Subject(M1) Policy for Rapid Tranquillisation in Adult ...

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Subject(M1) Title

Policy for Rapid Tranquillisation in Adult Patients

Directorate Clinical policy? Policy/Procedure No Author Pharmacy Services Copy No 1 Reviewer Rapid Tranquillisation group Implementation Date 2001 Status Authorised Last Review Date October 2012

Approved By Chief Pharmacist

Next Review Date October 2015

If a policy is past its review date then the content will remain extant until such time as the

policy review is complete and the new version published. 1. BACKGROUND 1.1 Rapid tranquillisation (RT) is a pharmacological strategy used to manage disturbed

behaviour. Tranquillisation means calming without sedating. Rapid implies that it is necessary to achieve calming as quickly as is safely possible. Occasionally sedation will be unavoidable but this is not an optimal result.

1.2 Careful thought must be given to ways of anticipating and minimising the emergence of disturbed behaviour. More proactive and assertive treatment of an underlying disorder (e.g. psychosis), or pre-empting adverse environmental factors (e.g. interpersonal conflict) may prevent the situation arising in the first place. The use of medication should not be seen as the first and only response to the management of disturbed patients but rather as one aspect of the total plan of management with contributions from all members of the multidisciplinary team. Ideally plans for the management of individual patients should be made in advance of the episode of acutely disturbed behaviour. This will usually involve a combination of nursing interventions, levels of supervision, placement in a safe environment and pharmacological methods.

1.3 This policy will provide prescribers and nurses with procedures and protocols that will aid them to make appropriate clinical decisions based on the characteristics of an individual patient and situation.

1.4 Rapid tranquillisation is not a prescriptive procedure and every clinical situation must be judged according to its unique presentation

2. FUNCTION

2.1 To provide guidance on the short term management of disturbed behaviour in adult NHS Fife settings. The guidance applies to all persons from the age of 16.

3. LOCATION

NHS Fife

4. RESPONSIBILITY

4.1 Directors and Senior Managers


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o Ensure that all managers and staff are aware of the guideline and promote good practice.

o Provide support and guidance regarding resources and the consistent application of the guideline and the future practice recommendations.

o Ensure that medical and nursing staff implement safe systems of work in accordance with the protocols and procedures referred to in the guideline.

o Ensure recommended training in the management of acutely disturbed (violent) patients and the prescribing and administration of rapid tranquillisation is undertaken appropriately

4.2 Medical Staff o All prescribing must be completed in line with NHS Fife Code of Practice Medicines

(COPM) 3-2 ”Prescribing for In and Day Hospital Patients o Prescribers are responsible for adhering to the prescribing requirements identified in

the guidelines and the actions to take in the event of an adverse incident or suspected drug reaction.

o Prescribers must always refer to the current BNF to check recommended drugs and dosages.

4.3 Nursing staff

o Senior Charge Nurses are responsible for implementing the guidance across their areas of responsibility and assessing the competencies of nursing staff to implement the procedures and protocols referred to in the policy.

o Ensure they are familiar with the policy and are responsible for adhering to the protocols and procedures referred to in the policy.

o Ensure recommended training is undertaken as outlined in the clinical guidelines. o Provide support and information to patients and carers with regards to the application

of guidelines implemented. o Ensure monitoring of practice standards o Ensure maintenance of equipment is carried out as recommended. o Non medical prescribers are responsible for adhering to the prescribing requirements

identified in the guidelines and the actions to take in the event of an adverse incident or suspected drug reaction

4.4 Pharmacy Staff o Responsible for providing guidance on monitoring requirements and safe and

appropriate usage of medication. 5 OPERATIONAL SYSTEM

5.1 The intervention selected must be a reasonable and proportionate response to the risk posed by the patient at that particular time. The reasons for using RT (and any other intervention) must always be explained to the patient at the earliest opportunity.

5.2 Review the use of non-pharmacological strategies for managing disturbed behaviour


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5.2.1 There are a variety of other approaches aside from pharmacological therapy to manage a high risk of imminent violence. These include

o de-escalation o distraction techniques o consideration of placement o physical restraint o nursing in a low stimulus environment.

