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Background Geriatric hospital wards are highly medicalised environments with limited opportunities for choice and control, and can be distressing for older survivors of psychological trauma. While trauma-informed models of care (TIC) are effectively applied across mental health and other settings, the utility of these models in aged care settings has not been assessed. The objective of this study was to examine whether TIC can reduce responsive behaviour, chemical restraint, and improve staff skills and patient experiences in inpatient geriatric settings. Methods Four wards participated in this type I hybrid implementation-effectiveness study across southern Adelaide, Australia, including 79 beds. Using a co-design method, the principles of TIC were transformed into an implementation strategy including staff training, establishment of highly trained ‘champions’ on each ward, screening for trauma-related needs, and amending ward policies and procedures. Primary outcomes will be examined using an interrupted time-series design and are monthly incidence of responsive behaviour incidents and use of chemical restraint. Process evaluation will be used to examine secondary, implementation outcomes including the acceptability, feasibility, and fidelity to the implementation strategy. Discussion Trauma-informed care has potential to improve the safety and accessibility of hospital wards for older people who have survived psychologically traumatic events and has an extensive evidence base supporting its effectiveness in other settings. Identifying trauma-related needs and amending care to reduce the risk of re-traumatisation and distress may also reduce the incidence of responsive behaviour change, which has a significant impact on the quality of life of hospital patients and staff and is very costly. The inclusion of a process evaluation will allow us to identify and report changes made on each ward and make recommendations for future implementation efforts.

Background: Over- and potentially inappropriate prescribing of psychotropic medications is a major public health concern among people with dementia. Objective: Describe the CHemical Restraints avOidance MEthodology (CHROME) criteria and evaluate its effects on psychotropic prescribing and quality of life (QoL). Methods: Observational, prospective, two-wave study conducted in two nursing homes. A multicomponent program to eliminate chemical restraints and attain quality prescription of psychotropic medications was implemented. CHROME’s diagnostic criteria comprise constellations of behavioral and psychological symptoms of dementia under six primary syndromic diagnoses. Since pharmacologic treatment is aimed at only one syndrome, polypharmacy is avoided. Psychotropic prescription, QoL, neuropsychiatric symptoms (NPS), and other clinical measurements were collected before and one year after the intervention. Results are presented for all residents (n = 171) and for completer subjects (n = 115). Results: Mean age (SD) of the residents was 87.8 (5.7), 78.9% were women, and 68.5% suffered advanced dementia. Psychotropic prescriptions decreased from 1.9 (1.1) to 0.9 (1.0) (p

Background Butorphanol-azaperone-medetomidine (BAM™) has not been evaluated in horses. Objectives The objective of this study was to evaluate BAM™ for chemical restraint of feral horses. Study design Retrospective and prospective descriptive studies. Methods Data were collected retrospectively from medical records of 28 feral horses immobilised with BAM™ over a 6-year period. Prospectively, 0.0125 mL/kg bwt of BAM™ (butorphanol 27.3 mg/mL, azaperone 9.1 mg/mL and medetomidine 10.9 mg/mL) intramuscularly (im) was administered to eight stallions via dart, and once recumbent, 1.0 mg/kg bwt ketamine was given intravenously (iv). Induction and recovery time and quality via a standardised rubric (1 = very poor; 5 = excellent) and visual analogue scale (VAS), need for additional darts, weight tape measurement and serial physiological parameters were recorded. Serial arterial blood gas analysis was performed during recumbency. Following castration, horses were given 0.1 mg/kg bwt atipamezole (25% iv and 75% im) and allowed to recover unaided. Results Retrospectively, 28 horses were successfully immobilised with BAM™ without a major complication. Prospectively, eight horses were given a median (range) actual BAMTM dose of 0.0143 (0.0127-0.0510) mL/kg bwt. Three of eight horses needed 1, 2 or 5 additional darts. Median (range) time to recumbency was 11 (2-44) minutes. Median (range) induction (n = 4) and recovery (n = 6) scores via rubric and VAS were 5 (4-5) and 5 (5-5) and 92 (86-93) and 98 (92-99) cm, respectively. Four of seven horses were hypoxaemic at ≥1 time point with otherwise acceptable physiological parameters. Following atipamezole, median (range) time to sternal recumbency and standing was 12 (2-18) and 17 (11-52) minutes, respectively (n = 6). Main limitations The sample size was small. Data could not be collected before darting or after recovery. Some data were missing from retrospective analysis. Conclusions Intramuscular BAM™ with iv ketamine provided chemical restraint suitable for field castration of feral horses with no mortality. Hypoxaemia occurred in the majority of horses.

Background 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. Aims 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. Method 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. Results 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. Conclusion 5 mg intravenous olanzapine is recommended for quick, safe emergency management of people with acute behavioural disturbances associated with mental illness.

Dementia symptoms can manifest in a variety of ways, such as anxiety, agitation and an inability to communicate unmet needs. In emergency departments (EDs), these symptoms, as well as various environmental factors, can lead to behaviour that challenges in people with dementia. Therefore, ED staff must be skilled in screening, assessing and managing this patient group effectively. This article details a literature review that was conducted to explore the evidence on managing behaviour that challenges in people with dementia in the ED and what de-escalation strategies may be useful. A literature search of eight databases was undertaken, resulting in 11 articles that were included in this literature review. Four main themes were identified: violence and aggression towards staff; manual and chemical restraint in the ED; identifying delirium and dementia; and environment and person-centred care. Strategies identified to de-escalate and reduce the risk of behaviour that challenges include: making environmental modifications to the ED; providing person-centred care; excluding or evaluating pain and unmet needs; using various tools and strategies to improve communication; and using distraction techniques.

Chemical restraint in dairy calves is necessary to enable diagnostic and surgical procedures. It is unclear whether xylazine or detomidine differ with regard to desirable and unwanted effects.In a prospective randomized interventional study, 10 healthy Holstein-Friesian calves (age range 3-6 month) were sedated with either xylazine (0.1 mg/kg, Group X, n = 5) or detomidine (0.03 mg/kg, Group D, n = 5) intravenously, followed by butorphanol (0.1 mg/kg i. v.) in all animals. Characteristics of sedation and selected pharmacodynamic parameters were compared between groups using a non-parametric Mann-Whitney U test.All calves (5/5) in Group X and (3/5) calves in Group D became laterally recumbent within 5 minutes. Two calves (40 %) in Group D remained standing and could not been positioned in lateral recumbency 15 minutes after initial administration of the sedation agents. Sedation scores, onset and duration of sedation did not differ between groups. Heart and respiratory rate decreased in both groups. Mean arterial pressure was with around 30 mmHg significantly higher in Group D (tand clinical relevance The xylazine-butorphanol combination provided reliable recumbent chemical restraint. With detomidine-butorphanol recumbency failed in some individuals, but a sufficient clinical sedation was achieved. Based on the limited monitoring used in this study, the side effects are of minor clinical relevance in healthy individuals.Diagnostische und chirurgische Eingriffe erfordern eine medikamentöse Ruhigstellung von Milchkälbern. Unklar ist, inwiefern sich Xylazin und Detomidin in Bezug auf ihre erwünschten und unerwünschten Wirkungen unterscheiden.Im Rahmen dieser prospektiven, randomisierten, interventionellen Studie wurden 10 gesunde Holstein-Kälber (Altersbereich 3–6 Monate) untersucht. Die intravenöse Sedation der Tiere erfolgte mit Xylazin (0,1 mg/kg, Gruppe X, n = 5) oder Detomidin (0,03 mg/kg, Gruppe D, n = 5). Anschließend erhielten alle Tiere Butorphanol (0,1 mg/kg i. v.). Neben Sedationscharakteristika wurden ausgewählte pharmakodynamische Parameter zwischen den Gruppen mit einem nicht parametrischen Mann-Whitney U Test verglichen.Alle Kälber (5/5) der Gruppe X und (3/5) Kälbern der Gruppe D legten sich innerhalb von 5 Minuten nieder. Zwei Kälber (40 %) der Gruppe D blieben stehen und konnten auch 15 Minuten nach Verabreichung der initialen Sedierung nicht in Seitenlage verbracht werden. Hinsichtlich Sedationscore, Beginn und Dauer der Sedation konnten keine Unterschiede zwischen den Gruppen festgestellt werden. Herz- und Atemfrequenz waren in beiden Gruppen während der Sedation vermindert. Der mittlere arterielle Blutdruck lag in Gruppe D um etwa 30 mmHg und damit signifikant höher (Zeitpunkt tRelevanz Die Kombination von Xylazin und Butorphanol bewirkte eine verlässliche medikamentöse Ruhigstellung und ein Niederlegen der Tiere. Mit Detomidin-Butorphanol hingegen ließ sich bei einigen Kälbern trotz ausreichender klinischer Sedationstiefe kein Niederlegen erzielen. Nebenwirkungen dieser Medikamente, die im Rahmen dieser Studie mit eingeschränktem Monitoring beobachtet werden konnten, haben bei gesunden Individuen geringe klinische Relevanz.

