Can im haldol be given iv

With hindsight, it is likely that she began experiencing akathisia as a side effect of the IV haloperidol used to sedate her which caused worsening restlessness, agitation, and myoclonic jerking. Diagnosing akathisia in an agitated patient can be difficult. How could this complication be avoided in the future? Technically, haloperidol is not FDA-approved for intravenous use. However, shortly after intramuscular haloperidol was released, physicians realized that it could be given intravenously.

Over time, IV haloperidol became widespread and accepted. IV olanzapine was initially utilized in Australia Chan , What does the evidence show? The efficacy of IM olanzapine has been investigated more thoroughly than IV olanzapine. These studies either found that the two drugs were equally effective or that olanzapine was slightly more effective depending on the relative doses utilized 3. Chan performed a prospective RCT of agitated emergency department patients who received titrated open-label midazolam in addition to being randomized to receive one of three treatments: 5 mg IV olanzapine, 5 mg IV droperidol, or placebo.

Droperidol and olanzapine were equally effective. It can be hard to determine whether a drug causes torsade de pointes TdP , because this event is rare. Several sources of evidence bear consideration:.

As shown above, olanzapine's affinity for HERG channels is 6, times below haloperidol's affinity. Additionally, a guinea pig model suggests that olanzapine tends to be less concentrated within myocardial tissue. These concentrations are well below the half-maximal inhibitory concentration IC of 6, nM, predicting an absence of proarrhythmia Titier Ando studied the arrhythmic potential of intravenous risperidone or olanzapine in a canine model.

Risperidone caused prolongation of ventricular repolarization only at supra-therapeutic doses. Although QT interval isn't perfect, it remains a clinically relevant measurement of how drugs affect cardiac repolarization.

Harrigan performed a prospective RCT comparing the effect of several antipsychotic agents on the QTc interval.

Lack of effect on QTc has been validated by other studies Lindborg , Shafti , Takeuchi Currently there is only one case report in the literature of a patient with TdP related to olanzapine Huang However, this woman also had cardiomyopathy status post placement of an implantable defibrillator, hypomagnesemia, and hypokalemia, making it impossible to establish causality between olanzapine and TdP.

Overall there is a notable absence of case reports of TdP. Population-wide correlations between antipsychotic use and sudden death yield conflicting results, without any consistent hierarchy of risk among different antipsychotics Ray , Danielsson , Leonard Due to confounding variables and contradictory results, no conclusions can be drawn from this data. There is no indication for monitoring the QT interval in patients receiving olanzapine.

Olanzapine causes fewer extrapyramidal symptoms than haloperidol. This has been shown in RCTs comparing haloperidol vs. With haloperidol, intravenous use is associated with fewer extrapyramidal side effects compared to oral administration.

If the same relative reduction in extrapyramidal symptoms were true of IV olanzapine compared to oral olanzapine, it would suggest that IV olanzapine should have a very low rate of extrapyramidal symptoms.

One large study of IV olanzapine reported a 0. Some concerns have been raised about over-sedation due from the combination of IM olanzapine with benzodiazepines. However, the RCT by Chan discussed above reported no increase in adverse effects among patients receiving IV olanzapine plus midazolam, compared to patients receiving placebo plus midazolam. There was actually a trend towards increased desaturation in the placebo group, likely due to higher doses of midazolam required in the placebo group.

IV olanzapine may be safer than IM olanzapine, because IV olanzapine works faster, allowing it to be titrated accurately. Alternatively, agitated patients who receive IM olanzapine may continue to receive several doses of benzodiazepine, before the olanzapine has taken effect. Thus, titrated doses of IV olanzapine may reduce the total dose administered.

Martel reported a retrospective cohort study examining side effects experienced by patients who received IV olanzapine in the emergency department. The only safety concern raised in this article were three intubations potentially related to olanzapine adjacent box. These intubations might have been required regardless of the choice of antipsychotic. Overall this study is reassuring, since it represents a large pragmatic description of olanzapine use in acutely ill patients that failed to reveal any unexpected problems.

Olanzapine is currently off-patent, but it may remain somewhat more expensive than haloperidol 4. However, haloperidol is associated with costs of obtaining EKGs and more frequent treatment of extrapyramidal reactions e.

Additionally, although TdP is rare, the cost of treating a single episode can be enormous. Formal pharmacoeconomic analyses show that the primary determinant of the cost of managing an agitated patient is time : anything which prolongs the ED or ICU length of stay is expensive e.

