agitation get it under control quickly

Upload: ekrams

Post on 04-Apr-2018

214 views

Category:

Documents


0 download

TRANSCRIPT

  • 7/29/2019 Agitation Get It Under Control Quickly

    1/2

    www.medscape.com

    Hello. This is Dr. Scott Irwin, Chief of Psychiatry and Psychosocial Services at San Diego Hospice and The Institute for

    Palliative Medicine. Today I'd like to talk to you about what I call an "agitation code." Agitation is highly distressing for patients,

    families, and staff members. We want to get it under control quickly. In the setting of reversible delirium, antipsychotics are the

    gold standard. I 'd like to talk today about using antipsychotics to get agitation under control quickly.

    The way we think of agitation is as a breakthrough symptom,just like pain, and so we want to dose medications like we do for

    pain. Most antipsychotics follow first-order kinetics. They also have a time to maximum concentration (Cmax) in the blood.

    The single biggest mistake that people make is dosing medications on the half-life for symptoms that are out of control. If you

    have a symptom that is out of control, like pain or agitation, and the medication is not working at the time of maximum

    concentration, then it's not going to work past that time. What you want to do is dose breakthrough medications on the time to

    Cmax and schedule routine doses on the time to half-life.

    It turns out that for most antipsychotics, 24 hours is the half-life, and time to Cmax for medications [that follow first-order

    kinetics] is actually dependent on route. So, for IV medications it's 15 minutes, for sub-Q or IM it's 30 minutes, and for PO

    (oral) medications it's 60 minutes. These are rough approximations, but they're safe approximations that work well clinically.

    Agitation: Get It Under Control QuicklyScott A. Irwin, MD, PhD

    Posted: 09/05/2012

    tion: Get It Under Control Quickly (printer-friendly) http://www.medscape.com/viewarticle/769

    12/09/2012

  • 7/29/2019 Agitation Get It Under Control Quickly

    2/2

    For something like haloperidol, which is the gold standard for agitation in the context of reversible delirium, you can usually

    start at 0.5 mg or, if you wanted, 1 mg. If we're going to give this SQ, that would be [a dose] every 30 minutes. If you gave it

    orally it would be every 60 minutes, as needed for agitation. I like to add something else to the physician order and that is "I f

    not effective in 3 doses call MD." The reason I do this is because if it's not working in 3 doses (that's an hour and a half that

    this patient has been distressed) then I want to know about it. I either have the wrong drug, the wrong diagnosis, or the wrong

    dose. This [dose of haloperidol] is well within safety measures. You can use up to 100 mg of haloperidol a day. Typically, we

    don't see the need to go over 10 mg a day with most of our patients, but you need to reevaluate where you're going.

    For more moderate or severe agitation, you could actually double the dose every time to Cmax. So for SQ you could start at0.5 mg, then give 1 mg, then 2 mg, and then 4 mg [every 30 minutes]. Or if you were giving it orally it would be the same thing

    but you would give the dose every hour instead of every 30 minutes.

    For extremely severe agitation, where the safety of the patient, staff, or family is at risk, then you might want to use much

    stronger medications to get agitation under control immediately and then figure out what the best course of action is. For

    example, you could add 1 or 2 mg of lorazepam to the haloperidol with 50 or 100 mg of Benadryl as well, and then again

    repeat it on the time to Cmax until the agitation is under control.

    Once you figure out how many doses you needed to get the agitation under control you add those up and dose them on the

    half-life so that the scheduled total dose needed for control over 24 hours is dosed divided on the half-life, which for most

    antipsychotics is 24 hours. For example, if you needed 3 mg to get this patient's agitation under control, you would schedule 3

    mg every 24 hours, plus the PRN dose for any breakthrough symptoms. I f the person continues to need more and morebreakthrough doses you would add this to the scheduled dose. Again, agitation is highly distressing for all those involved and

    we want to get it under control quickly. These are the basics of how to do that.

    Thank you for listening. This is Dr. Scott Irwin, Chief of Psychiatry and Psychosocial Services at San Diego Hospice and The

    Institute for Palliative Medicine.

    2012 WebMD, LLC

    tion: Get It Under Control Quickly (printer-friendly) http://www.medscape.com/viewarticle/769

    12/09/2012