SECTION 8: MANAGEMENT OF ACUTELY DISTURBED BEHAVIOUR. Formulary and Prescribing Guidelines

Transcription

1 SECTION 8: MANAGEMENT OF ACUTELY DISTURBED BEHAVIOUR Frmulary and Prescribing Guidelines

2 8.1 Management f acutely disturbed ADULTS : (See CG52 fr full guidelines) Befre cnsidering pharmaclgical measures: Cnsider de-escalatin, using nn drug appraches: seclusin/mving t a lw stimulus area, talking dwn, time ut, distractin If pssible, d a mental state examinatin and physical state examinatin, take a histry including drug/alchl status, drug sensitivities, cncurrent medicatin Check fr intercurrent illness and recent illicit substance use Establish a wrking diagnsis Check fr any advance directive in relatin t medicines NON-PHARMACOLOGICAL MEASURES UNSUCCESSFUL INAPPROPRIATE L E V E L 1 Disturbed BUT accepting ral medicatin L E V E L 2 Disturbed AND refusing ral medicatin nurse in a quiet area Review all medicatin prescribed within last nging verbal de-escalatin 24hurs (BNF limits, side effects etc) fd and fluid t be prvided Cnsultant pinin may have t be sught review current medicatin decide whether additinal medicatin required PARENTERAL interventins (IM) Lrazepam IM (1-2mg; max 4mg in 24 hurs) AL interventins (PO) Lrazepam (1-2mg; max 4mg in 24 hurs) Prmethazine (50mg; max 100mg /24 Hurs) Can be repeated after 1 Hur Halperidl (5-10mg; max 20mg p / 24 hurs) Ensure cardiac status f patient is knwn, preferably with previus ECG Risperidne (2mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablets Olanzapine (10mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablet Sedatin in minutes; peaks 1-3 hurs; Lasts 4-6 hurs Prmethazine IM (50mg) (can repeated in 1-2 hurs, if needed, up t max: 100 mg/day)may be used in benzdiazepine-tlerate patients and is the first line alternative during shrtages f lrazepam AND/ Halperidl IM (5mg; max 12mg IM in 24 hurs) Used as mn-therapy r in cmbinatin with Lrazepam r Prmethazine Sedatin in 10 minutes; peaks in minutes; Half life hurs Ensure cardiac status f patient is knwn, preferably with previus ECG Olanzapine IM as mntherapy (5-10mg; max 3 injectins in 24 hurs & Max 20mg in 24 Hurs) Peaks in minutes. D nt repeat within 2 hurs D nt use Lrazepam IM within ne hur f administering Olanzapine IM Aripiprazle IM (5.25mg-15mg:max 3 injectins in 24hurs). Max 30mg in 24 hurs. Peaks in 1-3 hurs Cnsultant s direct invlvement mandatry Cnsult n-call pharmacist Secnd pinin f anther cnsultant Avid Diazepam if ECT is being cnsidered L E V E L 3 Diazepam 10mg IV ver at least 5 minutes. Can be repeated up t 3 times if insufficient effect. 2

