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Capture or exertional myopathy is an attendant complication of manual restraint in ratites, asides physical injuries that handlers may suffer. This work was carried out to restrain and immobilize two ostriches (Struthio camelus) in a bid to facilitate their clinical examination and transportation from one location to another, without subjecting the birds to capture myopathy that arises from the stress and exertion associated with physical restraint and capture. Two ostriches, male and female, weighing 120kg and 105kg respectively, were requested to be immobilized for relocation from Onireke to Jericho area in Oyo State, Nigeria. The birds were fasted overnight, administered with diazepam (3mg/kg) orally and ketamine (10mg/kg) intramuscularly. Mild sedation was achieved with diazepam after one hour. The birds were successfully transported. Complete recovery was achieved at about 8hours post-administration of ketamine. Anaesthetic agents did not alter the haematologic parameters. We conclude that the diazepam-ketamine combination is generally safe for ratites and that oral administration of diazepam accompanied by intramuscular administration of ketamine provides restraint in ratites while also avoiding the risk of capture myopathy. It is suggested that the current dose of diazepam might need to be increased if the oral route is to be employed so as to shorten the onset of sedation and increase the depth of sedation.

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.

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.

Objective:Describe and validate the CHROME (CHemical Restraints avOidance MEthodology) criteria.Design:Observational prospective longitudinal study.Setting:Single nursing home in Las Palmas de Gran Canaria, Spain.Participants:288 residents; mean age: 81.6 (SD 10.6). 77.4% had dementia.Intervention:Multicomponent training and consultancy program to eliminate physical and chemical restraints and promote overall quality care. Clinicians were trained in stringent diagnostic criteria of neuropsychiatric syndromes and adequate psychotropic prescription.Measurements:Psychotropic prescription (primary study target), neuropsychiatric syndromes, physical restraints, falls, and emergency room visits were semi-annually collected from December 2015 to December 2017. Results are presented for all residents and for those who had dementia and participated in the five study waves (completer analysis, n=107).Results:For the study completers, atypical neuroleptic prescription dropped from 42.7% to 18.7%, long half-life benzodiazepines dropped from 25.2% to 6.5%, and hypnotic medications from 47.7% to 12.1% (ppConclusions:Implementing the CHROME criteria reduced the prescription of the most dangerous medications in institutionalized people with dementia. Two independent audits found no physical or chemical restraint and confirmed prescription quality of psychotropic drugs. Adequate diagnosis and independent audits appear to be the keys to help and motivate professionals to optimize and reduce the use of psychotropic medication. The CHROME criteria unify, in a single compendium, neuropsychiatric diagnostic criteria, prescription guidelines, independent audit methodology, and minimum legal standards. These criteria can be easily adapted to other countries.

Background There is scarce information detailing clinical and physiological effects of reversible injectable protocols of chemical restraint on Neotropical primates. Methods Nineteen captive Spix´s Owl monkeys (Aotus vociferans) were assessed in a double-blind randomized crossover study using the following: ketamine/xylazine [KX], ketamine/midazolam [KM] and ketamine/xylazine/midazolam [KXM]. During immobilization, respiratory and pulse rates, rectal temperature, haemoglobin oxygen saturation and arterial blood pressure were recorded at 5-minute intervals during a 20-minute period; afterwards, antagonist drugs (yohimbine for xylazine and flumazenil for midazolam) were, respectively, administered. Quality and duration of induction, immobilization and recovery periods were recorded. Results Ketamine/xylazine increased manipulation sensitivity and produced poor muscle relaxation. KM maintained all assessed parameters within physiological ranges. KXM produced depressant cardiorespiratory effects and hypotension. All protocols produced hypothermia. Conclusions Based on its adequate anaesthetic depth and minimum effects on physiological parameters, KM is suitable for immobilizing A vociferans and performing short-term procedures lasting around 20 minutes.