Ten free-living adult coatis (two males and eight females) were chemically restrained with "ZAD-50", a concentrated formulation prepared with the dehydrated content of a Zoletil/50® vial diluted with 0.25mL of 1% atropine, 0.265mL of Dormiun-V®, and 2.2mL of distilled water, being exactly 3.0mL. The formula was administered to each animal previously captured and physically contained with a net. The loss of righting reflex (RR) occurred at 2.3±0.8 minutes post-injection (MPI), with anesthesia beginning at 4.4±2.7 MPI. Myorelaxant and analgesia were considered excellent at all moments of the evaluation. Conscious reactions were observed at 78.7±22.2 MPI, the return of the RR occurred at 101 ± 18 MPI, and normal ambulation was acquired at 137.0±31.0 MPI. The mean values of physiological parameters measured every 10 minutes between 10 and 50 MPI were 152.2 heartbeats per minute for heart rate, 66.4 respiratory movements per minute for respiratory rate, 39.2oC for rectal temperature, 86.2% for SpO2 and 14.6 mmHg for systolic blood pressure. In the same times, the EEG registered sinus rhythm. No adverse reactions were observed, and the assessed vital parameters remained compatible with the state of chemical restraint.

Complaints reflect a person’s or family’s experience within the aged care system and provide important insight into community expectations and consumer priorities. Crucially, when aggregated, complaints data can serve to indicate problematic trends in care provision. Our objective was to characterize the areas of medication management most frequently complained about in Australian residential aged care services from 1 July 2019 to 30 June 2020. A total of 1134 complaint issues specifically referenced medication use. Using content analysis, with a dedicated coding framework, we found that 45% of these complaints related to medicine administration processes. Three categories received nearly two thirds of all complaints: (1) not receiving medication at the right time; (2) inadequate medication management systems; and (3) chemical restraint. Half of the complaints described an indication for use. These were, in order of frequency: ‘pain management’, ‘sedation’, and ‘infectious disease/infection control’. Only 13% of medication-related complaints referred to a specific pharmacological agent. Opioids were the most common medication class referred to in the complaint dataset, followed by psychotropics and insulin. When compared to complaint data composition overall, a higher proportion of anonymous complaints were made about medication use. Residents were significantly less likely to lodge complaints about medication management, probably due to limited engagement in this part of clinical care provision.

In the context of psychiatric emergencies, it is important to distinguish between so-called controllable agitation and uncontrollable agitation. In this context, physical restraint of the adult patient is sometimes necessary, but remain an exceptional measure. Restraints must be applied rapidly and in a protocolised manner. It should be used sparingly in the elderly patient. Physical restraint is a medical prescription that must be accompanied by chemical restraint.

Behavioural assessment units (BAU) have been established in emergency departments (EDs) to provide short-term observation, treatment, and care to people experiencing acute behavioural disturbance. A prospective observational study was conducted in a cohort of adult patients admitted to one BAU located within an ED (July-December 2017) to compare clinical characteristics, treatment outcomes, and use of restrictive interventions for those who received a specialist mental health (MH) assessment with those who did not. Of the 457 patients, 61.5% received a specialist MH assessment. This group had a lower acuity (Australasian Triage Score 10.4%; CI 0.2-2.0% vs 13.6%; CI 9.3-19.5%); more arrived with police (28.8%; CI 23.8-34.3 vs 5.1%; CI 2.7-9.4%); and were subjected to restrictive interventions while in the BAU. Security responses for unarmed threat (code grey) were higher (10.9%; CI 7.8-15.0% vs 4.4%; CI 2.3-8.5%), as was the use of chemical restraint (4.2%; CI 2.4-7.2 vs 0.0% CI 0.0 - 2.1%). Those requiring specialist MH assessment had a longer length of stay (12.7 vs 5.2 hours). Further development of the BAU model of care must include targeted, evidence-based strategies to minimize the use of restrictive interventions and ensure timely access to acute mental health services.

OBJECTIVE To explore the use of a modified pupillometry technique in dogs without chemical restraint. MATERIALS AND METHODS Following dark adaptation, pupillary light reflexes were assessed in six dogs with sudden acquired retinal degeneration syndrome, in the unaffected eye of eight dogs with unilateral primary glaucoma ("predisposed"), and in 11 healthy dogs. Responses to red, blue and white lights were recorded and relative pupil sizes subsequently determined based on video recordings of each test. RESULTS Mean testing time was 2.3 minutes (range 1.8 to 3.1 minutes), excluding time for dark adaptation. Baseline pupil size in dogs with sudden acquired retinal degeneration syndrome was greater than in normal and predisposed eyes. Pupil constriction was reduced in predisposed compared to normal and sudden acquired retinal degeneration syndrome eyes when stimulated with high-intensity blue light. Compared to normal eyes, those with sudden acquired retinal degeneration syndrome had reduced pupil constriction when stimulated with low- and high-intensity red light, low-intensity blue light and white light. CLINICAL SIGNIFICANCE Quantitative measures of pupil function were obtained from healthy and diseased eyes without the need for chemical restraint. Further investigations are warranted to validate the technique and evaluate its use in the management of canine glaucoma.

The prevalence of security guards in health care settings is growing worldwide. There is a need to explore and understand their role and actions to inform policy and training and support least restrictive practices in health care. The aim of this study was to conduct a retrospective chart audit of security guard logs to investigate security guard involvement in Code Blacks, called in emergency situations of personal threats including patient and/or visitor violence, in medical and surgical wards in a large metropolitan health network in South Australia. Security guards attended 1664 Code Blacks (0.63% of admissions) over the 2.5-year study period. Events were more frequently reported in medical than surgical wards. The most common reasons for security guard attendance were patients threatening/harming staff and patients threatening/harming themselves. The most frequent security guard actions were "Attend only/standby," "Physical restraint," and "Patient located and returned to the ward." The most frequent outcomes were physical restraint, chemical restraint, and de-escalation respectively. Results highlight the imperative that health services maintain and increase efforts to support least restrictive practice through policy directives and staff training.