3 8.2 Management f acutely disturbed OLDER ADULTS Befre cnsidering pharmaclgical measures: (see CG52 fr mre infrmatin) Cnsider de-escalatin, using nn drug appraches: seclusin/mving t a lw stimulus area, talking dwn, time ut, distractin If pssible, d a mental state examinatin and physical state examinatin, taking int accunt frailty, drug/alchl status, drug sensitivities, cncurrent medicatin, dementia Check fr intercurrent illness and recent illicit substance use Establish a wrking diagnsis Check fr any advance directive in relatin t medicines NON-PHARMACOLOGICAL MEASURES UNSUCCESSFUL INAPPROPRIATE L E V E L 1 Disturbed BUT accepting ral medicatin L E V E L 2 Disturbed AND refusing ral medicatin nurse in a quiet area Review all medicatin prescribed within last nging verbal de-escalatin 24hurs (BNF limits, side effects etc) fd and fluid t be prvided Cnsultant pinin may have t be sught review current medicatin decide whether additinal medicatin required PARENTERAL interventins (IM) AL interventins (PO) Lrazepam (0.5-1mg; max 2mg/24H). Wrsens cnfusin in BPSD Halperidl ( mg; max 20mg/24H) Ensure cardiac status f patient is knwn, preferably with previus ECG Risperidne (0.5-1mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablets Preferred ptin in BPSD Olanzapine (2.5-5mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablet Lrazepam IM (0.5-1mg; max 2mg/24H) Sedatin in mins; peaks 1-3 hurs; Lasts 4-6 hurs, D nt use lrazepam within ne hur f administering lanzapine IM Prmethazine IM (25mg; 50mg/24H) Can be repeated in 1-2 hurs, may be used in benzdiazepine-tlerant patients Prmethazine is the first line alternative during shrtages f lrazepam AND/ Halperidl IM (1-2.5mg; max 12mg/24H) Use alne r in cmbinatin with lrazepam, sedatin in 10 mins, peaks in mins, half life hurs, Ensure cardiac status f patient is knwn (ECG) Olanzapine IM as mntherapy (5-10mg; max 20mg/24H) Peaks in mins D nt repeat within 2 hurs Aripiprazle IM (5.25mg-15mg:max 3 injectins in 24hurs). Max 30mg in 24 hurs. Peaks in 1-3 hurs L E V E L 3 Refer t cnsultant Refer t cnsultant 3

4 8.3 Management f acutely disturbed CHILDREN & ADOLESCENTS Befre cnsidering pharmaclgical measures: (see CG52 fr mre infrmatin) Cnsider de-escalatin, using nn drug appraches: seclusin/mving t a lw stimulus area, talking dwn, time ut, distractin If pssible, d a mental state examinatin and physical state examinatin, take a histry including drug/alchl status, drug sensitivities, cncurrent medicatin Check fr intercurrent illness and recent illicit substance use Establish a wrking diagnsis Check fr any advance directive in relatin t medicines NON-PHARMACOLOGICAL MEASURES UNSUCCESSFUL INAPPROPRIATE L E V E L 1 Disturbed BUT accepting ral medicatin nurse in a quiet area nging verbal de-escalatin fd and fluid t be prvided review current medicatin decide whether additinal medicatin required If patient is unknwn t services initially treat with Lrazepam and avid antipsychtics if pssible AL interventins (PO) Lrazepam (ver 12 years 1-2mg; max 4mg in 24 hurs / Under 12 years 0.5-1mg; max 2mg in 24 hurs) Prmethazine (ver 10 years 25-50mg / between 5-9 years 20-25mg) Risperidne (0.5-1mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablets Olanzapine (5mg) Ordispersible tablets may be cnsidered if the patient is likely t spit ut the tablet L E V E L 2 Disturbed AND refusing ral medicatin Review all medicatin prescribed within last 24hurs (BNF limits, side effects etc) Cnsultant pinin may have t be sught PARENTERAL interventins (IM) Lrazepam IM (ver 12 years 1-2mg; max 4mg in 24 hurs / Under 12 years 0.5-1mg; max 2mg in 24 hurs) Sedatin in minutes; peaks 1-3 hurs; Lasts 4-6 hurs Prmethazine IM (ver 10 years 25-50mg / between 5-9 years 10-25mg) Prmethazine is the first line alternative during shrtages f lrazepam Aripiprazle IM (5.25mg-15mg:max 3 injectins in 24hurs). Max 30mg in 24 hurs. Peaks in 1-3 hurs Olanzapine IM as mntherapy (ver 12 years 5-10mg; max 3 injectins/20mg in 24 hurs) Peaks in minutes. D nt repeat within 2 hurs D nt use lrazepam within ne hur f administering lanzapine IM Quetiapine (ver 12 years 25-50mg / under 12 years mg) 4

