Adjunctive drugs hasten sedation in the emergency department

By Eleanor McDermid, Senior medwireNews Reporter

Adding intravenous droperidol or olanzapine to midazolam shortens the time to adequate sedation in acutely agitated patients in the emergency department (ED), show findings from a randomized controlled trial.

Droperidol and olanzapine were equally effective, and significantly better than placebo, when combined with midazolam, report David Taylor (Austin Health, Heidelberg, Australia) and colleagues in the Annals of Emergency Medicine.

"The study involved highly agitated patients for whom management is difficult, and the attainment of informed patient consent was not feasible," say the researchers. "Two thirds of patients were accompanied by police on arrival, and the majority required physical restraint to enable the administration of sedative drugs.

"This study addresses an important therapeutic area in which there are limited published data."

The median time to adequate sedation was 10 minutes for patients given a saline control followed by incremental intravenous midazolam boluses (2.5 to 5 mg). But the time was significantly shorter for those who received intravenous droperidol (5 mg) or olanzapine (5 mg) prior to midazolam, at 6 and 5 minutes, respectively. The corresponding average times were 68, 21, and 14 minutes.

The team defined adequate sedation as a score of 2 or lower on a 6-point scale, ranging from 0 (asleep) to 5 (highly aroused and violent). A total of 336 patients were enrolled and randomly assigned to the three study groups.

At 10 minutes after they received the study drug, 56% of patients in the control group had achieved adequate sedation, compared with 74% of each of the active adjunct treatment groups, which was a significant difference. The control group needed a median of 10 mg midazolam to achieve sedation, compared with 5 mg for the other two groups.

Use of the adjunctive treatments did not result in an increased rate of adverse events. The most common events were oxygen desaturation, airway obstruction, and hypotension.

Taylor et al obtained electrocardiograms for 211 patients in all. Droperidol has previously been linked to an increased risk for a prolonged QT interval and torsades de pointes, but the team found no evidence to support this; two patients had a QTc interval of 500 ms or more, and neither was in the droperidol group.

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