Violent, combative and intoxicated patients are a common problem in the emergency department, and the emergency physician must be prepared to control the situation safely and effectively when a patient begins to exhibit dangerous behavior. This article reviews initial de-escalation techniques to reduce the need for patient restraint. It then details the 2 types of restraints (physical and chemical) and the clear indications for each type. The high-risk nature of utilization of restraints is reviewed, as well as the means by which to ensure patient and staff safety and decrease adverse outcomes.

OBJECTIVE: Mental health (MH) presentations to ED are increasing in children and adolescents. Little is known about patients with severe acute behavioural disturbance (ABD). We set out to describe patients with ABD severe enough to trigger an acute crisis team response in ED (termed 'Code Grey') and how they differ from other MH patients. METHODS: Retrospective electronic medical record review of all ED patients with MH discharge codes at a tertiary children's hospital. We assessed the epidemiology and management of patients who triggered acute crisis team interventions (Code Grey) as proxy for severe ABD. We calculated the odds ratios (ORs with 95% confidence intervals) of key demographic factors compared to other MH patients. RESULTS: During 2018, there were 85 347 ED presentations of which 1695 (2.0%) were related to MH diagnoses; 84 MH patients had 141 MH presentations triggering 204 Code Greys (26 patients triggered 59% of Code Greys). These patients had higher triage acuity (OR 12.6 [8.3-19.0]), stayed longer in ED (>12 h OR 8.2 [5.1-13.1]) and were more likely to be admitted (OR 2.0 [1.4-3.0]) compared with non-Code Grey MH presentations. Patients were physically (19.2%), mechanically (31.9%) or chemically restrained (37.6%). Eight different medication approaches were used as either a single agent or a combination of oral and/or intramuscular agents. CONCLUSIONS: Children and adolescents with severe ABD differ from other MH presentations and often require physical or chemical restraint. Anticipatory management plans may be valuable for repeat presenters.

Background This study evaluated and compared cardiorespiratory and blood gas parameters, as well as sedation, analgesia and recovery of two protocols: ketamine (10 mg/kg) or dexmedetomidine (10 μg/kg), with midazolam (0.5 mg/kg) and butorphanol (0.3 mg/kg), IM (KBM and DBM, respectively) in brown howler monkeys (Alouatta guariba clamitans). Material and methods Twelve brown howler monkeys were selected in two groups and evaluated for cardiorespiratory parameters and sedation, from 5-30 minutes after latency. Blood gas and arterial lactate were taken at 5 and 30 minutes. In the end, time and quality of recovery were evaluated. Results The HR in DBM group was significantly lower at all times. The sedation score was higher in DBM. Recovery in DBM was faster. All animals had moderate hypoxaemia. Conclusion Both protocols produce satisfactory anaesthesia and analgesia, but DBM provides deeper sedation with faster recovery. Oxygen supplementation is recommended in both due to hypoxaemia.

WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.

The field of lizard sedation, anesthesia, and locoregional anesthesia is advancing with new drug protocols being evaluated, and new locoregional techniques being developed and evaluated. Inducing and maintaining effective and safe chemical restraint in lizards can be challenging, particularly in systemically diseased individuals. Understanding the anatomic and physiologic adaptations of lizards, using reversible or partially reversible injectable protocols, and using locoregional anesthesia may increase the quality of chemical restraint, facilitate faster recoveries, and limit anesthesia-related morbidity and mortality.

Restraint use in Australian residential aged care has been highlighted by the media, and investigated by researchers, government and advocacy bodies. In 2018, the Royal Commission into Aged Care selected ‘Restraint’ as a key focus of inquiry. Subsequently, Federal legislation was passed to ensure restraint is only used in residential aged care services as the ‘last resort’. To inform and develop Government educational resources, we conducted qualitative research to gain greater understanding of the experiences and attitudes of aged care stakeholders around restraint practice. Semi-structured interviews were held with 28 participants, comprising nurses, care staff, physicians, physiotherapists, pharmacists and relatives. Two focus groups were also conducted to ascertain the views of residential and community aged care senior management staff. Data were thematically analyzed using a pragmatic approach of inductive and deductive coding and theme development. Five themes were identified during the study: 1. Understanding of restraint, 2. Support for legislation, 3. Restraint-free environments are not possible, 4. Low-level restraint, 5. Restraint in the community is uncharted. Although most staff, health practitioners and relatives have a basic understanding of restraint, more education is needed at a conceptual level to enable them to identify and avoid restraint practice, particularly ‘low-level’ forms and chemical restraint. There was strong support for the new restraint regulations, but most interviewees admitted they were unsure what the legislation entailed. With regards to resources, stakeholders wanted recognition that there were times when restraint was necessary and advice on what to do in these situations, as opposed to unrealistic aspirations for restraint-free care. Stakeholders reported greater oversight of restraint in residential aged care but specified that community restraint use was largely unknown. Research is needed to investigate the extent and types of restraint practice in community aged care.

This study aimed to evaluate the effectiveness of acepromazine as an adjuvant to ketamine, midazolam and methadone in the chemical restraint and anesthesia of cats undergoing ovariohysterectomy. We allocated 14 cats in two groups: group ketamine (GK), premedicated with ketamine 8 mg/kg, midazolam 0.3 mg/kg and methadone 0.3 mg/kg and group acepromazine (GAK), premedicated with acepromazine 0.05 mg/kg in addition to the above-mentioned drugs. At baseline (T0) and every 5 mins up to 20 mins (T5, T10, T15 and T20) after premedication, the sedation score was evaluated at 0 to 24 points. The sedation score was significantly higher at T5, T10, T15 and T20 in both groups. There were no significant differences in extubation times (3.7 ± 1.3 mins in GK; 5.2 ± 2.6 mins in GAK) and the time to reach a score equal to 0 on the sedation scale (88 ± 63.9 mins in GK; 133 ± 39.7 mins in GAK); however, the time of anesthetic release was significantly higher in the GAK than in GK (19.7 ± 6.5 mins vs 11 ± 5.9 mins) (P = 0.023). Sedation was adequate in both groups. The results indicated that the administration of acepromazine did not contribute to sedation in the protocol and could delay the anesthetic release. El objetivo de este estudio fue evaluar el efecto de la acepromazina con adyuvante al protocolo de ketamina, midazolam y metadona sobre la contención química y la anestesia de gatos sometidos a ovariosalpingohisterectomía. Los animales fueron divididos en dos grupos: grupo ketamina (GK), premedicado con ketamina 8 mg/kg, midazolam 0,3 mg/kg y metadona 0,3 mg/kg, y el grupo acepromazina (GAK), premedicado con acepromazina 0,05 mg/kg asociado a los fármacos mencionados anteriormente. Al inicio (T0) y cada 5 minutos hasta 20 minutos (T5, T10, T15 y T20), después de la premedicación, se evaluó un puntaje de sedación de 0 a 24 puntos. La sedación fue significativamente mayor en T5, T10, T15 y T20 en ambos grupos. No hubo diferencias significativas en los tiempos de extubación (3,7 ± 1,3 minutos en GK; 5,2 ± 2,6 minutos en GAK); y a tiempo para lograr una puntuación igual a 0 en la escala de sedación (88 ± 63,9 minutos en GK; 133 ± 39,7 minutos en GAK); sin embargo, el tiempo de descarga anestésico era perceptiblemente más largo en GAK que en GK (19,7 ± 6,5 minutos contra 11 ± 5,9 minutos) (P = 0,023). La sedación fue adecuada en ambos grupos. La administración de acepromazina no contribuyó a la sedación y aumentó el tiempo de anestésico alto. O objetivo desse estudo foi avaliar o efeito da acepromazina com adjuvante ao protocolo de cetamina, midazolam e metadona na contenção química e anestesia de gatas submetidas a ovariosalpingohisterectomia. Os animais foram divididos em dois grupos: grupo cetamina (GK), premedicados com cetamina 8 mg/kg, midazolam 0,3 mg/kg e metadona 0,3 mg/kg, e o grupo acepromazina (GAK), premedicados com acepromazina 0,05 mg/kg associada aos fármacos citados anteriormente. No momento basal (T0) e a cada 5 minutos até 20 minutos (T5, T10, T15 e T20), após a premedicação, um escore de sedação foi avaliado de 0 a 24 pontos. A sedação foi significativamente maior nos T5, T10, T15 e T20 em ambos os grupos. Não teve diferença significativa nos tempos de extubação (3.7 ± 1.3 minutos no GK; 5.2 ± 2.6 minutos no GAK); e no tempo para alcançar escore igual a 0 na escala de sedação (88 ± 63.9 minutos no GK; 133 ± 39.7 minuto no GAK); entretanto, o tempo de alta anestésica foi significativamente maior no GAK do que no GK (19.7 ± 6.5 minutos contra 11 ± 5.9 minutos) (P = 0.023). A sedação foi adequada em ambos os grupos. A administração de acepromazina não contribuiu para a sedação e aumentou a o tempo de alta anestésica.