5 8.4 Drugs apprved fr management f acute disturbed behaviur See latest BNF fr licensed indicatins. Drug and frm Time t max. plasma Cnc. Half life Halperidl IM injectin mins hurs Halperidl slutin 3-6 hurs hurs Halperidl tab 3-6 hurs hurs Cmments Lrazepam IM injectin Lrazepam tabs mins 2 hurs hurs 12 hurs The FDA has warned f a serius risk f death when benzdiazepines are used in cmbinatin with Opiid analgesic r cugh preparatins. 6 Olanzapine dispersible tab. 5-8 hurs hurs Olanzapine injectin mins hurs Olanzapine tab 5-8 hurs hurs Prmethazine IM injectin 2-3 hurs 5-14 hurs Risperidne dispersible tab. 1-2 hurs 24 hurs Risperidne liquid 1-2 hurs 24 hurs Risperidne tab 1-2 hurs 24 urs IM lanzapine may prduce a 5-fld increase in plasma cnc. vs. the same dse given rally Clnazepam IM is nn-frmulary due t the fact that it is an unlicensed preparatin in the UK. It is an intravenus prduct and IM use is an Off label indicatin. If clnazepam is required it shuld be requested n a nn-frmulary frm and there shuld be an entry in the patient s healthcare recrd that a full discussin has taken place with the patient and that they have given infrmed cnsent fr it t be prescribed. 8.5 Guidelines fr the use f Flumazenil Flumazenil is a specific reversal agent fr benzdiazepine-induced respiratry depressin. It is held at all sites where injectable lrazepam is stcked. Indicatins fr use Cntra-indicatins Cautin Dse and rute f administratin If the respiratry rate falls belw 10/minute after the administratin f lrazepam (diazepam r midazlam) Patients with epilepsy wh have been receiving lng-term benzdiazepines Dse shuld be carefully titrated in hepatic impairment Initially 200 mcg intravenusly* ver 15 secnds (10 mcg/kg max single dse 200 mcg in children under 12 years) If the required level f cnsciusness is nt achieved after 60 secnds then subsequent dse: 100 mcg intravenusly ver 10 secnds Time befre dse can be repeated Maximum dse * IV injectin f flumazenil must be given by a dctr. 60 secnds Further dses f 100 mcg can be repeated at 60 secnd intervals where necessary t a maximum f 1 mg 1 mg in 24 hurs (ne initial dse and eight subsequent dses) 5

6 Side effects Management Mnitring What t mnitr? Hw ften? Patients may becme agitated, anxius r fearful n awakening Seizures may ccur in regular benzdiazepine users Side effects usually subside Respiratry rate Cntinuusly until respiratry rate returns t baseline level. Flumazenil has a very shrt half life s respiratry functin may appear t recver and then deterirate again. Nte: if respiratry rate des nt return t nrmal r patient is nt alert after initial dses given then assume sedatin due t sme ther cause. 8.6 Acute Disturbed Behaviur Mnitring Errr! Reference surce nt fund. Mnitring f vital signs must be recrded using the MEWS Frm r Track and Trigger and filed in the patient s healthcare recrd. This shuld als be used t recrd situatins where it is nt pssible t mnitr vital signs alng with the reasn why. After any parenteral drug administratin, mnitr and recrd n the MEWS chart the fllwing: 1. Temperature 2. Pulse 3. Bld pressure 4. Respiratin rate Every 5-10 minutes fr ne hur and then half hurly until patient is ambulatry. If the patient is asleep r uncnscius, the cntinuus use f pulse ximetry t measure xygen saturatin is desirable. A nurse shuld remain with the patient until ambulatry. ECG and haematlgical mnitring are als necessary when parenteral antipsychtics are administered, especially when higher dses are used. Hypkalaemia, stress and agitatin place the patient at risk f cardiac arrhythmias. A crash bag shuld be available within 3 minutes 8.7 Remedial Measures in ADULTS 1 Prblem Acute dystnia (including culgyric crises) Reduced respiratry rate (<10/minute) r xygen saturatin <90% Irregular r slw pulse Remedial Measures Give prcyclidine 5-10 mg IM r benzatrpine 1-2 mg IM Prcyclidine mg in children Given xygen; raise legs; ensure patient is nt lying face dwn Give flumazenil if benzdiazepine-induced respiratry depressin suspected (see sectin 13) If induced by any ther sedative agent ventilate mechanically Refer t specialist medical care 6

