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Yan VKC, Haendler M, Lau H, Li X, Lao KSJ, Tsui SH, Yap CYL, Knapp MRJ, Chan EW. Cost-Effectiveness of Midazolam Versus Haloperidol Versus Olanzapine for the Management of Acute Agitation in the Accident and Emergency Department. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1099-1106. [PMID: 35151559 DOI: 10.1016/j.jval.2021.11.1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 10/31/2021] [Accepted: 11/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES A multicenter randomized clinical trial in Hong Kong Accident and Emergency (A&E) departments concluded that intramuscular (IM) olanzapine is noninferior to haloperidol and midazolam, in terms of efficacy and safety, for the management of acutely agitated patients in A&E setting. Determining their comparative cost-effectiveness will further provide an economic perspective to inform the choice of sedative in this setting. METHODS This analysis used data from a randomized clinical trial conducted in Hong Kong A&E departments between December 2014 and September 2019. A within-trial cost-effectiveness analysis comparing the 3 sedatives was conducted, from the A&E perspective and a within-trial time horizon, using a decision-analytic model. Sensitivity analyses were also undertaken. RESULTS In the base-case analysis, median total management costs associated with IM midazolam, haloperidol, and olanzapine were Hong Kong dollar (HKD) 1958.9 (US dollar [USD] 251.1), HKD 2504.5 (USD 321.1), and HKD 2467.6 (USD 316.4), respectively. Agitation management labor cost was the main cost driver, whereas drug costs contributed the least. Midazolam dominated over haloperidol and olanzapine. Probabilistic sensitivity analyses supported that midazolam remains dominant > 95% of the time and revealed no clear difference in the cost-effectiveness of IM olanzapine versus haloperidol (incremental cost-effectiveness ratio 667.16; 95% confidence interval -770.89, 685.90). CONCLUSIONS IM midazolam is the dominant cost-effective treatment for the management of acute agitation in the A&E setting. IM olanzapine could be considered as an alternative to IM haloperidol given that there is no clear difference in cost-effectiveness, and their adverse effect profile should be considered when choosing between them.
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Affiliation(s)
- Vincent K C Yan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Miriam Haendler
- School of Pharmacy, University College London, London, England, UK
| | - Hayden Lau
- Department of Accident and Emergency, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Xue Li
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D(2)4H), Hong Kong Science Park, Hong Kong Special Administrative Region, China
| | - Kim S J Lao
- Global Medical and Scientific Affairs, Merck Research Laboratories, Merck Sharp & Dohme, Xuhui, Shanghai, China
| | - Sik-Hon Tsui
- Department of Accident and Emergency, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Celene Y L Yap
- Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Australia
| | - Martin R J Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, England, UK
| | - Esther W Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D(2)4H), Hong Kong Science Park, Hong Kong Special Administrative Region, China; Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China.
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Lo WL, Mok KL, Poon YY. A retrospective study on the safety and effectiveness of olanzapine versus midazolam for pre-hospital management of excited delirium syndrome. HONG KONG J EMERG ME 2021. [DOI: 10.1177/10249079211020868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To evaluate the safety and effectiveness of olanzapine compared to midazolam for the pre-hospital management of excited delirium syndrome. Methods: A retrospective review of patients who were treated by ambulance crew for excited delirium syndrome from 2016 to 2019 was performed. The drug of choice was given per Fire Service Department’s paramedic protocol (intramuscular midazolam January 2016 to October 2018 and intramuscular olanzapine October 2018 to December 2019). The primary outcome was the proportion of patients experienced at least one adverse event. The secondary outcome was the successful sedation rate. Results: A total of 201 patients were included in the study. Ninety-nine patients had pre-hospital midazolam and 102 received olanzapine. Thirty-one patients experienced adverse event after arrival to A&E, including a drop of Glasgow Coma Scale score to below 8 (90%), hypotension (6%), and airway obstruction (3%): 17 (17% patients; 1 airway obstruction and 16 Glasgow Coma Scale score below 8) in midazolam group and 14 (14% patients; 2 hypotension and 12 Glasgow Coma Scale score below 8) in olanzapine group (p = 0.41). Sixty-eight patients (69%) in midazolam group achieved successful sedation, compared with 79 (77%) in olanzapine group (p = 0.20). More adverse events were seen with midazolam than olanzapine in alcohol intoxication subgroup with statistical significance (12 vs 2, p = 0.03). Conclusion: Both midazolam and olanzapine can achieve a satisfactory success rate of sedation. More adverse events are associated with midazolam use in patients with acute alcohol intoxication, especially over-sedation and airway compromise. Olanzapine would be a safer choice in the pre-hospital setting where the resource is limited, and differentiation of underlying causes is not always possible.