Capybara (Hydrochoerus hydrochaeris) is the main host of tick-borne pathogens causing Brazilian spotted fever; therefore, controlling its population is essential, and this may require chemical restraint. We assessed the impact of chemical restraint protocols on the partial pressure of arterial oxygen (PaO2) and other blood variables in 36 capybaras and the effect of different flows of nasal oxygen (O2) supplementation. The capybaras were hand-injected with dexmedetomidine (5 μg/kg) and midazolam (0.1 mg/kg) and butorphanol (0.2 mg/kg) (DMB, n = 18) or methadone (0.1 mg/kg) (DMM, n = 18). One-third of the animals were maintained in ambient air throughout the procedure, and one-third were administered intranasal 2 L/min O2 after 30 min whereas the other third were administered 5 L/min O2. Arterial blood gases, acid-base status, and electrolytes were assessed 30 and 60 min after drug injection. The DMB and DMM groups did not vary based on any of the evaluated variables. All animals developed hypoxaemia (PaO2 44 [30; 73] mmHg, SaO2 81 [62; 93] %) 30 min before O2 supplementation. Intranasal O2 at 2 L/min improved PaO2 (63 [49; 97] mmHg and SaO2 [92 [85; 98] %), but 9 of 12 capybaras remained hypoxaemic. A higher O2 flow of 5 L/min was efficient in treating hypoxaemia (PaO2 188 [146; 414] mmHg, SaO2 100 [99; 100] %) in all the 12 animals that received it. Both drug protocols induced hypoxaemia, which could be treated with intranasal oxygen supplementation.

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast-acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre-hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.

Maximizing animal wellbeing by minimizing drug-related side effects is a key consideration when choosing pharmaceutical agents for chemical restraint in nonhuman primates. One drug combination that may promote this ideology is butorphanol (27.3 mg/mL), azaperone (9.1 mg/mL), and medetomidine (10.9 mg/mL; BAM). Based on results from a pilot study, 2 doses of BAM (16 and 24 μL/kg IM) were compared in healthy, 3-y-old rhesus macaques. Physiologic parameters and anesthetic quality were assessed and recorded every 5 min. Experimental endpoints were established for hypoxemia (85% or less peripheral oxygen saturation with oxygen supplementation), pulse rate (80 bpm or less for 2 consecutive readings), mean arterial pressure (MAP; 50 mm Hg or less), and hypothermia (97 °F or less); if any endpoint was achieved, medetomidine was reversed by using atipamezole (0.22 mg/kg IM). Both BAM doses resulted in immobilization of all animals with no clinically significant differences between groups. All animals initially exhibited hypoxemia that resolved with oxygen supplementation. Regardless of dose, most macaques (71%) reached established experimental endpoints for bradycardia (62 to 80 bpm) or hypotension (44 to 50 mm Hg MAP). Given the results of this study, our recommendation regarding the use of 16- or 24-μL/kg BAM for immobilizing rhesus macaques is dependent on caution regarding cardiopulmonary parameters and the provision of supplemental oxygen.

Reducing and/or eliminating the use of coercive measures in psychiatric services is a priority worldwide. Chemical restraint is one such measure, yet to date has been poorly defined and poorly investigated. The aim of this study was to examine chemical restraint use in 12 adult acute inpatient psychiatric units in Adelaide, South Australia. Methods involved the analysis of all reported chemical restraint events occurring over a 12-month period analysed using a descriptive quantitative design. There were 166 chemical restraint events involving 110 consumers. The highest prevalence rate in an individual unit was 28.78 events per 1000 occupied bed days, with the lowest being 0.12 events per 1000 occupied bed days. More males (n = 69, 57.5%) were involved in chemical restraint than females. Schizophrenia, schizotypal, and delusional disorders were the predominant diagnoses among consumers who were chemically restrained. The most events occurred during three time blocks: 14.00-14.59 pm, 16.00-16.59 pm, and 21.00-21.59 pm. The two most common medications used were olanzapine and clonazepam. The study presents a general picture of the practice of chemical restraint in Adelaide and identifies areas of concern in relation to the need for monitoring of side effects and completion of systematic processes of documentation regarding chemical restraint events. Findings highlight the need for sustained focus on reducing the need for chemical restraint and exploring less restrictive measures with those most likely to receive medication against their will.

Objectives: The aim of this study was to describe the sedative and some physiological effects of tiletamine?zolazepam following buccal administration (BA) in cats. Methods: Seven healthy spayed European Shorthair cats (three males, four female) were studied twice in this randomized, blinded, crossover study. Each cat received two doses of tiletamine?zolazepam by BA: the low-dose (LD) consisted of 5 mg/kg of each drug, and the high dose (HD) consisted of 7.5 mg/kg of each. Baseline systolic blood pressure (SAP), heart rate (HR), respiratory rate (RR) and a sedation score were recorded prior to administration of each treatment. The same variables plus the percentage of hemoglobin saturated with oxygen as measured by pulse oximetry (SpO 2 ) were recorded at predefined intervals for the next 2 h. Results: All cats completed the study. No retching or vomiting were observed. Hypersalivation was observed in 0/7 and 3/7 for LD and HD, respectively (P = 0.2). There were significant changes in scores over time for posture, response to clippers and response to manual restraint for both groups, without differences between groups. RR, HR and SAP changed significantly over time. SAP and RR were significantly lower for HD than for LD. No values for hemoglobin saturation

Anesthetic blocks of hind limbs play a fundamental role in the diagnosis of conditions affecting these sites. However, some restless horses can make this procedure much more difficult. Many clinicians believe that the use of chemical restraint to facilitate joint injections may interfere with the lameness intensity. This study aimed to assess whether sedation with xylazine hydrochloride alone or associated with butorphanol tartrate ameliorate or even abolish induced hind limb lameness. Intravenous injection of xylazine (0.3 mg/kg) alone (XG) or associated with butorphanol (0.01 mg/kg) (XBG) were given randomly to 16 adult horses. A third control group (CG) was left untreated. All horses participated in all groups. Lameness induction was performed with the placement of a circumferential metal clamp causing pressure on the hoof wall. Sedation was assessed using a descriptive physical and behavioral scale and by the head height above ground (HHAG) before the treatment (0 minutes) and 20, 30, and 40 minutes following treatment. Objective lameness evaluations were performed before sedation (after lameness induction) and at 20, 30, and 40 minutes postsedation. There was no difference in pelvic asymmetry between xylazine, xylazine with butorphanol, and untreated control group at the different evaluation times. Spearman's correlation showed that there was no correlation between the factors HHAG and LI (rs = 0.148). Xylazine alone or associated with butorphanol at the recommended doses may be used as chemical restraint to turn an anesthetic block of the hind limbs into a safer procedure without masking lameness intensity for at least 40 minutes postadministration.

