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Chemical restraint research is growing with multiple healthcare disciplines increasing focused on understanding uses, harms of restraint and restraint reduction in inpatient mental health settings. Despite increased restraint research relatively little is known about nurses' experiences of administering chemical restraint. The research question guiding this study was: what are mental health nurses' experiences of using chemical restraint interventions in times of behavioural emergency on adult inpatient acute mental health units? The purpose of the research was to understand direct care nurses' first-hand experiences in use of chemical restraint interventions. Eight adult acute inpatient mental health nurses were interviewed using hermeneutic phenomenological method. The aim of this paper to discuss three themes that emerged in the research which clearly highlight the complex ethical issues and education needs of mental health nurses who use chemical restraint: working within constraints, making medication choices, and transitioning from novice to expert. Research findings indicated a need for further focus on medication best practice, policy development and nurse education. These exploratory research findings can be used to both inform and challenge dominant inpatient mental health practice to guide nurses, health care leaders, and policy makers by increasing understanding of the complex ethical decision-making required for use of chemical restraint interventions. Education strategies can be developed from the findings which highlight integral ways that nurses make meaning in their administering of chemical restraint, and their accompanied insights into the complex clinical and ethical decision-making aspects involved in nursing care. • The reasearch question was: what are mental health nurses' experiences of using chemical restraint interventions in times of behavioural emergency on adult inpatient acute mental health units? • Three themes that emerged were: (1) working within constraints, (2) making medication choices, and (3) transitioning from novice to expert. • This exploratory research provides insights into the complex clinical and ethical decision-making involved in mental health nurses' use of chemical restraint interventions. • Findings can be used to develop standard policy, practice and education strategies that consider ways nurses make meaning of chemical restraint use. [ABSTRACT FROM AUTHOR]

To determine the effective dosage of the combination tiletamine–zolazepam–ketamine–xylazine (TKX), with or without methadone, in dogs. Prospective, randomized, experimental study. A total of 29 dogs. Dogs were randomly administered TKX (group TKX, n = 13) or combined with 0.3 mg kg–1 of methadone (group TKXM, n = 16) intramuscularly. The TKX solution contained tiletamine (50 mg mL–1), zolazepam (50 mg mL–1), ketamine (80 mg mL–1) and xylazine (20 mg mL–1). The effective dosages for immobility in 50% and 95% of the population (ED 50 and ED 95) were estimated using the up-and-down method. Approximately 20 minutes after drug administration, a skin incision was performed and the response was judged as positive or negative if the dogs moved or did not move, respectively. The TKX volume for the subsequent dog in the same group was increased or decreased by 0.005 mL kg–1 if the response of the previous dog was positive or negative, respectively. Heart and respiratory rates, and sedation/anesthesia scores (range 0–21) were recorded before and 15 minutes after drug administration. Estimated ED 50 and ED 95 (95% confidence intervals) were: TKX, 0.025 (0.020–0.029) and 0.026 (0.010–0.042) mL kg–1; TKXM, 0.022 (0.018–0.025) and 0.033 (0.017–0.049) mL kg–1. Median (interquartile range) scores for sedation/anesthesia were 17 (16–18) and 17 (15–20), and times until lateral recumbency were 5 (4–6) and 6 (4–10) minutes in TKX and TKXM, respectively (p > 0.05). In both groups heart and respiratory rates decreased, but values remained acceptable for anesthetized dogs. The results provide a guide for volumes of TKX and TKXM in dogs requiring restraint for minimally invasive procedures. Inclusion of methadone in the TKX combination did not influence ED 50. [ABSTRACT FROM AUTHOR]

Aggressive and violent behaviours often lead to the use of coercive interventions in health and forensic institutions. Restraint minimization is now a legal or governmental requirement in most jurisdictions. While physical restraint and seclusion are relatively well-understood, chemical restraint remains problematic to define and measure. The aim of this review is to explore the international understandings of chemical restraint and to formulate an operational definition to support the development of quality indicators and care standards. This review was the first step prior to a realist synthesis to clarify the scope of chemical restraint intervention. PRISMA extension for Scoping Review was used. A keyword-based literature review (2006–2020, French and English) was conducted in health and social science databases. Chemical restraint or sedation of behavioural symptoms involves an emergency (STAT), as needed (PRN), regular or continuous medication with sedative properties, administered with the intention of preventing or controlling harmful behaviours or behaviours that interfere with diagnostic or therapeutic interventions, AND/OR administered to avoid physical restraint or seclusion; AND/OR without the person's consent. This first operational definition of chemical restraint could support the development of quality indicators in addition to allowing initiatives to improve health outcomes, safety and promote person-centred care. • Elimination of chemical restraint has been stated as a global priority. • No operational definition of chemical restraint or valid quality indicator exist. • Defining chemical restraint requires uncovering the intentions of the provider in charge of the administration. • This definition can support measurement, security and quality improvement. [ABSTRACT FROM AUTHOR]