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Affiliation(s)
- Wai Ling Lo
- Accident and Emergency Department, Ruttonjee Hospital, HKSAR
| | - Ka Leung Mok
- Accident and Emergency Department, Ruttonjee Hospital, HKSAR
- Fire and Ambulance Services Academy, Fire Services Department, HKSAR
| | - Ying Ying Poon
- Accident and Emergency Department, Ruttonjee Hospital, HKSAR
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Chan EW, Lao KS, Lam L, Tsui SH, Lui CT, Wong CP, Graham CA, Cheng CH, Chung TS, Lam HF, Ting SM, Knott JC, Taylor DM, Kong DC, Leung LP, Wong IC. Intramuscular midazolam, olanzapine, or haloperidol for the management of acute agitation: A multi-centre, double-blind, randomised clinical trial. EClinicalMedicine 2021; 32:100751. [PMID: 33681744 PMCID: PMC7910711 DOI: 10.1016/j.eclinm.2021.100751] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The safety and effectiveness of intramuscular olanzapine or haloperidol compared to midazolam as the initial pharmacological treatment for acute agitation in emergency departments (EDs) has not been evaluated. METHODS A pragmatic, randomised, double-blind, active-controlled trial was conducted from December 2014 to September 2019, in six Hong Kong EDs. Patients (aged 18-75 years) with undifferentiated acute agitation requiring parenteral sedation were randomised to 5 mg intramuscular midazolam (n = 56), olanzapine (n = 54), or haloperidol (n = 57). Primary outcomes were time to adequate sedation and proportion of patients who achieved adequate sedation at each follow-up interval. Sedation levels were measured on a 6-level validated scale (ClinicalTrials.gov Identifier: NCT02380118). FINDINGS Of 206 patients randomised, 167 (mean age, 42 years; 98 [58·7%] male) were analysed. Median time to sedation for IM midazolam, olanzapine, and haloperidol was 8·5 (IQR 8·0), 11·5 (IQR 30·0), and 23·0 (IQR 21·0) min, respectively. At 60 min, similar proportions of patients were adequately sedated (98%, 87%, and 97%). There were statistically significant differences for time to sedation with midazolam compared to olanzapine (p = 0·03) and haloperidol (p = 0·002). Adverse event rates were similar across the three arms. Dystonia (n = 1) and cardiac arrest (n = 1) were reported in the haloperidol group. INTERPRETATION Midazolam resulted in faster sedation in patients with undifferentiated agitation in the emergency setting compared to olanzapine and haloperidol. Midazolam and olanzapine are preferred over haloperidol's slower time to sedation and potential for cardiovascular and extrapyramidal side effects. FUNDING Research Grants Council, Hong Kong.