7 (<50/minute) Fall in bld pressure (>30mmHg rthstatic drp r <50mmHg diastlic) immediately Lie patient flat; tilt bed twards head. Mnitr clsely 8.8 Guidelines fr the Use f Clpixl Acuphase (zuclpenthixl acetate) 1.0 Zuclpenthixl acetate (Clpixl Acuphase ) is nt an apprpriate drug fr use in rapid tranquillisatin, althugh it is used in the pharmaclgical treatment f acute psychsis. It has a significantly delayed nset f actin and a relatively lng duratin f actin. 1.1 It may have a rle in the nging management f a risk f vilence nce tranquillisatin has been satisfactrily achieved, and shuld nly be used after an acutely psychtic patient has required repeated injectins f shrt achieving antipsychtic drugs such as halperidl and lanzapine, r sedative drugs such as lrazepam. 1.2 It is imprtant t cnsider the pharmackinetics f ther drugs when prescribing it. Fr example, cautin is necessary in a patient wh has recently received a dse f a dept antipsychtic which has nt yet reached peak levels. 1.3 Acuphase shuld nly be given when enugh time has elapsed t assess the full respnse f previusly injected drugs. At least 15 minutes shuld be allwed after IV injectins and 60 minutes after IM injectins. 1.4 Acuphase shuld never be administered: in an attempt t hasten the antipsychtic effect f any ther antipsychtic therapy fr treatment f acutely disturbed behaviur at the same time as ther parenteral antipsychtics r benzdiazepines at the same time as dept medicatin as a test dse fr Zuclpenthixl t a patient wh is uncnscius t a patient wh is physically resistive due t the risk f intravasatin and il emblus. t thse with cardiac disease, hepatic r renal impairment r in pregnancy r under 12 years ld t thse wh are sensitive t extrapyramidal side effects t thse wh the neurleptic-naive 1.5 Dses f mg may be given up t a maximum f 400mg ver a tw week perid, with at least 24 hurs between dses. There is n such thing as a curse f Acuphase and the patient shuld be assessed befre each administratin. The maximum dse 7

8 per 2 weeks is intended t allw a treatment plan t be put in place and des nt indicate that there are knwn harmful effects frm mre prlnged use. Hwever, such use wuld be exceptinal. 1.6 Sedative effects usually begin t be seen 2 hurs after injectin and peak after 12 hurs. The effects may last fr up t 72 hurs Nte: Acuphase has n place in rapid tranquillisatin: its actin is nt rapid. 1.7 Zuclpenthixl is a ptentially txic preparatin with little evidence t supprt its use. It shuld therefre be avided in acute episdes, unless specifically stated in the ntes r in an advance directive that the patient respnds best t this prduct.errr! Bkmark nt defined. 8.9 NICE Clinical Guidelines NICE NG10, May 2015, Vilence and Aggressin: Shrt term management in mental health, health and cmmunity settings. NICE defines Rapid Tranquillisatin as the use f medicatin by the parenteral rute (usually intramuscular r exceptinally, intravenus) if ral medicatin is nt pssible r apprpriate and urgent sedatin with medicatin is needed. All staff that prescribe and administer the abve medicatins shuld be: Aware f the risks assciated with pharmaclgical management f acutely disturbed patients, such as: damage t the therapeutic relatinship between service user and Health Care Prfessinal (NICE endrses requesting service users accunts f their experiences upn discharge t anther unit) ver-sedatin leading t lss f alertness and lss f cnsciusness (NICE guidelines mandate that the service user must be able t respnd t cmmunicatin thrughut and if verbal cmmunicatin is lst, then the same level f care as fr general anaesthesia must be used). cardivascular and respiratry cllapse [see mnitring after administratin which cnsists f: temperature (risk f neurleptic malignant syndrme), respiratin rate, xygen saturatin, BP, HR (pulse), level f cnsciusness and any evidence f EPSE. The physical and mental status f the service user shuld be taken int accunt in deciding the initial dse and subsequent dse increments. interactin f the medicines used in management with medicines already taken by the patient (whether prescribed by his/her GP, r illicit) Familiar with the medicines used in management, their crrect prescriptin, and that ral (PO) and intramuscular (IM) dses must be prescribed separately 8