Chemical restraint (CR) is emergency drug management for acute behavioural disturbances in people with mental illness, provided with the aim of rapid calming and de-escalating potentially dangerous situations. To describe a systematic review of Randomised Controlled Trials (RCTs) reporting on short-term safety and effectiveness of drugs used for CR, administered to non-consenting adults with mental health conditions, who require emergency management of acute behavioural disturbances. A meta-analysis was conducted of those RCTs with comparable interventions, outcome measures and measurement timeframes. Academic databases were searched for RCTs published between 1 January 1996 and 20th April 2020. Relevant RCTs were critically appraised using the 13-item JBI checklist. All RCTs were described, and step-wise filters were applied to identify studies suitable for meta-analysis. For these, forest and funnel plots were constructed, and Q and I2 statistics guided interpretation of pooled findings, tested using MedCalc Version 19.1. Of 23 relevant RCTs, 18 (78.2% total) had excellent methodological quality scores (at least 90%). Eight RCTs were potentially relevant for meta-analysis (six of excellent quality), reporting 20 drug arms in total. Adverse events for 6–36% patients were reported in all 20 drug arms. Four drug arms from two homogenous studies of N = 697 people were meta-analysed. These RCTs tested two antipsychotic drugs (droperidol, olanzapine) delivered intravenously in either 5 mgs or 10 mg doses, with outcomes of time to calm, percentage calm within five or 10 min, and adverse events. There were no significant differences between drug arms for either measure of calm. However, 5 mg olanzapine incurred significantly lower risk of adverse events than 10 mg olanzapine (OR 0.4 (95%CI 0.2−0.8)), although no dose differences were found for droperidol. 5 mg intravenous olanzapine is recommended for quick, safe emergency management of people with acute behavioural disturbances associated with mental illness. [ABSTRACT FROM AUTHOR]

To evaluate if intramuscular (IM) lidocaine potentiates the sedative effects of alfaxalone and results in cardiopulmonary changes in sedated bearded dragons. Prospective experimental crossover study. A group of eight adult bearded dragons (Pogona vitticeps) weighing 334 ± 46 g. Animals were administered alfaxalone (10 mg kg−1 subcutaneously) and 15 minutes later either lidocaine 2% (4 mg kg−1) or 0.9% sodium chloride (0.2 mL kg−1) was administered IM in the thoracic limb. The treatments were randomized and separated by 7 days. Sedation was scored based on body position, eye closure, jaw tone, swallowing, pick up response, righting reflex and pelvic limb withdrawal reflex. Heart rate (HR) and respiratory rate (f R) were recorded every 5 minutes until recovery from sedation. Lidocaine had no significant effect on duration or depth of alfaxalone sedation. HR increased significantly for <10 minutes following lidocaine administration by a median (interquartile range) of 33% (28–37%; p = 0.024). No clinically significant effects on f R occurred following lidocaine injection. Administration of lidocaine 2% (4 mg kg−1) IM did not potentiate alfaxalone sedation but resulted in a transient clinically relevant increase in HR. [ABSTRACT FROM AUTHOR]