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Affiliation(s)
- Esther W. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China
- Corresponding author at: Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
| | - Kim S.J. Lao
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
- Global Medical Affairs, Merck Sharp & Dohme, Xuhui, Shanghai, China
| | - Lam Lam
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
| | - Sik-Hon Tsui
- Accident and Emergency Department, Queen Mary Hospital, Pok Fu Lam, Hong Kong SAR
| | - Chun-Tat Lui
- Accident and Emergency Department, Tuen Mun Hospital, Tuen Mun, Hong Kong SAR
| | - Chi-Pang Wong
- Accident and Emergency Department, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR
| | - Colin A. Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR
- Department of Emergency Medicine, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR
| | - Chi-Hung Cheng
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR
- Department of Emergency Medicine, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR
| | - Tong-Shun Chung
- Accident and Emergency Department, Ruttonjee Hospital, Wan Chai, Hong Kong SAR
| | - Hiu-Fung Lam
- Accident and Emergency Department, United Christian Hospital, Kwun Tong, Hong Kong SAR
| | - Soo-Moi Ting
- Accident and Emergency Department, United Christian Hospital, Kwun Tong, Hong Kong SAR
| | - Jonathan C. Knott
- Department of Critical Care, University of Melbourne, Parkville, Australia
| | - David M. Taylor
- Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - David C.M. Kong
- Pharmacy Department, Ballarat Health Services, Ballarat, Victoria, Australia
- Centre for Medicine Use and Safety, Monash University, Victoria, Australia
| | - Ling-Pong Leung
- Emergency Medicine Unit, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR
| | - Ian C.K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
- Corresponding author at: Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
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Kim HK, Leonard JB, Corwell BN, Connors NJ. Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium. Expert Opin Drug Saf 2021; 20:123-138. [PMID: 33327811 DOI: 10.1080/14740338.2021.1865911] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.
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Affiliation(s)
- Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy , Baltimore, MD, USA
| | - Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Nicholas J Connors
- Department of Emergency Medicine, HCA Healthcare Trident Medical Center , Charleston, SC, USA
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Muir-Cochrane E, Oster C, Grimmer K. International research into 22 years of use of chemical restraint: An evidence overview. J Eval Clin Pract 2020; 26:927-956. [PMID: 31318109 DOI: 10.1111/jep.13232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice. AIMS To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995. METHODS This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures. RESULTS This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). DISCUSSION A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042
| | - Candice Oster
- On-Line Education and Development, Flinders Human Behaviour and Health Research Unit (FHBHRU), College of Medicine and Public Health, Flinders University, South Australia, Australia, 5042
| | - Karen Grimmer
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042.,Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Prescription practices in the treatment of agitation in newly hospitalized Chinese schizophrenia patients: data from a non-interventional naturalistic study. BMC Psychiatry 2019; 19:216. [PMID: 31291931 PMCID: PMC6617899 DOI: 10.1186/s12888-019-2192-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 06/23/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Data on the pharmacological management of acute agitation in schizophrenia are scarce. The aim of this study is to investigate the prescription practices in the treatment of agitation in Chinese patients with schizophrenia. METHODS We conducted a large, multicenter, observational study in 14 psychiatry hospitals in China. Newly hospitalized schizophrenia patients with the PANSS-EC total score ≥ 14 and a value ≥4 on at least one of its five items were included in the study. Their drug treatments of the first 2 weeks in hospital were recorded by the researchers. RESULTS Eight hundred and 53 patients enrolled in and 847 (99.30%) completed the study. All participants were prescribed antipsychotics, 40 (4.72%) were prescribed benzodiazepine in conjunction with antipsychotics and 81 were treated with modified electric convulsive therapy (MECT). Four hundred and 12 (48.64%) patients were prescribed only one antipsychotic, in the order of olanzapine (120 patients, 29.13%), followed by risperidone (101 patients, 24.51%) and clozapine (41 patients, 9.95%). About 435 (51.36%) participants received antipsychotic polypharmacy, mostly haloperidol + risperidone (23.45%), haloperidol+ olanzapine (17.01%), olanzapine+ ziprasidone (5.30%), haloperidol + clozapine (4.37%) and haloperidol + quetiapine (3.90%). Binary logistic regression analysis suggests that a high BARS score (OR 2.091, 95%CI 1.140-3.124), severe agitation (OR 1.846, 95%CL 1.266-2.693), unemployment or retirement (OR 1.614, 95%CL 1.189-2.190) and aggressiveness on baseline (OR 1.469, 95%CL 1.032-2.091) were related to an increased antipsychotic polypharmacy odds. Male sex (OR 0.592, 95%CL 0.436-0.803) and schizophrenia in older persons (age ≥ 55 years, OR 0.466, 95%CL 0.240-0.902) were less likely to be associated with antipsychotic polypharmacy. CONCLUSION The present study demonstrates that monotherapy and polypharmacy display equally common patterns of antipsychotic usage in managing agitation associated with schizophrenia in China. The extent and behavioral activities of agitation and several other factors were associated with polypharmacy.