Background: Coercion and restraint practices in psychiatric care are common phenomena and often controversial and debatable ethical issue. Caregivers’ attitude and perspective on coercion and restraint practices on psychiatric inpatients have received relatively less research attention till date. Aims: Caregivers’ attitude and perspective on coercion and restraint practices on psychiatric inpatients. Methodology: This is a hospital-based, a descriptive, cross-sectional study. A total of 200 (n = 200) consecutive patient and their caregivers were chosen between June 2013 and September 2014 through computer-generated random numbers sampling technique. We used a semi-structured interview questionnaire to capture caregivers’ attitude and perspective on coercion and restraint practices. Sociodemographic and coercion variable were analyzed using descriptive statistics. McNemar test was used to assess discrete variables. Results: The mean age was 43.8 (±14.9) years. About 67.5% of the caregivers were family members, 60.5% of them were male and 69.5% were from low-socioeconomic status. Caregivers used multiple methods were used to bring patients into the hospital. Threat (52.5%) was the most common method of coercion followed by persuasion (48.5%). Caregivers felt necessary and acceptable to use chemical restraint (82.5%), followed by physical restraint (71%) and electroconvulsive therapy (ECT) (56.5%) during acute and emergency psychiatric care to control imminent risk behavior of patients. Conclusion: Threat, persuasion and physical restraint were the common methods to bring patients to bring acutely disturbed patients to mental health care. Most patients caregivers felt the use of chemical restraint, physical restraint and ECT as necessary for acute and emergency care in patients with mental illness.

A variety of medical and social factors have contributed over the last decades to the overuse of psychotropic drugs in people with dementia. One social factor is probably the frequent failure to provide adequate person-centered care, be it in the community or in institutional settings. This unfortunate reality has been reacted upon with numerous guidelines to reduce prescriptions of the most dangerous drugs (e.g., neuroleptics). Each psychotropic drug prescription can in principle be assessed around three dimensions: (a) adequate, (b) inadequate, and (c) chemical restraint. The CHemical Restraints avOidance MEthodology (CHROME) defined chemical restraint as any prescription based on organizational convenience, rather than justified with medical diagnosis. Two validation studies revealed that one of the main medical reasons of over- and miss-prescriptions was symptom-based prescription. By switching to syndrome-based prescription, a large proportion of drugs could be de-prescribed and some re-adjusted or kept. Paucity of research and weakness of data are not conclusive about the adequacy of specific drugs for the myriad of cases presented by patients with dementia and comorbid conditions. Clinical practice, however, leads us to believe that even under optimal care conditions, psychotropics might still contribute to quality of life if based on an adequate diagnosis. This article explains the rationale that underlies a syndromic approach aimed at optimizing psychotropic treatment in people with dementia whose significant suffering derives from their thought, affective, or behavioral problems. The results of previous validation studies of this new methodology will be discussed and conclusions for future results will be drawn.

Background This study evaluated the cardiopulmonary effects and anaesthetic depth induced by a propofol infusion rate of 0.8 mg/kg/min in monkeys (Sapajus apella). Materials and methods Five capuchin monkeys received dextroketamine-midazolam intramuscularly. After a maximum duration of 5 min, the values of the physiological parameters were recorded, and a venous catheter was placed. After recovery from chemical restraint, the animals were anaesthetized with propofol intravenously, which was maintained for 1 h. Physiological parameters, anaesthetic depth, the time and quality of anaesthetic recovery were evaluated. Results Heart and respiratory rates, systolic blood pressure and rectal temperature during propofol infusion were lower than those during anaesthesia induction with dextroketamine-midazolam. Unconsciousness, muscle relaxation and lack of response to tail clamping were observed during propofol infusion. No animals showed excitement or vocalization during anaesthetic recovery. Conclusion Propofol infusion rate of 0.8 mg/kg/min promoted surgical general anaesthesia, with transient hypotension, which showed excellent anaesthetic recovery.

Made available in DSpace on 2021-06-25T11:08:06Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-01-01 Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) Objective: To evaluate the efficacy and cardiopulmonary effects of ketamine–midazolam for chemical restraint, isoflurane anesthesia and tramadol or methadone as preventive analgesia in spotted pacas subjected to laparoscopy. Study design: Prospective placebo-controlled blinded trial. Animals: A total of eight captive female Cuniculus paca weighing 9.3 ± 0.9 kg. Methods: Animals were anesthetized on three occasions with 15 day intervals. Manually restrained animals were administered midazolam (0.5 mg kg–1) and ketamine (25 mg kg–1) intramuscularly. Anesthesia was induced and maintained with isoflurane 30 minutes later. Tramadol (5 mg kg–1), methadone (0.5 mg kg–1) or saline (0.05 mL kg–1) were administered intramuscularly 15 minutes prior to laparoscopy. Heart rate (HR), respiratory rate, mean arterial pressure (MAP), peripheral oxygen saturation (SpO2), end-tidal CO2 partial pressure (PE′CO2), end-tidal concentration of isoflurane (FE′Iso), pH, PaO2, PaCO2, bicarbonate (HCO3−), anion gap (AG) and base excess (BE) were monitored after chemical restraint, anesthesia induction and at different laparoscopy stages. Postoperative pain was assessed by visual analog scale (VAS) for 24 hours. Variables were compared using ANOVA or Friedman test (p < 0.05). Results: Chemical restraint was effective in 92% of animals. Isoflurane anesthesia was effective; however, HR, MAP, pH and AG decreased, whereas PE′CO2, PaO2, PaCO2, HCO3− and BE increased. MAP was stable with tramadol and methadone treatments; HR, FE′Iso and postoperative VAS decreased. VAS was lower for a longer time with methadone treatment; SpO2 and AG decreased, whereas PE′CO2, PaCO2 and HCO3− increased. Conclusions and clinical relevance: Ketamine–midazolam provided satisfactory restraint. Isoflurane anesthesia for laparoscopy was effective but resulted in hypotension and respiratory acidosis. Tramadol and methadone reduced isoflurane requirements, provided postoperative analgesia and caused hypercapnia, with methadone causing severe respiratory depression. Thus, the anesthetic protocol is adequate for laparoscopy in Cuniculus paca; however, methadone should be avoided. Institute of Agrarian Sciences Federal University of Jequithonha and Mucury Valleys (UFVJM) Department of Veterinary Pathobiology and Theriogenology São Paulo State University (Unesp) “Julio de Mesquita Filho” Department of Medicine and Veterinary Surgery Federal Rural University of Rio de Janeiro (UFRRJ) Department of Large Animal Clinic Federal University of Santa Maria (UFSM) Department of Veterinary Pathobiology and Theriogenology São Paulo State University (Unesp) “Julio de Mesquita Filho” CAPES: 14835126 FAPESP: FAPESP 2012/00724-6