Background Negative effects of restraint use have been well-documented. However, the prevalence of restraints use has been high in long-term care facilities in Hong Kong compared with other countries and this goes against the basic principles of ethical and compassionate care for older people. The present study aimed to review the change in the prevalence of physical and chemical restraint use in long-term care facilities (LTCFs) over a period of 11 years in Hong Kong and to identify the major factors associated with their use. Methods This is an observational study with data obtained from the Hong Kong Longitudinal Study on LTCF Residents between 2005 and 2015. Trained assessors (nurses, social workers, and therapists) used the Minimum Data Set Resident Assessment Instrument to collect the data from 10 residential LTCFs. Physical restraint was defined as the use of any of the following: full bedside rails on all open sides of bed, other types of bedside rails used, trunk restraint, limb restraint, or the use of chair to prevent rising during the past 7 days. Chemical restraint was defined as the use of any of the following medications: antipsychotic, antianxiety, or hypnotic agents during past 7 days, excluding elder residents with a diagnosis of psychiatric illness. Outcomes Annual prevalence of restraint use over 11 years and factors that were associated with the use of physical and chemical restraints. Results We analyzed the data for 2896 older people (978 male individuals, mean age = 83.3 years). Between 2005 and 2015, the prevalence of restraint use was as follows: physical restraint use increased from 52.7% to 70.2%; chemical restraint use increased from 15.9% to 21.78%; and either physical or chemical restraint use increased from 57.9% to 75.7%. Physical restraint use was independently associated with older age, impaired activities of daily living or cognitive function, bowel and bladder incontinence, dementia, and negative mood. Chemical restraint use was independently associated with older age, falls, bladder incontinence, use of feeding tube, dementia, poor cognitive function, delirium, behavioral problems, and negative mood. The increasing time-trend of physical but not chemical restraint use remained significant after adjusting for other factors as mentioned above (coefficient = 0.092, P < .001). Conclusions Use of physical and chemical restraint was highly prevalent among LTCF residents in Hong Kong, with an increasing trend over a period of 11 years, especially targeting the most physically and cognitively frail older people. Appropriate healthcare staff education and policy change are urgently needed to ensure personal care that is characterized by respect, dignity, empathy, and compassion for the older generation. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of hyaluronidase on uptake, duration and speed of elimination of xylazine-tiletamine-zolazepam administered in the subcutaneous fat over the dorsal lumbar region of swine. Study design Blinded, randomized, crossover study. Animals Six healthy Landrace/Large White pigs weighing 132 ± 24 kg (mean ± standard deviation). Methods Animals were administered xylazine (1 mg kg-1) and tiletamineezolazepam (8 mg kg-1) (control treatment, CON), or xylazine-tiletamine-zolazepam at the same doses with hyaluronidase (400 IU) (treatment HYA). The treatments were administered into the dorsal lumbar adipose tissue, 2.5-3.0 cm laterally from the spinous process of the second lumbar vertebra. The latency, anesthesia and recovery periods were measured. Heart rate, noninvasive systolic, diastolic, and mean arterial pressures, respiratory rate, hemoglobin oxygen saturation and rectal temperature were recorded every 10 minutes for up to 50 minutes. Results One animal in CON and one animal in HYA were responsive to stimulation and did not allow safe handling. No significant difference was found between treatments for latency (CON 11.3 ± 5.9 minutes, HYA 7.4 ± 5.1 minutes) and anesthesia (CON 53 ± 53 minutes, HYA 49 ± 38 minutes) periods. Recovery period was shorter in HYA (9 ± 6 minutes) than in CON (32 ± 16 minutes) (p < 0.05). Physiological variables were not significantly changed over time and were within accepted normal clinical limits for the species in both treatments. Conclusion and clinical relevance Hyaluronidase (400 IU) administered into adipose tissue in pigs did not reduce the latency and duration of dissociative anesthesia, but was associated with faster recovery. [ABSTRACT FROM AUTHOR]

Two protocols to immobilise free-ranging Pampas foxes for ear-tagging or radio-collaring were evaluated. One hundred fifteen foxes were injected with ketamine-xylazine (K-X) and thirteen with tiletamine- zolazepam (T-Z). The use of both T-Z and K-X combinations typically resulted in a smooth induction and recovery. In 86% of the cases K-X protocol was judged effective (mean ± SD, K: 10.7 ± 3.3 mg/kg, X: 1.0 ± 1.0 mg/kg) while T-Z protocol was judged effective in 92% of the cases (T: 3.6 ± 1.05 mg/kg, Z: 3.6 ± 1.05 mg/kg). The primary differences between the two drug combinations were that the time necessary for the complete recovery was longer with T-Z, and thermic problems were found more frequently with K-X. Additionally, our results suggest that thermic stress may be a relatively frequent complication for Pampas foxes. This study provides baseline data on some physiologic variables in Pampas foxes captured with different methods and drugs in field conditions. [ABSTRACT FROM AUTHOR]