This makes it unwise to choose a cheaper drug that may occasionally prolong length of stay. Is IV olanzapine ready for prime time? IV olanzapine is newer, so it is possible that additional side effects may emerge over time. However, we already know that there are significant problems with IV haloperidol. IV haloperidol can cause TdP.

Patients receiving this should be monitored with serial EKGs to minimize their risk. However, in practice it may be impossible to obtain an EKG in an agitated patient. This represents a systemic source of risk to our patients. The switch to olanzapine might be justifiable solely on the basis that we could spend less time checking EKGs and debating the damn QTc. Humans have a limited capacity to make decisions and pay attention to details. As discussed by Scott Weingart in the John Hinds Memorial Lecture , making too many decisions even minor decisions leads to decision fatigue.

Eliminating unnecessary decisions and interruptions could free up physicians and nurses to pay attention to more important problems. Ultimately, weighing the known versus the unknown is a matter of judgment. Some centers e.

Hennepin County Hospital have already broadly adopted IV olanzapine. Another approach might be to selectively use IV olanzapine for patients at higher risk of harm from haloperidol e. For agitation, a reasonable dose appears to be 2. The warning came on top of the fact that IV haloperidol for delirium at any time is an off-label use. The drug is nevertheless commonly used when patients with delirium have severe agitation.

In the wake of the black-box warning, Ethan Cumbler, MD, a hospitalist and director of the acute care for the elderly ACE service at the University of Colorado Hospital, began noticing that the drug was still being used throughout the hospital, sometimes even in the ACE unit. Their results were published in the January issue of the Journal of the American Geriatrics Society.

A never event? Cumbler also notes that the median first dose of IV haloperidol given to these elderly inpatients was 2 mg, while one in five received a first dose of 5 mg or more. The good news? Cumbler says. But he likens this prevention effort to that of preventing wrong-side surgery. Finding alternatives Dr. Cumbler adds that alternative treatments for delirium-related agitation should be the first-line therapy. When an antipsychotic is still needed, Dr.

Cumbler says, a better choice may be an oral dose or an IM injection. The obvious next intervention, he adds, is the kind of alert that Dr. Pell has helped implement. You instead need to build safety into the system. Building the right alert According to Dr. Pell, having the alert in place is certainly a good start. For one, physicians on the clinical decision-support committee working on the project are still debating whether the alert needs to be a hard stop or if doctors should be able to continue to click their way through an IV haloperidol order.

Am J Emerg Med. Use of high-dose intravenous haloperidol in the treatment of agitated cardiac patients. J Clin Psychopharmacol. Rapid tranquilization of the agitated intensive care unit patients. J Intensive Care Med. Adams F. Emergency intravenous sedation of the delirious, medically ill patient. Conduction disturbances associated with administration of butyrophenone antipsychotics in the critically ill: a review of the literature. Use of haloperidol infusions to control delirium in critically ill adults.

Ann Pharmacother. Torsades de Pointes associated with intravenous haloperidol in critically ill patients. Am J Cardiol. Electrocardiogram showing torsade de pointes.

Torsade de pointes, which generally occurs in patients with prolonged QT intervals, is characterized by QRS complexes that change amplitude and direction, or "twist. To sign up for updates or to access your subscriber preferences, please enter your email address below. We want to hear from our users about how we can improve the PSNet experience. Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest.

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Improvement Resources. About PSNet. All Content. Current Weekly Issue. Past Weekly Issues. Curated Libraries. The Fundamentals. Continuing Education. Training Catalog. Editorial Team. Technical Expert Panel. Don't Push Save. Copy URL. The Case A year-old HIV-positive woman was brought to the emergency room by her family because she had exhibited altered mentation for 3 days.

The Commentary The almost fatal outcome in this case directly resulted from treatment with high and frequent doses of haloperidol, administered according to a commonly used critical care protocol that calls for multiple, sometimes escalating doses of the drug, at minute intervals. Take-Home Points Obtain a detailed history of the type and temporal course of mental status changes in HIV-positive patients before initiating medical workup and treatment of the changes.

Treat psychotic symptoms in HIV-positive patients with low oral doses of an atypical antipsychotic drug, such as aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone or offer IM ziprasidone , depending on the clinical status of the patient and need for rapid control.

If sedation is truly urgent for medical or safety reasons, use IV push haloperidol but attempt to keep the dose as low as necessary. Pretreatment ECG, measurement of QTc, and ongoing monitoring for development of torsade de pointes throughout course of treatment with IV haloperidol and during recovery is indicated.

Efficacy and safety of IM ziprasidone vs. IV haloperidol need to be studied in randomized clinical trials. References 1. Department of Health and Human Services.

Readers should not interpret any statement in this report as an official position of AHRQ or of the U.