Background : The taxonomic order Anura is composed of frogs and toads, with approximately 6000 species worldwide, of which 900 species are found in Brazil. Rhinella marina , popularly known as “sapo-cururu,” is the most commonly found frog in Brazil. Although most of these animals are found in research laboratories and zoos, they are increasingly being reared as pets. Therefore, sedation or anesthesia is often necessary for these animals to facilitate medical care, complementary examinations, or surgical procedures. However, there are only a few reports of anesthesia in frogs. Therefore, the present report aimed to describe the anesthetic protocol for femoral osteosynthetic surgery in an adult cane toad. Case : An adult cane toad presented with a history of difficulty in moving the left hindlimb and loss of limb movements. Radiography showed a simple, complete, transverse, and closed average shaft of the left femur and bone shaft fracture deviation. The animal was referred for an osteosynthetic surgery to stabilize the fracture. Animal restraint was performed using humidified gloves on the operating table. As premedication, ketamine, meloxicam, and morphine were administered, and general anesthesia was induced with isoflurane through a face mask. The anesthesia was maintained with isoflurane through a drip on the animal's back for cutaneous absorption. Lidocaine (2%) anesthetic gel was applied on the incision line to complement the somatic analgesia. The fracture was fixed using an intramedullary Kirschner pin. The heart rate was measured based on the beep of the arterial pulse using a Doppler ultrasonic device, respiratory rate was recorded by visual observation of the animal’s respiratory motion, and body temperature was assessed using an esophageal digital thermometer—all of these remained stable during the procedure. Morphine, enrofloxacin, and meloxicam were administered postoperatively. The animal was discharged from the hospital seven days after the surgery, and 14 days later, the animal was deemed clinically stable with favorable wound healing. Discussion : Toads use their skin to breathe and maintain osmotic balance. Therefore, their skin is extremely sensitive to dehydration, requiring constant wetting. General anesthesia in amphibians is recommended for prolonged and painful procedures, as in the present case. Different anesthetics, analgesics, and associated drugs may be used. Ketamine is often used for chemical restraint in amphibians, and the induction and recovery times may vary due to sensitivity and drug resistance. Inhalational anesthesia with isoflurane may also be effective; in the present case, the anesthetic was administered using a mask placed on the frog’s skin, without any irritation. Analgesia is essential for any animal, and amphibians have opioid receptors that may be used as targets of non-steroidal anti-inflammatory agents. As indicated for all species, the animal was monitored throughout the procedure. Assessment of heartbeat is the simplest way to monitor anesthesia using Doppler (on the heart or throat); in the present case, was placed on the axillary artery for clear auscultation. In addition, other parameters, such as temperature and primary respiratory movements, were monitored. Anesthetic recovery can take hours or even days, whereas excretion depends on the metabolic rate of each animal. In the present case, recovery was observed 4 h after completion of the procedure, using fresh water on the animal’s body to accelerate recovery, as indicated in the literature. This case demonstrated that anesthesia and medications used for anesthesia induction, maintenance, and recovery are safe in toads. For cane toads, during femoral osteosynthesis, this anesthetic procedure has never been described previously in the literature. Finally, such information can aid veterinarians in performing safe and adequate analgesic and anesthetic procedures for the wellbeing of animals. Keywords: amphibians, analgesia, surgery, skin absorption.

Background : The hooded capuchin that occurs in the Brazilian states of Mato Grosso and Mato Grosso do Sul belongs to the species Sapajus cay . This robust species of capuchin monkey is characterized by its highly varied diet. Although it is well adapted to the natural environment, the survival of this species has come under increasing threat. In fact, several animals have been rescued and taken into veterinary medical care, where its correct capture and restraint minimize the occurrence of adverse effects to the animal and to veterinary anesthesiologists. This paper reports on the emergency care of a hooded capuchin ( S. cay ) rescued by the Environmental Police of the state of Mato Grosso do Sul, Brazil, and sent to veterinary medical care. Case : An adult female hooded capuchin, weighing 1.6 kg, was subjected to veterinary care to treat trauma probably caused by being run over. The animal exhibited intense prostration, 10% dehydration, pale and slightly jaundiced oral and ocular mucous membranes, impaired consciousness, cachexia, muscle weakness, sarcopenia, a probable fracture in the proximal portion of the left tibia and a laceration and possible fracture of the right metatarsus. The patient was stabilized by subjecting her to fluid therapy with Ringer’s lactate solution supplemented with glucose and vitamins. The animal was anesthetized with an intramuscular injection of 11 mg/kg ketamine and 0.6 mg/kg midazolam, and blood count, serum biochemistry and electrocardiography were performed. Blood tests revealed hypochromic microcytic anemia, liver disease and a slight increase in urea to 56 mg/dL (reference: 14.4-48.9 mg/dL). The electrocardiogram revealed the following: HR: 260 b.p.m; P axis: -115.36o; QRS axis: 50.17o; T duration: 36 ms; R amplitude: 0.68 mV; P amplitude: 0.17 mV; P duration: 44 ms: PR interval: 52 ms; S amplitude: -0.12 mV; T amplitude: 16 ms; ST elevation: -0.05 mV; QT interval: 106 ms; Q amplitude: -0.2 mV; QRS duration: 54 ms. The patient exhibited tachycardia and sinus rhythm. Antibiotic treatment was administered via intravenous (IV) injection with 50 mg/kg ceftriaxone and 25 mg/kg metronidazole, while analgesia was administered subcutaneously (SC) with 2 mg/kg tramadol hydrochloride and 25 mg/kg sodium dipyrone and intramuscularly (IM) with 0.2 mg/kg meloxicam. The patient was stabilized and transferred by the Environmental Police to the Wild Animal Rehabilitation Center (CRAS) located in the municipality of Campo Grande, Mato Grosso do Sul, to continue its treatment, perform complementary tests such as radiography of the fractured limb and clinical and surgical treatment. Discussion : Proper physical restraint is essential to the success and quality of biological samples that are collected. Surgical procedures, simple clinical exams and the collection of biological material may all require the use of anesthetics, and the type most commonly used for the restraint of wild animals are dissociative anesthetics. Ketamine is an neuroleptanalgesic drug widely used in primates, and can be administered separately or in combination with other anesthetics, such as midazolam, to increase chemical restraint and anesthesia and enable handling of the patient. As for hematological changes, female nonhuman primates are known to undergo blood loss during their menstrual cycle, which reduces the parameters of the erythrogram. In the case of this capuchin, the blood count revealed hypochromic microcytic anemia, which may be related to the menstrual cycle of the species. With regard to biochemistry serum levels, liver function showed the greatest change, with altered aspartate aminotransferase - AST (368 U/L) and alanine aminotransferase - ALT enzyme levels (151 U/L), indicating possibly chronic liver damage. On the other hand, research involving Cebus flavius found that adult males had higher ALT levels than juveniles.

Practical relevance: Procedural sedation and analgesia (PSA) describes the process of depressing a patient’s conscious state to perform unpleasant, minimally invasive procedures, and is part of the daily routine in feline medicine. Maintaining cardiopulmonary stability is critical while peforming PSA. Clinical challenges: Decision-making with respect to drug choice and dosage regimen, taking into consideration the cat’s health status, behavior, any concomitant diseases and the need for analgesia, represents an everyday challenge in feline practice. While PSA is commonly perceived to be an uneventful procedure, complications may arise, especially when cats that were meant to be sedated are actually anesthetized. Aims: This clinical article reviews key aspects of PSA in cats while exploring the literature and discussing complications and risk factors. Recommendations are given for patient assessment and preparation, clinical monitoring and fasting protocols, and there is discussion of how PSA protocols may change blood results and diagnostic tests. An overview of, and rationale for, building a PSA protocol, and the advantages and disadvantages of different classes of sedatives and anesthetics, is presented in a clinical context. Finally, injectable drug protocols are reported, supported by an evidence-based approach and clinical experience.