All of these strategies should be considered in each case. Rapid tranquillisation is likely to be appropriate only when some of these have been tried and have failed. Even when rapid tranquillisation is used, the other strategies should continue to be used alongside rapid tranquillisation, as each is likely to augment the effect of the others. Particular caution is necessary if combining rapid tranquillisation with nursing in a low stimulus environment. Patients who are sedated must not be nursed in a low stimulus environment unless appropriate direct monitoring / observation is in place to identify adverse effects

5.2.2 An attempt should be made to discuss with the patient the cause of the disturbance and possible ways to address any distress and anger.

5.3 Mental Health Act Considerations 5.3.1 Patients detained under the Mental Health (Care and Treatment)

(Scotland) 2003 Act are subject to Consent to Treatment. If they have been detained for more than 2 months, they will require a Treatment Plan T2 or T3 to authorise specific treatments for use in emergency situations.

5.3.2 Emergency treatment under the Mental Health (Care and Treatment) (Scotland) 2003 Act may be given if it is in a patient’s best interests and follows the requirements of the Act. Emergency treatment should be recorded on a form T4. Further guidance can be found in the Mental Welfare Commission publication “Consent to treatment. A guide for mental health practitioners” available from www.mwcscot.org.uk.

5.3.3 For patients under the Adults with Incapacity (Scotland) Act 2000 ensure there is a Section 47 form completed.

5.3.4 All information relevant to MHA status must be fully documented in the medical notes.

5.3.5 The patient’s legal status should be reviewed whenever parenteral medication is considered. The enforced administration of medication by injection in an informal patient may necessitate use of the Mental Health Act.

5.4 Review patient records – Pre-administration checks

5.4.1 Prescribers must check previous medical history for any relevant details that may make the use of standard doses of medication listed in this guidance unsuitable e.g. cardiovascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, epilepsy, substance misuse etc.


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5.4.2 Patients with Learning Disability may often require lower doses of medication which should be taken into account during assessment and prior to prescribing and administration

5.4.3 Prescribers must check for recent investigations of biochemistry, haematology, electrocardiogram (ECG), radiology reports that may influence choice and dose of medication for rapid tranquillisation

5.4.4 Check if a patient specific behaviour management guideline exists. This should provide details of the most appropriate intervention based on past experience.

5.5 Consider physical examination (according to degree of co-operation)

5.5.1 During a period of acute disturbed behaviour it may not be feasible to undertake this complete battery of tests. In such circumstances reference should be made to whether recent tests have been undertaken to provide an up to date picture of the physical condition. If such current test results are not available this should generate greater caution in both the selection and doses of prescribed medicines

5.5.2 The purpose of the physical examination is to identify other causes of

acute disturbance such as delirium, acute neurological insults, intoxication or withdrawal of any medicine (prescribed or recreational), or other physically compromised states and to act as a baseline.

5.5.3 Assess for:

o Hydration status, blood pressure, pulse and temperature o Abnormal movements (underlying extrapyramidal side effects

(EPSE)) o Identification of previous medicine exposure and adverse

medicine reactions o General medical condition, especially delirium (see 5.5.5)

(including performing specific blood tests) o Evidence of concurrent substance use e.g. intoxification /

withdrawal and performance of baseline toxicology tests o Baseline ECG – to assist with prescription choice

5.5.4 Any clinically significant abnormality of any of the above requires

appropriate intervention, which may include referral to a medical registrar. 5.5.5 If delirium is suspected then refer to NHS Fife Delirium Pathway for

assessment and management information. The pathway is located online in the Geriatric Medicine folder within Public Folders on NHS Fife Intranet

5.6 Consult with a more senior doctor at any stage if unsure 5.6.1 The patients Responsible Medical Officer (RMO) or the duty consultant

psychiatrist out of hours can be called for advice at any stage e.g. by contacting the duty coordinator / going through main switchboard, if felt appropriate by the team managing the disturbed patient

5.7 Medication - Oral 5.7.1 If measures that do not involve medicines fail, the first medicine

intervention should involve the offer of oral therapy.