Aims and objectives: To identify key determinants, which lead to the decision to apply physical or chemical restraint on the critical care unit. Background: Psychomotor agitation and hyperactive delirium are frequently cited as clinical rationale for initiating chemical and physical restraint in critical care. Current restraint guidance is over a decade old, and wide variations in nursing and prescribing practice are evident. It is unclear whether restraint use is grounded in evidence‐based practice or custom and culture. Study design: Integrative review. Method: Seven health sciences databases were searched to identify published and grey literature (1995–2019), with additional hand‐searching. The systematic deselection process followed PRISMA guidance. Studies were included if they identified physical or chemical restraint as a method of agitation management in adult critical care units. Quality appraisal was undertaken using Mixed Methods Appraisal Tool. Data were extracted, and thematic analysis undertaken. Results: A total of 23 studies were included. Four main themes were identified: the lack of standardised practice, patient characteristics associated with restraint use, the struggle in practice and the decision to apply restraint. Conclusions: There are wide variations in restraint use despite the presence of international guidance. Nurses are the primary decision‐makers in applying restraint and report that caring for delirious patients is physically and psychologically challenging. The decision to restrain can be influenced by the working environment, patient behaviours and clinical acuity. Enhanced clinical support and guidance for nurses caring for delirious patients is indicated. Relevance to clinical practice: Delirium and agitation pose a potential threat to patient safety and the maintenance of life‐preserving therapies. Restraint is viewed as one method of preserving patient safety. However, use appears to be influenced by previous adverse experiences and subjective patient descriptors, rather than robust evidence‐based knowledge. The need for a precise language to describe restraint and quantify when it becomes necessary is indicated.

This article argues that there exist unnecessary gaps in the regulation of the use of physical, mechanical and chemical restraints in mental health and aged care settings. While the use of these forms of restraint may be rationalised on the basis of preventing harm to self or others, there are adverse consequences that necessitate the minimisation, if not elimination, of their use. The overuse of mechanical and chemical restraints at the Oakden Older Persons Mental Health Service in South Australia led to several scathing inquiries. This article looks at the lessons learned and suggests a multidimensional, consistent approach is overdue.

The aged care system in Australia is in crisis and people living with dementia are especially vulnerable to breaches of human rights to autonomy, dignity, respect, and equitable access to the highest quality of health care including meeting needs on account of disability. To be powerful advocates for themselves and others, people with dementia and the wider community with vested interests in quality aged care must be informed about their rights and what should be expected from the system. Prior to the Australian Royal Commission into Aged Care Quality and Safety, the Empowered Project was established to empower and raise awareness amongst people with dementia and their families about changed behaviours, chemical restraint, consent, end of life care, and security of tenure. A primary care-embedded health media campaign and national seminar tour were undertaken to meet the project aims of awareness-raising and empowerment, based on 10 Essential Facts about changed behaviours and rights for people with dementia, established as part of the project. Knowledge translation was assessed to examine the need and potential benefit of such seminars. We demonstrated that this brief educational engagement improved community knowledge of these issues and provided attendees with the information and confidence to question the nature and quality of care provision. With the completion of the Royal Commission and corresponding recommendations with government, we believe the community is ready to be an active player in reframing Australia’s aged care system with a human rights approach.

Objective Palliative care for dementia includes psychosocial interventions as first-line treatment for challenging behaviour. However, the national dementia plan in Japan contradicts recommendations for palliative care for dementia. This study aimed to examine the association between care quality for patients with dementia and professional caregivers' perspectives regarding palliative care for dementia in Japanese community care settings. Methods In total, 2116 professional caregivers from 329 agencies (217 in-home long-term care support providers; 29 small-scale, multiple home-care providers; and 83 group homes) in Tokyo prefecture, Japan, completed cross-sectional, paper-based questionnaires about 3603 people diagnosed with dementia, in May 2016. Quality of care measures included physical restraint and antipsychotic medication use and quality of life. Patients' quality of life was assessed via the Japanese version of the Alzheimer's Disease Health-related Quality of Life scale. The Japanese version of the Questionnaire on Palliative Care for Advanced Dementia was used to assess professional caregivers' knowledge and attitudes regarding palliative care for dementia. Results Professional caregivers' knowledge and attitudes regarding palliative care for dementia were positively associated with quality of life in patients with dementia. Physical restraint and antipsychotic medication were used regardless of professional caregivers' knowledge and attitudes. Conclusions Professional caregivers' perspectives regarding palliative care for dementia could have exerted a positive effect on quality of life in patients with dementia. A national strategy for advocacy and the protection of adults is required to integrate several laws and guidelines and prevent the use of antipsychotics as a form of chemical restraint. Copyright © 2016 John Wiley & Sons, Ltd.