The management of challenging behaviour, violence and aggression is not only an issue for mental health and learning disability nurses. Increasingly, nurses working in emergency departments (EDs), medical assessment units and general medical or surgical wards may encounter acts of challenging behaviour, violence and aggression on a regular basis. Restraint is sometimes used as a tool in the management of these patients; this may be in the form of physical, mechanical or chemical restraint. Rapid tranquillisation (RT) is often considered a form of chemical restraint, which may be used in an emergency situation when prescribed. If RT is given it should be done so as the least restrictive option, with intramuscular and intravenous administration as a last resort. Patient monitoring following administration is paramount. This article explores best practice in the administration of RT from a clinical perspective.

Background Use of physical and chemical restraints are common in residential aged care facilities worldwide. Restraint use can pose harm to residents even causing deaths. Objective To synthesize the prevalence and variability in physical and chemical restraint use, and examine factors that may contribute to this variability of prevalence rates. Methods 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. Results 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. Conclusion 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.

Background Agitation in older people is commonly associated with cognitive decline, complex medical diagnoses and polypharmacy. Impaired communication and comprehension within a dementia trajectory adds complexity to assessment and management. Despite high prevalence, agitated behaviours remain challenging to manage in residential aged care settings. Aim To explore staff perceptions of agitation in residents of aged care facilities, including the influence of dementia, when selecting management strategies to reduce agitated behaviour. Design Qualitative descriptive. Methods Semi-structured interviews with 11 aged care staff were conducted at two aged care sites. Transcripts were examined using content analysis to identify common issues and categories. The study complied with COREQ guidelines (see. Appendix S1). Results Participants reported managing resident agitation at least once per shift; most frequently manifesting as wandering, restlessness or aggression. Management strategies included distraction, providing space, knowing the resident, identifying causative factors, spending individual time and if necessary medication administration. Agitation management was more challenging for residents with dementia due to impaired communication or comprehension of instruction. Conclusions While participants strived to deliver individualized person-centred care, this was difficult given time and resource constraints. Contemporary management of agitation therefore remains variable in everyday practice, with resident preference used when causative factors were known. Conversely, for residents with impaired communication and/or comprehension, distraction and chemical restraint were commonly used. Nuanced education for assessment and management is recommended to better address this unmet need for some residents. Relevance to clinical practice For optimal care, appropriate allocation of time and resources is necessary to identify causative and contextual factors for individual residents. Recommendations are for additional staff training in communication and attitude, and collaborating with frontline staff to develop a practical guide for management of agitation in aged care. These simple initiatives may help to improve consistency of care delivery and resident outcomes.

OBJECTIVES Methamphetamine intoxication is an increasing cause of emergency department (ED) visits in the United States, particularly in the west. In San Francisco, California, 47% of patients visiting psychiatric emergency services are intoxicated with methamphetamine. Such patients often visit the ED due to acute psychiatric symptoms, yet ED-based research investigating the outcomes and resource utilization of these visits is limited. METHODS We examined a retrospective cohort of ED patients requiring ED-based psychiatric consultation from June 2017 to July 2018. We evaluated the association between methamphetamine visits and need for chemical restraint, psychiatric hospitalization, and length of stay (LOS). RESULTS We identified 2,087 ED visits with psychiatric consults. Based on urine toxicology results and discharge diagnosis, 403 visits involved methamphetamine with or without other drugs, 480 involved other drugs without methamphetamine, and 1,204 had no evidence of drug use. Methamphetamine visits were associated with increased odds of chemical restraint compared to visits without drug use (adjusted odds ratio [AOR] = 3.2, 95% CI = 2.1 to 5.2, p

Background: Physical and pharmacological restraints, defined as all measures limiting a person in his or her freedom, are extensively used to handle unsafe or problematic behavior in hospital care. There are increasing concerns as to the extent with which these restraints are being used in hospitals, and whether their benefits outweigh their potential harm. There is currently no comprehensive literature overview on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in the hospital setting. Methods: A systematic review of the existing literature will be performed on the beneficial and/or adverse effects of physical and pharmacological restraints in the hospital setting. Relevant databases will be systematically searched. A dedicated search strategy was composed. A visualization of similarities (VOS) analysis was used to further specify the search. Observational studies, and if available, randomized controlled trials reporting on beneficial and/or adverse effects of physical and/or pharmacological restraints in the general hospital setting will be included. Data from included articles will be extracted and analyzed. If the data is suitable for quantitative analysis, meta-analysis will be applied. Discussion: This review will provide data on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in hospital care. With this review we aim to guide health professionals by providing a critique of the available evidence regarding their choice to either apply or withhold from using restraints. A limitation of the current review will be that we will not specifically address ethical aspects of restraint use. Nevertheless, the outcomes of our systematic review can be used in the composition of a multidisciplinary guideline. Furthermore, our systematic review might determine knowledge gaps in the evidence, and recommendations on how to target these gaps with future research. Systematic Review Registration: PROSPERO registration number: CRD42019116186.

Capturing wild capybaras for scientific projects, population control or medical interventions is a growing necessity. With this study, we intended to evaluate a Ketamine/Dexmedetomidine as a reversible chemical restraint in free-ranging synanthropic capybaras, seeking enhanced anesthetic and recovery characteristics while testing a specialized remote drug delivery system (RDDS). For this purpose, 18 adult capybaras (male n = 8; females n = 10) (67.3 ± 9.45 kg), prior to chemical restraint, were physically confined, subsequently darted intramuscularly with 9 mg kg-1 ketamine and 0,005 mg kg-1 dexmedetomidine. Post-intervention, 0,005 mg kg-1 atipamezole, administered IM, was used as a reversal agent (RA), (n = 5). Anesthetic effects were recorded as latency period (LP I/first observed effects) (LP II /lateral recumbency plus time to handle the animal). Recovery time was divided into (R1/no RA, fully recovered/ready for release), (R2a/R2b, with RA, time to ambulant position plus time to full recovery/release, respectively). Vital signs were recorded at a 15-minute interval. GraphPad Prism 8.1.1 was used to perform unpaired t-test, with a p-value ˂ 0,05 considered significant. Results: Mean LP I: 3 ± 1 min.; LP II: 10 ± 2 min. Procedure duration: 49 ± 5 min. Recovery time without RA, (R1): 55 ± 15 min., compared to 18 min., with RA (R2a) to ambulant position (with severe discoordination), requiring additional time until full recovery (ready for release): ± 45 min (R2b). Total time, to release (R2a/b): mean ± SD = 67 ± 13.85 min. Concluding for clinical relevance that the association of Ketamine and Dexmedetomidine performed satisfactorily, providing effective sedation and analgesia, and relative short latency periods. Used RA did not shorten total recovery time significantly (P-value = 0,7328). Adverse effects such as the risk of acute cecal tympany, due to the lack of pre-anesthetic fasting, concurrent to collateral effects of injectable and volatile anesthetics on the motility of the digestive tract, and induced bradycardia/hyperthermia warrant extra caution. The employed RDDS provided reliable drug delivery under field conditions., Capturar capivaras selvagens para projetos científicos, controle populacional ou intervenções médicas é uma necessidade crescente. Com este estudo, pretendemos avaliar uma associação de cetamina / dexmedetomidina como uma contenção química reversível em capivaras sinantrópicas de vida livre, buscando melhorar as características anestésicas e de recuperação e, ao mesmo tempo, testar um sistema remoto de liberação controlada de medicamentos (RDDS). Para tanto, 18 capivaras adultas (machos n = 8; fêmeas n = 10) (67,3 ± 9,45 kg), antes da contenção química, foram fisicamente confinadas, e receberam dardos por via intramuscular com 9 mg kg-1 de cetamina e 0,005 mg kg-1. dexmedetomidina. Após a intervenção, 0,005 mg kg-1 de atipamezol foi administrado via IM, e utilizado como agente de reversão (RA), (n = 5). Os efeitos anestésicos foram registrados como período de latência (LP I / primeiros efeitos observados) (LP II / decúbito lateral mais tempo para manipular o animal). O tempo de recuperação foi dividido em (R1 / sem AR, totalmente recuperado / pronto para liberação da contenção física), (R2a / R2b, com AR, tempo para deambular mais tempo para recuperação total / liberação, respectivamente). Os sinais vitais foram registrados em um intervalo de 15 minutos. O GraphPad Prism 8.1.1 foi utilizado para realizar o teste t não pareado, com um valor p ˂ 0,05 considerado significativo. Resultados: LP médio I: 3 ± 1 min; LP II: 10 ± 2 min. Duração do procedimento: 49 ± 5 min. Tempo de recuperação sem AR, (R1): 55 ± 15 min., Em comparação aos 18min, com AR (R2a) até em posição para caminhar (com descoordenação grave), necessitou de tempo adicional até a recuperação completa (pronto para liberação): ± 45 min (R2b) . Tempo total, para liberação (R2a / b): média ± DP = 67 ± 13,85 min. Concluiu-se, por relevância clínica, que a associação de cetamina e dexmedetomidina teve um desempenho satisfatório, proporcionando sedação e analgesia eficazes e períodos relativamente curtos de latência. A RA utilizada não reduziu significativamente o tempo total de recuperação (valor P = 0,7328). Os efeitos adversos, como o risco de timpanismo no ceco agudo, devido à falta de jejum pré-anestésico, concomitante aos efeitos colaterais dos anestésicos injetáveis ​​e voláteis sobre a motilidade do trato digestivo, e bradicardia / hipertermia induzida, exigem cautela extra. O RDDS utilizado forneceu entrega confiável de medicamentos em condições de campo.