9 that tw drugs f the same class shuld nt be written tgether (fr example, d nt write up diazepam and lrazepam, and/r halperidl * and lanzapine n the prn side f the drug chart) that medicatins shuld nt be mixed in the same syringe (that is, lrazepam shuld be given by separate injectin and site, frm a cncurrent halperidl injectin if cmbined antipsychtic/ benzdiazepine is clinically required) the NEED F CONSENT, r else ensure that the apprpriate Mental Health Sectin(s) is in place the prperties f drugs used that is BNF and SPC requirements, including need fr baseline ECG and the ptential f individual drugs t lengthen (directly r indirectly) the QTc interval. Additinally they must knw the ttal daily dses allwed and the need t titrate dse t effect. the risks assciated with particular classes f medicines: Benzdiazepines: lss f cnsciusness; respiratry depressin r arrest; cardivascular cllapse when receiving bth clzapine and benzdiazepines Antipsychtics: excessive sedatin; lss f cnsciusness; cardivascular/respiratry cmplicatins and cllapse; seizures; akathisia; dystnia; dyskinesia; neurleptic malignant syndrme Antihistamines: excessive sedatin; painful injectin; additinal antimuscarinic effects the medicines NOT recmmended, namely: PO/IM chlrprmazine IM diazepam Thiridazine (n lnger marketed in the UK) IM dept antipsychtics Olanzapine (fr dementia-related disturbance) Zuclpenthixl acetate due t lng nset and duratin f actin. Hwever, it may be cnsidered as an ptin where there is a past histry f gd and timely respnse, r where there is an advance directive and when the service user has a histry f disturbed behaviur ver an extended time perid. Aware that there are preferred levels f administratin (the preferred methd f drug administratin being PO, then intramuscular IM and then, and nly if immediate tranquillisatin is essential, IV) and that: if patient will accept ral and is nt psychtic, NICE recmmends ral lrazepam. Alternatively, if psychtic and taking ral, cnsider an antipsychtic (e.g. halperidl r lanzapine) in additin t ral lrazepam. if patient will nt accept ral (r, frm previus experience, this is cnsidered ineffective) cnsider IM lrazepam fr nn-psychtic patients. Alternatively, if psychtic and nt accepting ral, cnsider 9

10 use f IM lrazepam in additin t IM antipsychtic (e.g. halperidl r lanzapine). IM Lrazepam and IM Olanzapine can nly be given cncurrently if a minimum f ne hur has elapsed between the tw agents (When using antipsychtics parenterally, ensure ready availability f parenteral prcyclidine. NICE als recmmends parenteral benztrpine, but this prduct has, since, been discntinued in the UK.) Familiar with pst management prcedures, such as: Regular mnitring and recrding f BP, HR (pulse), RR, O2 saturatins, level f cnsciusness, EPSE and temperature; the frequency f which must be increased if IM/IV administratin has been used BNF/SPC dsages have been exceeded High-risk situatins such as knwn/suspected illicit drug use Patient has a significant medical histry/is n prescribed medicatin If verbal respnsiveness is lst use same level f mnitring as fr general anaesthesia Upn transfer t anther unit, ensure that full dcumentatin is cmplete with: References Full medicatin histry (that is, which medicines were/were nt effective and any adverse drug interactins); Frmulatin f advance directive(s); Service user s accunt f their experience (if feasible). 1. The Suth Lndn and Maudsley NHS Fundatin Trust and Oxleas NHS Fundatin Trust 2015 Prescribing Guidelines. 12 th Editin. Wiley Blackwell 2. NICE CG 25, Feb 2005 Vilence: The shrt-term management f disturbed/vilent behaviur in psychiatric in-patient settings and emergency departments (Accessed Dec 2015) 3. British Natinal Frmulary (72 nd Editin, September 2017) 4. Summary f Prduct Characteristics[accessed Dec 2015] 5. NICE NG 10 May Vilence and Aggressin: Shrt term management in mental health, health and cmmunity settings Accessed September British Natinal Frmulary fr Children Accessed July