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Yap CYL, Taylor DM, Kong DCM, Knott JC, Taylor SE, Graudins A, Keijzers G, Kulawickrama S, Thom O, Lawton L, Furyk J, Finucci D, Holdgate A, Watkins G, Jordan P. Management of behavioural emergencies: a prospective observational study in Australian emergency departments. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Celene Y. L. Yap
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department The Royal Melbourne Hospital Melbourne Australia
- Centre for Medicine Use and Safety Monash University Melbourne Australia
| | - David McD. Taylor
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department Austin Health Melbourne Australia
| | - David C. M. Kong
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Centre for Medicine Use and Safety Monash University Melbourne Australia
- Pharmacy Department Ballarat Health Services Ballarat Australia
| | - Jonathan C. Knott
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department The Royal Melbourne Hospital Melbourne Australia
| | | | - Andis Graudins
- Emergency Department Monash Health Melbourne Australia
- Department of Medicine, Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Gerben Keijzers
- Emergency Department Gold Coast University Hospital Gold Coast Australia
- School of Medicine Bond University Gold Coast Australia
- School of Medicine Griffith University Gold Coast Australia
| | | | - Ogilvie Thom
- Emergency Department Nambour General Hospital Nambour Australia
| | - Luke Lawton
- Emergency Department The Townsville Hospital Townsville Australia
| | - Jeremy Furyk
- Emergency Department The Townsville Hospital Townsville Australia
| | - Daniel Finucci
- Emergency Department Liverpool Hospital Sydney Australia
| | - Anna Holdgate
- Emergency Department Liverpool Hospital Sydney Australia
| | - Gina Watkins
- Emergency Department Sutherland Hospital Sydney Australia
| | - Peter Jordan
- Emergency Department The Northern Hospital Melbourne Australia
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Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial. Ann Emerg Med 2017; 69:318-326.e1. [DOI: 10.1016/j.annemergmed.2016.07.033] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 11/18/2022]
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Korczak V, Kirby A, Gunja N. Chemical agents for the sedation of agitated patients in the ED: a systematic review. Am J Emerg Med 2016; 34:2426-2431. [PMID: 27707527 DOI: 10.1016/j.ajem.2016.09.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/04/2016] [Accepted: 09/14/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Chemical agents commonly used to sedate agitated patients in the emergency department include benzodiazepines, antipsychotics, or a combination of the 2 classes. Our objective was to determine if a class or combination therapy is (1) more effective, as measured by the proportion sedated at 15-20 minutes and the need for repeat sedation, and (2) safer, as measured by the proportion of reported adverse events. METHODS Systematic literature review and meta-analysis of studies comparing 2 or more chemical agents for sedation of agitated patients in the emergency department were carried out in PubMed, PsycINFO, Embase, and the Cochrane database. Meta-analyses for pairwise comparisons of drug class (benzodiazepine, antipsychotic, or combination) were carried out for each outcome: proportion sedated, need for repeat sedation, and adverse events. RESULTS Seven studies with 1135 patients were included. At 15-20 minutes, the proportion of patients sedated was greater with combination therapy than benzodiazepines alone (risk ratio [RR] = 1.31, P < .0001). Antipsychotics and combination agents required significantly less repeat sedations than benzodiazepines alone (RR = 0.49, P < .0001 and RR = 0.64, P = .002). There was significant heterogeneity in adverse event data, with respiratory system adverse events (desaturation, and need for airway and ventilatory support) being the most commonly reported. Benzodiazepines were associated with a higher incidence of adverse events than antipsychotics or combination therapy. CONCLUSION Combination therapy sedated a greater proportion of patients at 15-20 minutes than benzodiazepines alone. Antipsychotics and combination therapy were more effective, requiring less repeat doses for sedation than benzodiazepines. The risk of any adverse event was higher with benzodiazepines.
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Affiliation(s)
| | | | - Naren Gunja
- Westmead Hospital, Sydney, Australia; Discipline of Emergency Medicine, Sydney Medical School, University of Sydney, New South Wales, Australia.
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