I agree with both Niruj & Stephen. Occasional use of midazolam could be acceptable. midazolam could also be administered buccally (as for epilepsy patients) (Epistatus), which may be better than intranasal administration in this case!!

Shoumi

Professor Shoumitro Deb, MBBS, FRCPsych, MD
________________________________________
From: Discussion and current awareness re psychiatry and neurology [[log in to unmask]] On Behalf Of Stephen Tyrer [[log in to unmask]]
Sent: 22 January 2010 17:21
To: [log in to unmask]
Subject: Re: advice on sedation

Dear Janet

You have a difficult problem and it is easy to give advice from a
distance. It would be helpful to observe your patient and determine as far
as possible what factors improve her agitation and what factors make it
worse. This process is called functional analysis and is often carried out
by psychologists but could be performed well by an informed nurse. Ideally
a 24-hour assessment should be made at a time when no unusual
circumstances are likely to arise. Specific triggers to behavioural
disturbance may be found using this technique and it then may be able to
avoid these.

I agree with Niruj that, on the whole, benzodiazepines are not
recommended. However, for specific procedures, when it is found that
agitation is most evident, the very quick-acting benzodiazepine,
midazolam, may assist. Midazolam is the fastest acting of its class
because of its lipophilic properties. It works within a few minutes and
the effects normally only last up to half an hour, and often less than
this. Midazolam can be given intranasally or intramuscularly. The
intranasal dose is 0.2 mg/kg and the intramuscular dose is 0.04-0.1 mg/kg.
I have found this drug very useful in enabling short, perceived to be
unpleasant procedures, like taking blood, to be carried out successfully.

As with all benzodiazepines tolerance occurs so it is not advisable to use
midazolam on a regular basis. However, use on 2 or 3 occasions a week does
not normally pose a problem.

I wish you luck in helping to settle your patient successfully.

Best wishes

Stephen


On Fri, January 22, 2010 8:27 am, Butler Janet wrote:

> Does anyone have expereince of regular heavy sedation.
>
> I have been asked for advice on sedation for a young woman with NMDA
> encephalitis who is extremely agitated and confused (apparently improving
> a little now but is still only at the level of occasionally recognising
> close family). They don't want anything with significant risk of motor
> side effects due to troublesome motor symptoms initally. She has been in
> hospital several weeks and continues to pull out all lines etc and hasn't
> eaten at all. She started quite slim and is now clearly malnourished. The
> neurologists feel she would pull out a PEG or TPN line and asked for
> advice as to sedating her overnight for several hours of NG feeding. They
> don't want her too sedated in the day.
>
> They already had her on 15mg tds (8am, 4pm and midnight) diazepam plus 3pm
> nocte risperideon and carbemazepine tds plus (prn) 1-2 daily doses doses
> of lorazepam 2mg (usually given around 4pm). She'd been on the BDZ for
> several weeks. My first change was to change the risperidone to olanzepine
> 10mg, and alter the BDZ to 10, 10, 25mg with the aim to further decrease
> daytime levels and, if needed, increase the night time dose (which I also
> made to be given with the olanzepine).
>
> This change has had minimal effect (increased sleep to about 2hrs). I
> discovered today the patient is having all medication via NG tube - which
> is thus forcibly being inserted 4 times a day and is then immediately
> pulled out by the patient. Clearly the family and nursing staff are
> finding this very distressing (as I expect is the patient). Nurses on the
> ward are very good at managing behavioural disturbance but are now
> apparently going sick and asking not to be asigned to her. She has to be
> nursed on the floor on mattresses due to her constant agitation.
>
> I can increase the evening diazepam to 40mg  and olanzepine to 15mg but I
> wonder whether that will help NG feeding and I'm concerned about tolerance
> and paradoxical disinhibition of BDZs. I've asked for anaesthetic and
> nutrition team advice.
>
> Does anyone have any magic solutions??? Or even just better guesses or
> ideas? I'm feeling a bit out of my depth!
>
>
> Dr Janet Butler
> Consultant Liaison Psychiatrist
> Department of Psychological Medicine
> Southampton General Hospital
>
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