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5.7.2 The aim of the management of acute disturbance is calming with rapid

onset. Treatment choice should ideally be guided by previous response to a drug. Any intervention with medicines should be tailored to the particular clinical situation and the efficacy monitored closely. The decision to use oral therapy rather than intramuscular (IM) injection will result in a slower onset of action. Even with syrups and dispersible tablets, oral formulations may take at least two hours to achieve peak effect. See appendix 7.4 “Summary of drugs used in RT, their properties and side effects” for specific pharmacokinetic details.

5.7.3 Even if the patient is responsive to verbal direction and accepting of oral medicines ensure the background physical examination and formulation of causes is available and up to date.

5.7.4 Check and take into account ALL medications, including “As required” received by the patient over the past 24 hours. It is important to remember that medication given recently may not have reached full effect, and to consider any regular doses which are due in the next few hours. Appendix 7.6 “Recently administered medication summary sheet” may be used to document medications taken over the past 24 hours.

5.7.5 Before a decision is made to repeat the administration of a dose of the selected medicine a review of the level of sedation should take place taking into account the kinetics of oral formulations.

5.7.6 For quick reference information on oral medication recommended for use in Rapid Tranquillisation see Appendix 7.2, 7.3 and 7.4. For information on individual drugs see website www.medicines.org.uk/emc

5.7.7 If at least two doses of oral medication are not successful or oral medication is refused then intramuscular medication should be considered the next step.

5.7.8 A short course of a longer acting medication e.g. diazepam may help a rapid recurrence of disturbed behaviour

5.8 Medication – Short Acting Intramuscular (IM) Preparations

5.8.1 If non-pharmacological strategies and oral medication is refused or has failed to achieve calming of the disturbed patient, IM therapy should be used. Ideally the medicine chosen should be rapidly absorbed and calming in action.

5.8.2 Before administration of IM therapy an agreed schedule of monitoring should be agreed by the clinical team to encompass blood pressure, pulse, temperature and respiratory rate. This must be documented on a FEWS chart

5.8.3 Particular attention should be made to observing for adverse effects and clinicians should be aware of the management of common adverse effects of medicines used for rapid tranquillisation. See appendix 7.4

5.8.4 Medicines recommended for IM use for rapid tranquillisation are found in appendix 7.2, 7.3 and 7.4


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5.8.5 If the patient remains disturbed after repeated IM injections then a senior colleague should be consulted to review the patient and the management plan

5.9 Medication – Longer acting Intramuscular Medication

5.9.1 Many authorities do not regard the IM antipsychotic zuclopenthixol acetate (Clopixol Acuphase®) as appropriate for the acute management of disturbed behaviour. The delay in onset of action is too long for acute management. If the patient is not responsive to verbal direction, refusing oral medication and requiring repeated IM injections the longer-acting IM antipsychotic zuclopenthixol acetate (Clopixol Acuphase®) may be indicated.

5.9.2 The use of Clopixol Acuphase® is recommended as a Consultant Psychiatrist only decision. Clopixol Acuphase® should not be prescribed as a ‘prn’ option, but only as a ‘stat’ dose at a specific time.

5.9.3 See Appendix 7.5 “The Use of Zuclopenthixol Acetate (Clopixol Acuphase)”

5.10 Monitoring / Observations of patient requiring medication for rapid tranquillisation

5.10.1 Physical observations must be performed and recorded on the Fife Early Warning Score (FEWS) chart.

5.10.2 The frequency of physical observations must be decided by the multidisciplinary team prior to administration of medication

5.10.3 The FEWS algorithm specific for CHPs (appendix 7.7) must be adhered to in order to minimise harm to patients

5.11 Steps following Rapid Tranquillisation

5.11.1 All patients should be offered the opportunity to discuss their experiences and should be provided with a clear explanation of the decision to use rapid tranquillisation. They should be given an opportunity to write their account of their experience in the notes.

5.11.2 Staff and other patients should have the opportunity to discuss the incident of rapid tranquillisation

5.11.3 In accordance with Code of Practice Medicines and standards for record keeping recommended by professional bodies full documentation should be completed in medical and nursing notes to support clear clinical decision making and to describe the procedure that was followed for each clinical situation, giving reasons if the guidance in this document was not followed.