History Caridian BCT apheresis machines require a ~285 mL priming volume (extracorporeal blood) that is withdrawn from the patient in ~10 minutes. Therefore, apheresis in dogs has generally been limited to dogs > ~20 kg to assure <20% of the blood volume is removed in the priming phase. Animals/physical examination Three dogs weighing <14 kg (13.6, 10.5, and 9.9 kg) with lymphoma that underwent apheresis. Management The dogs were premedicated for placement of apheresis catheters with hydromorphone (0.1 mg kg−1) IM. Anesthesia was induced with propofol, to effect, intravenously and general anesthesia was maintained with isoflurane in oxygen. Following catheter placement, dogs were allowed to recover from isoflurane but were kept sedated with either a dexmedetomidine constant rate infusion ( CRI) or a propofol CRI. Real time autologous blood priming was not performed in any of the dogs. Instead, priming solutions were composed of a combination of hetastarch, lactated Ringer's solution, and/or autologous blood that was harvested 4 days before the procedure. During apheresis, dogs received anticoagulant citrate-dextrose, solution-A ( ACD-A) to prevent clotting and 10% calcium gluconate as needed to maintain normal ionized calcium concentrations. Dogs were monitored for cardiovascular and cardiopulmonary stability, anemia and lactic acidosis. Follow-up All of the dogs had cardiovascular and cardiopulmonary values within clinically acceptable ranges. Immediately following apheresis all of the dogs were mildly to moderately anemic ( PCV; 17-35%) although none of the dogs required a transfusion or had an increased lactate concentration. Conclusions Dogs as small as 9.9 kg can successfully undergo apheresis with a variety of priming solutions. Dexmedetomidine or propofol given as a CRI provides sufficient sedation for this procedure. [ABSTRACT FROM AUTHOR]

Summary: An important goal of the care for the mechanically ventilated patient is to minimize patient discomfort and anxiety. This is partly achieved by frequent use of chemical and physical restraints. The majority of patients in intensive care will receive some form of sedation. The goal and use of sedation has changed considerably over the past few decades with literature evidencing trends toward overall lighter sedation levels and daily interruption of sedation. Conversely, the use of physical restraint for the ventilated patient in ICU differs considerably between nations and continents. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. Recent literature suggests minimal use of physical restraint in the ICU, and that reduction programmes have been initiated. However, very few papers illuminate the patient''s experience of physical and chemical restraints as a treatment strategy. In Part 1 of this two-part review, the evidence on chemical and physical restraints was explored with specific focus on definitions of terms, unplanned extubation, agitation, delirium as well as the impact of nurse–patient ratios in the ICU on these issues. This paper, Part 2, examines the evidence related to chemical and physical restraints from the mechanically ventilated patient''s perspective. [Copyright &y& Elsevier]

Summary: Chemical and physical restraints are frequently used in the intensive care unit (ICU) to control agitated patients and to prevent self-harm and unplanned extubations. Published work relating to the numerous issues of the care and treatment strategies for these patients remains conflicting and unclear. Literature regarding sedation and chemical restraint reveals a trend towards management with lighter sedation, use of sedation assessment tools and sedation protocols. It remains unclear which treatment is best for agitated and delirious patients, and the evidence on the effect of sedation is conflicting. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. The purpose of this paper is to provide a summary of the existing literature on the use of physical and chemical restraints in the ICU setting. In Part 1 of this two-part paper, the evidence on chemical and physical restraints is explored with specific focus on definition of terms, unplanned extubation, agitation, delirium and the impact of nurse–patient ratios in the ICU on these issues. Part 2 of the paper examines the evidence related to chemical and physical restraints from the perspective of the mechanically ventilated patient. [Copyright &y& Elsevier]