The sedative effects of diazepam, midazolam, and xylazine after intranasal administration were evaluated in 72 (36 male and 36 female) juvenile healthy ostriches ( Struthio camelus ), weighing 50-61 kg and aged 4-5 months. The birds were randomly divided into 3 groups (n = 24), then each group was further subdivided to 4 subgroups (n = 6). For each drug, 4 different doses were chosen and the total calculated dose was equally administered into either naris of the individual bird. The appropriate dose of each drug to produce standing chemical restraint or sternal recumbency was evaluated based on the onset time, the duration of maximum effect, and the duration of sedation. Midazolam showed significantly shorter onset time (2.9 ± 1.2 minutes) compared with xylazine (4.4 ± 1 minute) and diazepam (4.3 ± 0.4 minutes). Longer duration of sedation was also achieved with midazolam compared with xylazine and diazepam. Moderate sedation was achieved with diazepam (0.8 mg/kg), midazolam (0.4 mg/kg), and xylazine (2 mg/kg) for standing chemical restraint, with the maximum duration effects of 7.0 ± 1.4, 17.7 ± 4.1, and 9.2 ± 2.5 minutes, respectively. Deep sedation was also achieved with midazolam (0.8 mg/kg) and xylazine (4 mg/kg), with sternal recumbency duration of 21.7 ± 4.9 and 13.5 ± 2.6 minutes, respectively. The results of the present study show that intranasal administration can be an effective route for delivery of sedatives in juvenile ostriches. Intranasal midazolam and xylazine could be suggested for standing chemical restraint or inducing sternal recumbency in juvenile ostriches.

Objective In 1987, the Omnibus Reconciliation Act (OBRA) called for a dramatic overhaul of the nursing home (NH) quality assurance system. This study examines trends in facility, resident, and quality characteristics since passage of that legislation. Methods We conducted univariate analyses of national data on US NHs from 3 sources: (1) the 1985 National Nursing Home Survey (NNHS), (2) the 1992-2015 Online Survey Certification and Reporting (OSCAR) Data, and (3) LTCfocUS data for 2000-2015. We examined changes in NH characteristics, resident composition, and quality. Setting and participants US NH facilities and residents between 1985 and 2015. Results The proportion of NHs that are Medicare and Medicaid certified, members of chains, and operating not-for-profit has increased over the past 30 years. There have also been reductions in occupancy and increases in the share of residents who are racial or ethnic minorities, admitted for post-acute care, in need of physical assistance with daily activities, primarily supported by Medicare, and diagnosed with a psychiatric condition such as schizophrenia. With regard to NH quality, direct care staffing levels have increased. The proportion of residents physically restrained has decreased dramatically, coupled with changes in inappropriate antipsychotic (chemical restraint) use. Conclusions and implications Together with changes in the long-term care market, the NHs of today look very different from NHs 30 years ago. The 30th anniversary of OBRA provides a unique opportunity to reflect, consider what we have learned, and think about the future of this and other sectors of long-term care.

Background: Psychotropic medication is widely prescribed to treat mental illness. However, it is controversial when used as a chemical restraint (CR) to manage challenging behaviours (CBs) of adults with intellectual disability (ID). CR has potentially negative consequences and affects human rights. Method: Qualitative research conducted between 2014 and 2015 explored the views of ‘guardian’ decision makers appointed under unique Queensland legislation oversighting the use of CR. Results: Findings included (1) negative conceptualization of CR, (2) concerning relationships with prescribers and disability sector staff, (3) challenges to information seeking about people with ID prescribed CR and (4) problematic implementation of positive behaviour support plans. Conclusion: According to guardians, CR may be used in lieu of community supports, and prescribers sometimes diagnose mental illness to avoid CR legislative requirements. Guardians, prescribers and professionals would benefit from training that addresses the intersection between physical and mental health, CB and CR.

Aims and objectives To investigate the prevalence of physical restraint among mechanically ventilated intensive care unit patients in Jordan and to identify predicting factors and consequences. Background Physical restraint has been widely used among intensive care unit patients in many countries. Despite the benefits it offers in protecting patients from disrupting their medical treatment, it has been reported that restraint has many physical and psychological adverse effects. Method A cross-sectional and observational study was conducted during a period of 3 months (April-June 2017). A sample of 321 intensive care unit patients was selected from five governmental and one university-affiliated hospital in the north and middle of Jordan. The Restraint Prevalence Tool was used to collect data from the patients. Results The study found that the prevalence of physical restraint use on intensive care unit patients in Jordan was 35.8%. This prevalence rate varied across the units, ranging from 33.3%-57.1%. The factors that predicted physical restraint use were younger age (odds ratio = 0.96), large intensive care unit (odds ratio = 6.14), the surgical intensive care unit (odds ratio = 10.36), the night shift (odds ratio = 3.57), a conscious patient (odds ratio = 2.24) and longer hospital stay (odds ratio = 1.07). However, hospital type, gender and being on chemical restraint were not significantly associated with physical restraint. Many patients were observed to have physical complications from restraint use, such as redness, bruising and oedema. Conclusion Physical restraint is a common practice in Jordan. Not following standard restraint practices may lead to many physical complications among intensive care unit patients. Relevance to clinical practice This study recommends implementing more policies/guidelines inside Jordanian hospitals. In addition, nursing education programs on the safe use of physical restraint should be implemented.

