugSedation starts at 4 hoursOnset of action 8 hours and peaks at 36 hoursDuration of action = 2-3 daysMax: dose 150mg per injection, 4 injections or 2 week course

Senior doctor to prescribe/advise

do observation sheet in guidelines for 24hrs

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Zuclopenthixol acetate (Acuphase)

NICE 2005 says:Service user will be disturbed/violent over an extended period of timePast history of good responsePast history of repeated injections needed

Cited in advance directive

NEVER give if antipsychotic naïve

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Complications of Rapid Tranquillisation

Benzodiazepines – loss of consciousness, resp depression, cardiovascular collapse Antipsychotics – loss of consciousness, cardiovascular complications (arrhythmias/QTc prolongation, postural hypotension) and collapse, seizures, EPSEs, NMS

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COVID positive patients

Avoid benzodiazepines due to likely respiratory problemsDo not use zuclopenthixol acetate (Acuphase) as lasts 3 days, only use short acting IM antipsychotics ie olanzapine, aripiprazole, haloperidol (care as COVID can cause cardiac problems)MEWs – patients with COVID can deteriorate rapidly so may need to do more stringent monitoring

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Flumazenil

Benzodiazepine antagonistIV injectionIf respiratory rate less than 10 breaths/minInitial dose – 200micrograms over 15 secsContra-indications – mixed intoxication,

Cautions – epilepsy, long-term benzos

Short half life (40-80 mins) – benzo may last longer - monitoring

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Restrictive Interventions

Complete DatixIf giving IM medicines for rapid tranquillisation or using oral medicines to restrict someone

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Any questions?

Speak to your pharmacy department to clarify anythingAlternatively if not urgent email Michael Dixon at michael.dixon1@nhs.net