Use of physical and chemical restraints are common in residential aged care facilities worldwide. Restraint use can pose harm to residents even causing deaths. To synthesize the prevalence and variability in physical and chemical restraint use, and examine factors that may contribute to this variability of prevalence rates. Six health science databases were searched from inception up to 21st January 2020. Quantitative studies investigating restraint use in residential aged care facilities that reported data from year 2000 onwards were included. Meta-analyses of binomial data using a random effect model were performed to pool proportions of physical or chemical restraints with 95% confidence intervals. Univariable meta-regression analyses were used to assess factors that may contribute to the variability in physical and chemical restraint prevalence. Multiple meta-regression analyses were performed where possible to construct models of factors contributing to these variations. Eighty-five papers were included. The pooled proportion of physical and chemical restraint use in residential aged care facilities were 33% and 32% respectively. Bedrails (44%) and benzodiazepines (42%) were the most prevalent forms of physical and chemical restraint respectively. Studies from North America (lower prevalence) [coefficient (95% CI): -0.15 (-0.27, -0.03)], measurement approaches using direct observation (higher prevalence) [0.17 (0.02, 0.33)] and a combination of multiple measurement approaches (higher prevalence) [0.17 (0.05, 0.29)] explained 25.5% of variability in the prevalence of physical restraint. Multiple meta-regression analyses were not performed to identify factors that may explain the observed variability in chemical restraint prevalence due to the small number of studies with data available. Variability in prevalence of physical restraint could be explained partly by different measurement approaches and geographical regions. Valid and reliable measurement approaches across different regions is required to understand cultural differences due to geographical region effects on the prevalence of physical restraint use. [ABSTRACT FROM AUTHOR]

AbstractObjective To assess the effectiveness of a detomidine infusion technique to provide standing chemical restraint in the horse. Design Retrospective study. Animals Fifty-one adult horses aged 9.5 ± 6.9 years (range 1–23 years) and weighing 575 ± 290.3 kg. Methods Records of horses presented to our clinic over a 3-year period in which a detomidine infusion was used to provide standing chemical restraint were reviewed. Information relating to the types of procedure performed, duration of infusion, drug dosages and adjunct drugs administered was retrieved. Results Detomidine was administered as an initial bolus loading dose (mean ± SD) of 7.5 ± 1.87 µg kg-1 . The initial infusion rate was 0.6 µg kg-1 minute-1 , and this was halved every 15 minutes. The duration of the infusion ranged from 20 to 135 minutes. Twenty horses received additional detomidine or butorphanol during the procedure. All horses undergoing surgery received local anesthesia or epidural analgesia in addition to the detomidine infusion. A wide variety of procedures were performed in these horses. Conclusions Detomidine administered by infusion provides prolonged periods of chemical restraint in standing horses. Supplemental sedatives or analgesics may be needed in horses undergoing surgery. Clinical relevance An effective method that provides prolonged periods of chemical restraint in standing horses is described. The infusion alone did not provide sufficient analgesia for surgery and a significant proportion of animals required supplemental sedatives and analgesics. [ABSTRACT FROM AUTHOR]

Abstract Objective To evaluate the sedative effects of medetomidine, and a medetomidine–midazolam combination, in Japanese macaques and the antagonism of medetomidine–midazolam with atipamezole. Study design Prospective randomized study. Animals Thirteen healthy Japanese macaques between 3 and 21 years old and weighing between 4.3 and 15.1 kg. Methods Medetomidine (120 µg kg-1) alone or a medetomidine (30 µg kg-1) plus midazolam (0.3 mg kg-1) mixture were injected intramuscularly in the hind limb of 12 animals (n = 6 for each group) and their effects, particularly behavioural changes, response to external stimuli, sedative onset time, time to lateral recumbency and time in lateral recumbency, were monitored for 120 minutes. Another group (n = 7) were given medetomidine–midazolam and injected 30 minutes later with atipamezole (120 µg kg-1). Behavioural changes and responses to external stimuli were assessed as before. Results Animals given medetomidine became sedated but could be aroused by external stimuli. Despite the lower (25%) dose of medetomidine involved, the effects of medetomidine–midazolam were more marked. Macaques given this combination became sedated in 4 ± 2 minutes (mean ± SD) and remained unresponsive to external stimuli for at least 60 minutes. Five out of six macaques became laterally recumbent for 74 ± 37 minutes. Intramuscular atipamezole effectively reversed sedation, shortening the arousal and total recovery time. The recovery from sedation was rapid and smooth, being completed 19 ± 11 minutes after antagonism. Conclusions The medetomidine–midazolam combination described provided useful chemical restraint and may prove useful in macaques undergoing some experimental, diagnostic or therapeutic procedures. The use of atipamezole as an antagonist increases the value of this technique in macaques. [ABSTRACT FROM AUTHOR]