PROPOFOL – 1st line in Psychosis?

OK, now that I have got your attention with a controversial headline lets discuss the real topic – safe sedation and management of acutely unwell psychiatric patients.  This is a hugely difficult scenario for many remote hospitals, which are not ‘Authorized’ Mental Health institutions, and are therefore required to transport patients to tertiary Psych hospitals for evaluation and management.  The sedation and transfer of patients admitted under the Mental Health Act is a minefield of disasters and sentinel events / coronial enquiries.

There has been a lot of paper spent in the various agencies on trying to resolve this dilemma, however the incidents keep happening.  Most efforts have been aimed at coming up with Sedation Protocols, however as a frontline worker I find it difficult to apply a single approach to all patients.  So after a lot of pondering and trial-and-error I have come up with my own approach – it is completely without evidence (other than my limited case series) and based on a lot of common-sense pharmacology and local logistical knowledge.

My hospital has one big ward – Geris, babies, surgical patients and usually 1 or 2 mental health inpatients – often 1 on sedation of some form or another.  There are no locked doors, security guards or even many trained Mental Health nurses.  This is far from ideal, but is the reality in most rural towns in Australia.

The basis of my “Safe Sedation Protocol” is a ‘matrix’ which combines both an assessment of the patient’s current risk – to self and others (Q: how dangerous is this patient?)  along with an assessment of their ‘anaesthetic risk’ (Q: How safe is it to sedate this patient?)  – including the airway assessment, medical risk, likelihood to tolerate prolonged sedation or intubation.

What am I trying to achieve with this approach?

1. Avoid the morbidity associated with prolonged sedation (sometimes 2 – 3 days awaiting transfer).  This morbidity almost exclusively occurs in the patient after admission / sedation whilst awaiting transfer – NOT in transit.
2. Avoid injury to the staff and the patient – high rate of staff injury makes it tough to retain good nurses
3. Prevent the deaths which still occur – these are entirely preventable and iatrogenic.
4. Maybe even save some $/resources???  Just my guess, no data to support this claim…
5. Put sedation in Psych on an even footing with other sedation.  No longer should we be sedating these people in darkened corners of the hospital, far from appropriate monitoring, with a single “nurse special” in attendance.  Seems obvious but we keep doing it!
6. Adhere to the “least invasive, least restrictive” principles of the Mental Health Act

Anyway this post is getting too long – so follow the links below if you are interested and let me know what you think:

SAFE Sedation Matrix:  Try and assess the risk and assign a “colour” to your patient – kinda like the NZ cardiovascular risk tool, eh bro! Print this out so you can follow the colour guide below (or tab back and forth if you know what I mean)

Sedate-by-colour  guide: I realise there is a lot of grey between the colours, but this is a “guide” only – designed to make you think twice before jumping into a possible disaster!  Patients are often in a state of flux – so be prepared to up or – down- grade them a colour if the situation changes.  In fact some of the sedation you use will hopefully move them into a cooler, more happy colour group (ie. you are more happy, not necessarily them!)

Sedative Agents – what I use and why.  It is a poor man’s pharmacy, but I like to keep it simple!  Currently being formulated…