It has been a busy month behind the scenes here at Broome Docs – lots of big projects and plans going on… wait and see what we are have in the offing.
One project that I have been working on with a group of great clinicians from all over Australia. It is called SURVIVING SEDATION 2015. Yes – that is a deliberate pun on the “Surviving Sepsis Guidelines” – and we want to install the idea that this is a high stakes situation, with lots of potential morbidity and unfortunate track record of mortality for these patients. The goal is to use early, goal-directed sedation to maintain a safe environment for staff and allow patients to be cared for in a standardised, safe fashion.
We have been sharing ideas, data and experience around the acute sedation of patients with psychosis or other behavioural disturbance. If you have been following the blog from the outset – then you will know that this is something that I am passionate about. There have been a lot of changes to the way I practice when it comes to sedating Psychiatric patients. This set of guidelines represents the vest available evidence, interpreted by front-line clinicians and presented in as simple, usable possible format.
Our lead “author” is Dr Minh le Cong – @ketaminh – the foremost Aussie researcher in Psychiatric retrieval. Also on the panel were Dr Tim Leeuwenburg @Kangaroobeach , Dr Andy Buck @edexam and Dr George Douros.
Pre-publication peer review was also done by Dr Amit Maini @sithlord2004, Dr Peter Fritz @pzfritz & Dr Michael Downes @ToxTalks.
It is really difficult to write a set of guidelines that can be applied to all scenarios – our panel practice everywhere from major tertiary EDs to tiny remote clinics with near-zero resources for this scenario. There is also a lot of variation in practice depending on your location. Many practitioners are working in locations that need to transfer Mental Health clients by air to a secure facility. Others work in hospitals that can provide this care immediately [though often not…] However, as a panel we have tried to come up with a basic toolkit of medications, a strategy and logistical considerations that may be applied in any setting.
For the full detail of the rationale – pop over to Minh’s blog on the PHARM to read his thoughts.
The actual short version (2 pages – front and back) is designed to be laminated for reference in the clinic / ED / ward etc.
I am going to leave it up on the blog here in the permanent top menu under clinical resources.
SO – what is new in this set of guidelines? Nothing too controversial. The main changes are to the way we plan the sedation.
- Treat any Psych sedation as a “procedural sedation” – where the procedure is the safety of the patient +/- transfer to an appropriate centre.
- Pharmacological minimalism – using less agents in a titrated fashion
- There is a specific objective sedation score (SAT) – with goals of therapy clearly laid out.
- Ketamine is used in several potential situations: as a 2nd line IV / IMI agent in severe agitation and also as an infusion for transfer by air.
- There is emphasis placed on making a pre-sedation assessment of the airway / Anaesthetic / medical risk of sedation for a given patient.
- We have deliberately recommended that appropriate airway equipment and personnel be present. No more dark, back room sedation supervised by the grad nurse up the far end of the ward.
- You will notice that midazolam does NOT feature in the mix. This is the result of several papers showing it can be dangerous. Diazepam is the chosen benzo – although this was largely due to its wide availability and clinical familiarity. [Personally I will be using long-acting benzos such as clonazepam or lorazepam in my ED.]
Now it is your turn – I know that there are a lot of experts out there – and I want to hear your thoughts on this project. So please have a read of the guidelines and the rationale on the PHARM site. Let us know what you like, don’t like or disagree with. If you have any evidence that you feel might be incorporated – then send me the link.
Safe sedating team