5.11.4 Multidisciplinary completion of a patient specific behaviour management guideline (see Appendix 7.8) should be considered to guide treatment for any future episode of disturbed behaviour. If competed in collaboration with the patient this could become part of an Advanced Statement.


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6. Risk 6.1 A NHS Fife Incident / Near Miss Reporting Form should be completed for all

episodes of rapid tranquillisation. Refer to NHS Fife Incident Management Policy (GP1)

6.2 Certain risks and possible injury to patients and healthcare staff could occur if the

policy is not taken into account, for example: o Administering medication before an assessment of physical health, concurrent

medication or if delirium or intoxication is suspected o Prescribing medication in doses and frequencies out-with what is

recommended in this document o Prescribing medication not included in this document o Physical monitoring parameters not completed and subsequent adverse

incident e.g. respiratory depression, cardiac arrest, inappropriate use of rapid tranquillisation before exclusion of medical cause

6.3 There is a risk of respiratory depression when using parenteral benzodiazepines

therefore it is recommended that the benzodiazepine antagonist flumazenil be available on wards where parenteral benzodiazepines are administered. It is accepted by NHS Fife that flumazenil is highly unlikely to be administered due to the license restrictions recommending it be administered by an anaesthetist or a doctor with experience in anaesthisiology. A FEWS algorithm for monitoring patients following administration of medication for rapid tranquillisation is available and provides necessary guidance on actions to take in the event of adverse effects.

6.4 The prescriber will evaluate any suspected adverse drug reaction in accordance

with the guidance issued by the Medicine and Healthcare Products Regulatory Agency (MHRA) and decide whether a “Yellow Card” needs completing to notify the MHRA of a suspected drug reaction. http://yellowcard.mhra.gov.uk/

7. Related Documents / Forms 7.1 Management Algorithm

7.2 Protocol for Rapid Tranquillisation (Adults 16-65 years)

7.3 Protocol for Rapid Tranquillisation (Adults 65 years +)

7.4 Summary of drugs used in RT, their properties and side effects

7.5 The use of Zuclopenthixol Acetate (Clopixol Acuphase)

7.6 Recently Administered Medication Summary Sheet

7.7 FEWS Algorithm

7.8 Behaviour management guidelines (template)

8. References

8.1 NICE Clinical Guideline 1: Schizophrenia. Core interventions in the treatment management of schizophrenia in primary and secondary care. National Institute of Clinical Excellence, December 2002. At www.nice.org.uk.


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8.2 NICE Clinical Guideline 25: Violence: The short term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. National Institute for Clinical Excellence, February 2005. At www.nice.org.uk.

8.3 Taylor D, Paton C, Kapur S. Informa Healthcare. The Maudsley Prescribing Guidelines 10

th Edition.

8.4 Pharmaceutical Press. British National Formulary 63 March 2012.

8.5 Royal Pharmaceutical Society of Great Britain, 2007. Martindale: The Complete Drug Reference 35

th Edition. Pharmaceutical Press

8.6 Mental Welfare Commission for Scotland. Consent to medication. A guide for mental health practitioners. December 2010

8.7 NHS Fife Geriatric Medicine Acute Care Pathways. Delirium Pathway. Available from NHS Fife Intranet – Public Folders – Geriatric Medicine. Accessed 12/9/12


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Appendix 7.1 MANAGEMENT ALGORITHM

PATIENT PRESENTS AS ACUTELY OR INCREASINGLY DISTURBED

Review Current Management Plan i.e.: Increase in Staff Resource

Increase in Observation Level Current Prescription/Use of “As required” medication Increase in Regular Medication Review of Mental Health Act Status Use of Seclusion or Low Stimulus Environment

Does the Patient require Rapid Tranquillisation?

NO

Review of Management Plan

Was Successful

YES

Is the Unit Equipped to implement the Rapid Tranquillisation Policy? i.e.: Are staff trained in physical restraint,

Basic Life Support and monitoring/administration of rapid tranquillisation medication. Does the unit carry emergency equipment? Are there enough staff available to implement the guideline?