Background Psychomotor agitation can be problematic in an overcrowded emergency department (ED) during uncontrolled procedural sedation. Although emergence phenomena have been studied, various presentations may exist. Case presentation During procedural sedation, a 58-year-old man was sedated with a dissociative dose of ketamine in conjunction with propofol. His shoulder dislocation was reduced successfully but eventually, an exaggerated agitation occurred resembling a post-traumatic stress disorder (PTSD) flashback of past war scenes He was controlled by physical and chemical restraint with an intramuscular injection of 0.1 mg/kg midazolam. After resolution of sedation in rather stable psychiatric conditions, he left the ED with his relatives insisting for discharge against medical advice. Conclusions A PTSD flashback may occur from ketamine sedation in patients with a past history of military experience and can be a manifestation of psychologic adverse effects of ketamine.

Objective: The goal of this study is to describe complications and outcomes of prehospital ketamine use for agitation as compared to other methods of physical or chemical restraint such as haloperidol plus benzodiazepine or physical restraint only. Methods: We conducted a single-center retrospective review of patient encounters in which restraint was administered in the prehospital setting. At the beginning of our study window, only physical restraint was available to paramedics managing agitated patients but subsequently, haloperidol and benzodiazepines were introduced, followed by ketamine 2 years later. By comparing patients before and after each transition, we divided subjects into 3 cohorts based on restraint type: physical restraint, haloperidol plus benzodiazepine, and ketamine. Demographic data were collected, and outcome measures included intubation rate, need for additional physical or chemical restraint, emergency department (ED) length of stay, need for hospital admission, and employee injury. Results: Of 214 subjects included in the study, 95 patients were administered ketamine, 68 received haloperidol and benzodiazepine, and 51 were physically restrained. Eleven of the patients (11.6%) who received ketamine were intubated. Compared to patients who received haloperidol plus benzodiazepine, patients who received ketamine were more likely to be intubated (odds ratio [OR] = 8.77, 95% confidence interval [CI], 1.10–69.68) and were more likely to require additional chemical restraint when compared to haloperidol/benzodiazepine or physical restraint only (OR =2.94, 95% CI, 1.49–5.80, and OR =2.15, 95% CI, 1.07–4.31, respectively). There were no differences between the 2 chemical sedation groups in terms of ED length of stay or hospital admission rate. Conclusions: This study demonstrates a lower intubation rate in patients administered ketamine than prior literature in association with a lower weight-based dosing regimen. Ketamine use was correlated with a higher frequency of intubation and a greater need for additional chemical restraint when compared with other restraint modalities, though exogenous factors such as provider preference may have impacted this result. There was no difference in ED length of stay or admission rate between the ketamine and haloperidol plus benzodiazepine groups. Further prospective study is needed to determine whether there is a subset of patients for whom ketamine would be beneficial compared to other therapies.

Background The Indian Mental Health Care Act 2017 (MHCA -2017) advocates the duty to provide treatment in the least coercive manner. Little data exists on how Indian patients perceive coercion in medical settings. Aims To study the prevalence of restraint in a Indian psychiatric inpatient unit, and to examine the level of perceived coercion correlating to various forms of restraint. Methodology This is a hospital based prospective observational study. Two hundred patients were recruited through computer generated random number sampling. In eligible subjects, demographic and clinical data, restraints used and assessments related to perceived coercion were completed within 3 days of admission. Perceived coercion was reassessed at the time or within 3 days before discharge. Results In 66.5% one or more restraint measures were used, physical restraints in 20%, chemical restraints in 58%, seclusion in 18%, and involuntary medication in 32%. ECT is associated with the lowest level of perceived coercion followed by isolation/seclusion, chemical restraint, involuntary medication and physical restraint. Male gender, being married, rural background, low socioeconomic status, having a mood disorder, and alcohol or drug dependence was associated with an increased risk of physical or chemical restraint. Having a mood disorder, being from a rural area and a lower socioeconomic status was associated with being subjected to more than one form of coercion. Conclusion Restraint measures are more prevalent in psychiatric hospital care in India than in Europe. Physical restraint is particularly associted with higher perceived coercion.

The term “Excited Delirium” is a subcategory of delirium, which describes a syndrome of altered mental status, agitation, and overactive adrenergic autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness. Hyperthermia, severe metabolic acidosis, rhabdomyolysis and hyperkalemia are also common features of Excited Delirium Syndrome. The pathophysiology of the Excited Delirium Syndrome is unclear, however it may involve dysregulation of dopaminergic pathways in the brain. Treatment involves rapid chemical restraint, treatment of hyperthermia, and treatment of metabolic derangements.

The use of serum lactate has become increasingly common in Veterinary Medicine, since it is an excellent marker of tissue oxygenation, elevated in situations of tissue hypoxia, where anaerobic glycolysis is used as an energy source. Studies point out its use in dogs as a prognostic factor in several affections; however it is not commonly used in domestic felines due to the high stress threshold of the species, which may interfere with their values. The aim of the present study was to evaluate serum lactate values in domestic cats during physical restraint and after chemical restraint using the combination of 8mg/kg ketamine-S, 0.4 mg/kg midazolam, and 2 mg/kg Tramadol. To this end, 20 clinically healthy female cats without defined race, from six months to five years of age, were divided into two groups, GPR (n = 10) represented by felines that had only physical restraint and the GCR (n = 10) by felines that underwent physical restraint (TPR) and after 30 hours by chemical restraint (TCR). It was observed that in both groups (GPR and CPR) during physical restraint presented hyperlactatemia (GPR = 6.23 ± 0.9 mmol/L – GCR – Tpr = 6.66 ± 1.59 mmol/L) and mean values of 4.42 ± 1.28 mmol/L during chemical restraint (GCR – Tcr). It was concluded that physical restraint interferes with serum lactate values, with the reduction of such values with the use of chemical restraint in the feline species.