NO

YES

Contact, refer and transfer to identified rapid tranquillisation resourced units:

i.e.: Describe patient’s presentation, risks and current management. (Send risk assessment if possible)

Implement Rapid Tranquillisation

Guidelines


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Procedure for Rapid Tranquillisation (Adults 16-65 years) Appendix 7.2 Step Intervention

1. • Review the use of non-pharmacological strategies for managing an imminent risk of violence

• Review the patients consent to treatment. Is it necessary to use the Mental Health (Care and Treatment) (Scotland) 2003 Act?

• Review their notes for previous medical history and recent investigations.

• Consider physical examination

• If necessary review the Policy for Rapid Tranquillisation in Adult Patients.

• Consult with a more senior doctor at any stage if unsure

2. Consider using oral medication. The options are:

Lorazepam 1 - 2mg (4mg/24hrs) Haloperidol 5 - 10mg (30mg/24hrs)

Lorazepam works quickly, oral antipsychotics will take considerably longer. Therefore there may be some advantage in combining them. If the patient is benzodiazepine tolerant or has respiratory disease, consider using antipsychotics alone. If the patient is established on regular antipsychotics or has cardiovascular disease, consider using benzodiazepines alone. Avoid Haloperidol in neuroleptic naïve patients

• Lorazepam may be repeated after 30 minutes

• Doses of oral antipsychotics should not be repeated for at least 45-60 minutes

• Doses can be repeated as necessary up to their maximum BNF doses. If two doses fail proceed to step 3.

• Monitor physical health of patients receiving frequent doses of oral sedatives at intervals agreed by the multidisciplinary team until the patient is active again. Document on FEWS chart

3. Consider using intramuscular medication if oral therapy unsuccessful or patient refuses/unable to take oral. The options are:

Lorazepam 1-2mg (dilute 1:1 with water for injection or 0.9% sodium chloride) Midazolam 5 - 7.5mg (15mg/24hrs)

Haloperidol 5 - 10mg (18mg/24hrs)

If the patient is benzodiazepine tolerant or has respiratory disease, consider using antipsychotics alone If the patient is established on regular antipsychotics or has cardiovascular disease, consider using benzodiazepines alone Avoid using Haloperidol in neuroleptic naïve patients BNF maximum Lorazepam 4mg/24hrs although in emergency situations it may be necessary to prescribe higher doses.

• Intramuscular Haloperidol may be repeated after at least 30 minutes

• Intramuscular benzodiazepines may be repeated after at least one hour

• Doses can be repeated at recommended intervals up to their maximum BNF doses

• Monitor physical health of patients receiving any parenteral medication at intervals agreed by the multidisciplinary team until the patient is active again. Document on FEWS chart.

• I.M. Procyclidine should be available if haloperidol is used due to the possibility of acute dystonic reactions occurring. Dose 5-10mg I.M.

4. Reconsider non-pharmacological measures and consult a senior colleague if you haven’t already

5. Pharmacological options following response include:

Zuclopenthixol acetate (Acuphase) 50-150mg. Maximum 400mg/2 weeks and at least 24hrs between doses, usually 2-3 days Short reducing course of a long acting benzodiazepine. E.g. Diazepam 5mg three times daily reduced over 3 days

Acuphase may have a role in the ongoing management of a risk of violence once tranquillisation has been satisfactorily achieved Acuphase should only be given after calming has been achieved, in those situations when it is likely that repeated doses of IM antipsychotics will be necessary The use of Clopixol Acuphase® is recommended as a Consultant Psychiatrist only decision. See Appendix 7.6 The use of zuclopenthixol acetate (Clopixol Acuphase) May help to prevent a rapid recurrence of disturbance


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Appendix 7.3 Procedure for Rapid Tranquillisation (Adults 65 years + )

Step Intervention

1. • Review the use of non-pharmacological strategies for managing an imminent risk of violence

• Review the patients consent to treatment. Is it necessary to use the Mental Health Act?

• For patients under the Adults with Incapacity Act (Scotland) 2000 ensure there is a Section 47 form completed.

• Review their notes for previous medical history and recent investigations.

• Consider physical examination

• For physically fit patients, and those currently/previously treated with higher doses of antipsychotics, the protocol for younger adults may be more appropriate.

• If necessary review the policy for Rapid Tranquillisation in Adult Patients.

• Consult with a more senior doctor at any stage if unsure

2. Consider using oral medication:

Lorazepam 500micrograms - 1mg (2mg/24hrs)

Haloperidol 500micrograms - 1mg (2mg/24hrs)

If the patient is benzodiazepine tolerant or has respiratory disease, consider using antipsychotics alone. If the patient is established on regular antipsychotics, has cardiovascular disease, Parkinson’s disease or Extrapyramidal side effects consider using benzodiazepines. Haloperidol is commonly used first line in patients with delirium – refer to NHS Fife Delirium Pathway

• Lorazepam may be repeated after 30 minutes

• Doses of oral antipsychotics should not be repeated for at least 45-60 minutes

• Doses can be repeated as necessary up to their maximum BNF doses

• Monitor physical health of patients receiving frequent doses of oral sedatives at intervals agreed by the multidisciplinary team until the patient is active again. Document on FEWS chart

• If two doses fail proceed to step 3

3. Consider using intramuscular medication if oral therapy unsuccessful or patient refuses/unable to take oral. The options are:

Lorazepam 0.5micrograms -2mg (dilute 1:1 with water for

injection or 0.9% sodium chloride) Midazolam 2.5 - 5mg (10mg/24hrs)

Haloperidol 1 - 5mg (9mg/24hrs)

If the patient is benzodiazepine tolerant or has respiratory disease, consider using antipsychotics alone. If the patient is established on regular antipsychotics or has cardiovascular disease, consider using benzodiazepines alone. Avoid using Haloperidol in neuroleptic naïve patients. BNF maximum Lorazepam 2mg/24hrs although in emergency situations it may be necessary to prescribe higher doses.

• Intramuscular Haloperidol may be repeated after at least 30 minutes

• Intramuscular benzodiazepines may be repeated after at least one hour

• Doses can be repeated at recommended intervals up to their maximum BNF doses

• Monitor physical health of patients receiving any parenteral medication at intervals agreed by the multidisciplinary team until the patient is active again. Document on FEWS chart.

• I.M. Procyclidine should be available if haloperidol is used due to the possibility of acute dystonic reactions occurring. Dose 5-10mg I.M.

4. Reconsider non-pharmacological measures and consult a senior colleague if you haven’t already

5. Pharmacological options following response include:

Zuclopenthixol acetate (Acuphase) 50-100mg. Maximum 400mg/2 weeks and at least 24hrs between doses, usually 2-3 days Short reducing course of a long acting benzodiazepine. E.g. Diazepam 2mg three times daily reduced over 3 days

Acuphase may have a role in the ongoing management of a risk of violence once tranquillisation has been satisfactorily achieved Acuphase should only be given after calming has been achieved, in those situations when it is likely that repeated doses of IM antipsychotics will be necessary The use of Clopixol Acuphase® is recommended as a Consultant Psychiatrist only decision. See Appendix 7.6 The use of zuclopenthixol acetate (Clopixol Acuphase) Diazepam may help to prevent a rapid recurrence of disturbance


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Appendix 7.4 Summary of drugs used in RT, their properties and side effects

2,20,22

DRUG ROUTE PHARMACOKINETICS MAJOR SIDE EFFECTS NOTES PREFERENCE

SHORT-ACTING ANTIPSYCHOTICS

Oral Peak 5-8 hours Less likely to cause extrapyramidal side effects (EPSE) than haloperidol

Not included in algorithm

Olanzapine

IM

Peak 15-45 minutes Half life (t½) 30 hours

Hypotension Bradycardia Syncope

IM administration results in initial maximum

plasma concentration 5× higher than same dose given orally Should not be used within one hour of benzodiazepine. Refer to “Guidance Document on the Use of Intramuscular Olanzapine”

Not included in algorithm.

Separate guidance available.

Risperidone Oral Peak 2 hours t½ 18 hours

EPSE ? Hypotension

Limited clinical experience or trial data Not included in

algorithm

Quetiapine Oral Peak 1.5-1.8 hours t½ 6-7 hours

? QT prolongation ? Hypotension

Limited clinical experience or trial data Not included in

algorithm

Aripiprazole IM Peak 1 hours t½ 75 – 146 hours

Nausea, dizziness and somnolence

Limited clinical experience. Refer to “Guidance Document on the Use of Intramuscular Aripiprazole”

Not included in algorithm.

Separate guidance available.

Oral Peak 4 hours t½ 21 hours

Included in algorithm

Haloperidol

IM Peak 20 minutes t½ 21 hours

EPSE Hypotension Neuroleptic Malignant Syndrome (NMS) Increased QTc, Arrhythmias Seizures Sudden death

Baseline ECG is recommended prior to treatment in all patients

Note risk of acute dystonias and ensure that an appropriate antimuscarinic is to hand.

Not recommended for intravenous use because of the risk of arrhythmias


BENZODIAZEPINES

Midazolam IM Peak 30 minutes t½ 1.5-2.5 hours

Limited clinical experience. Schedule 3 Controlled Drug. Requires to be ordered in Controlled Drug Order book and stored in Controlled Drug Cupboard


Oral Peak 2 hours t½ 12 hours


Lorazepam

IM Peak 60-90 mins t½ 12-16 hours


Diazepam Oral Peak 60 minutes t½ 24-48 hours

Respiratory depression Disinhibition

IM Lorazepam must be diluted with equal volume of Water For Injection / 0.9% Sodium Chloride A wide therapeutic index & respiratory depression is readily reversed with the specific antagonist flumazenil

Disinhibition is more likely to occur in those with organic brain disease, including learning disabilities, the under 18s and the over 65s, and perhaps those with impulse control problems

21


LONGER ACTING ANTIPSYCHOTICS

Zuclopenthixol acetate (Acuphase)

IM

Onset 2-8 hours Peak 24-36 hours t½ 60 hours

EPSE Sudden death Cardiac arrest Arrhythmias

This is not an appropriate drug for use in rapid tranquillisation. It may occasionally be used as part of a medium term strategy It should never be used in those who neuroleptic naive, who are struggling, who are sensitive to EPSE, those with cardiac disease, hepatic or renal impairment or in pregnancy



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Appendix 7.5 THE USE OF ZUCLOPENTHIXOL ACETATE (CLOPIXOL ACUPHASE)

� Zuclopenthixol acetate (Clopixol Acuphase) is not an appropriate drug for use in rapid tranquillisation (although it is used in the treatment of “acute psychosis”) and there is limited evidence for its value in the treatment of schizophrenia.

18,19

� It has a significantly delayed onset of action and a relatively long duration of action.

� It may have a role in the ongoing management of a risk of violence once

tranquillisation has been satisfactorily achieved. But it is important to consider the pharmacokinetics of other drugs when prescribing it. For example, caution is necessary in a patient who has recently received a dose of depot antipsychotic which has not yet reached peak levels.

� It should only be given after calming has been achieved, in those situations when it is

likely that repeated doses of IM antipsychotics will be necessary.

� It should never be used in those who are struggling or who are sensitive to EPSE

� It should be used with caution in patients with convulsive disorders, advanced hepatic, renal or cardiovascular disease

� Therefore, this drug should be avoided in acute episodes unless specifically stated that the patient responds best to Zuclopenthixol Acetate in the patient’s notes or in an advance statement.

� Doses of 50-150 mgs may be given up to a maximum of 400 mgs in 2 weeks, with at least 24 hours between doses, usually two to three days between doses. See the Summary of Product Characteristics (SPC) for more details www.medicines.org.uk/emc

� The dosage may need to be reduced in the elderly owing to reduced rates of

metabolism and elimination. Maximum dosage per injection should be 100mg.

� The use of Clopixol Acuphase® is recommended as a Consultant Psychiatrist only decision

� NB: There is no such thing as “a course of Acuphase”


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Appendix 7.6 Recently Administered Medication Summary Sheet Patient………………………………………… CHI No………………….. Consultant…………………………………… Date…………………………. This sheet is a useful way of documenting the amount of antipsychotic and benzodiazepine medication administered to the patient requiring rapid tranquillisation. It includes all “Regular” oral and depot medication and all as required “PRN” and “Once only” medication administered over the last 24 hours.

Antipsychotic Medication Taken over last 24 hours

“Regular” Antipsychotics administered

Route Dose Max. BNF Dose

% Of Max BNF Dose

Depot Antipsychotics administered in past month “As required” Antipsychotics administered “Once only” Antipsychotics administered

Benzodiazepine Medication Taken over last 24 hours

“Regular” Benzodiazepine administered

Route Dose Max. BNF Dose

% Of Max BNF Dose

“As required” Benzodiazepine administered “Once only” Benzodiazepine administered

High Dose Antipsychotic (HDA) Calculation Date of HDA Calculation

“Regular”/ Depot Antipsychotic administered: Total % “As required” Antipsychotic administered: Total %

Combined prescribed: Total %

If high dose antipsychotic exceeding 100% of the BNF maximum occurs, monitoring should take place as described in policy M1-P2-MH “Prescription of High Dose Antipsychotic Medication”


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RAPID ASSESSMENT UTILISE ABCDE

APPROACH

RAPIDLY DETERIORATING

PATIENT

URGENT MEDICAL REVIEW

POINTS FOR CONSIDERATION

• Utilise SBAR for communication with the patient – see FEWS

• If temp ≥ 38° Blood cultures. Consider antibiotic therapy

• If systolic BP < 100, assess patient’s ABCDE. Consider reasons

• If oxygen saturation ≤ 94% assess patient’s ABCDE, administer oxygen as per hospital policy. Consider ABGs

• If RR rate ≥ 25 assess patient’s ABCDE (CXR, Arterial Blood Gas (ABG) / peak flow

• If AVPU = Call for help if P or U and then perform Glasgow Coma Scale if trained to do so

• If BM < 4 give oral carbohydrate if patient conscious

• Pain VAS 0-10: no pain – worst pain imaginable

CONTACT RELEVANT MEDICAL

PRACTITIONER

FEWS ≥≥≥≥ 3

2222

Appendix 7.7 NHS FIFE COMMUNITY HEALTH PARTNERSHIPS


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Appendix 7.8 Behaviour Management Guidelines (DRAFT)

Joe Bloggs (1.1.11) Address

These guidelines aim to guide staff in the use of “As Required” medication in the management of Joe’s anxiety / agitation. Early recognition of signs of challenging behaviour and appropriate intervention with medication is essential to prevent further deterioration.

Step 1

If Joe becomes anxious or agitated and staff are concerned about his or other’s safety, and staff are unable to manage the situation using non-medical interventions ;

• Lorazepam 2mg should be given orally

Step 2

If anxiety / agitation continues for more than 1 hour after Step 1 ;

• Lorazepam 2mg should be given orally

AND contact the duty doctor after administering the medication

Step 3

If anxiety / agitation continues for more than 1 hour after Step 2 ;

• contact the duty doctor

Maximum dose in 24 hours : Lorazepam 4mg

Management of separate episodes of anxiety / agitation occurring within a 24-hour period

If agitation / aggression is resolved at Step 1, but a separate event arises more than 1 hour, but within 24-hours of Step 1 ;

• administer medication as per Step 2.

If agitation / aggression is resolved at Step 2, but a separate event arises more than 2 hours, but within 24-hours of Step 1 ;

• contact the duty doctor for advice.

Additional Notes

These guidelines are intended to be used as a guide to the safe and appropriate use of “As Required” medication. If anyone is unsure whether or when to administer it, contact the duty doctor for advice.

These guidelines do not preclude the duty doctor being contacted, at any stage, if staff are concerned about Joe’s behaviour or response to medication.

Details of Joe’s behaviour(s), recognised triggers, and non-medical interventions etc., can be found in his Care Plans. If behaviour(s) occur, which appear to be different to the above description(s), you may wish to discuss as a staff group, along with the Consultant. These guidelines should be reviewed regularly to ensure that intervention continues to be appropriate.

Subject(M1) Policy for Rapid Tranquillisation in Adult ...

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