BACKGROUND: Chemical restraint is often used to perform diagnostic and minor surgical procedures; α₂‐adrenoceptor agonists are the most commonly used drugs; however, the combination with an opiate can induce a profound sedation. There is a lack of kinematic studies examining the effects of the combination of these drugs on locomotor patterns. OBJECTIVES: The objective of the study was to evaluate the duration of the effects of sedation with detomidine and detomidine combined with a low dose of butorphanol on the movement patterns of horses. STUDY DESIGN: The study was a controlled, randomised, blinded and crossover experiment. METHODS: Each of six horses was injected intravenously with saline (0.9%) solution (10 mL), detomidine diluted in saline solution (0.01 mg/kg bwt) or a combination of detomidine (0.01 mg/kg bwt) and butorphanol (0.02 mg/kg bwt) diluted in saline solution, in a random order. A single accelerometer positioned at the sacrum was used for gait assessment 15 min before (baseline) and 5, 15, 30, 45, 60, 75, 90, 105 and 120 min after each injection. Eight variables were measured, including speed, stride frequency, stride length, regularity, dorsoventral power, propulsive power, mediolateral power and total power; force of acceleration and the three components of power were calculated. The degree of sedation was measured by the ground‐to‐lip distance. RESULTS: There were significant differences among groups, with shorter effects after the injection of the combination of drugs, for most parameters. MAIN LIMITATIONS: A small number of horses were involved in the study. CONCLUSIONS: The combination of detomidine and butorphanol produces a shorter effect on almost all accelerometric parameters, probably due to the excitement produced by the opioid drug causing a quicker return to normal values. Accelerometry offers a method of objectively monitoring gait abnormalities in walking sedated horses.

Novel psychoactive substances (NPS) are being created and introduced at an unprecedented rate, causing frequent, large-scale epidemics. Current identification of NPS in clinical settings in the USA is limited to the retrospective case or small cluster analysis.The purpose of this study was to assess the utility of non-targeted comprehensive drug screening in the agitated patients in an emergency department (ED) setting.This is a prospective, observational case series that was conducted in the ED of an urban Level I Trauma Center with an annual census of approximately 65,000 patients per year. Since it is common clinical practice at this facility for haloperidol to be used as a second-line chemical restraint when initial dose(s) of benzodiazepines are deemed insufficient, we surmised that the subset of ED patients with psychomotor agitation severe enough to receive both these pharmaceuticals would be likely users of NPS. For 1 month, biweekly pharmacy medication audits identified 49 of these patients. There were sufficient, remaining blood samples from 23 of these patients for analysis. Serum from stored blood samples was analyzed using liquid chromatography-time-of-flight mass spectrometry (LC-TOF/MS; LC 1260, TOF/MS 6230, Agilent). Retrospective chart review was done to identify patient clinical information.Six patient samples yielded seven different NPS: JWH-073, JWH-081, JWH-200, methylenedioxybenzylpiperazine, mephedrone, methoxetamine, and herkinorin.This study demonstrates that prospective, non-targeted NPS screening in a selected ED patient population is feasible and effective in identifying NPS.

Purpose The purpose was to describe characteristics and outcomes of restrained and nonrestrained patients enrolled in a randomized trial of protocolized sedation compared with protocolized sedation plus daily sedation interruption and to identify patient and treatment factors associated with physical restraint. Methods This was a post hoc secondary analysis using Cox proportional hazards modeling adjusted for center- and time-varying covariates to evaluate predictors of restraint use. Results A total of 328 (76%) of 430 patients were restrained for a median of 4 days. Restrained patients received higher daily doses of benzodiazepines (105 vs 41 mg midazolam equivalent, P μ g fentanyl equivalents, P P P = .02), and more daily benzodiazepine boluses (0.2 vs 0.1, P P = .02) and atypical antipsychotics (17% vs 4%, P = .003). More restrained patients experienced unintentional device removal (26% vs 3%, P P = .01). In the multivariable analysis, alcohol use was associated with decreased risk of restraint (hazard ratio, 0.22; 95% confidence interval, 0.08-0.58). Conclusions Physical restraint was common in mechanically ventilated adults managed with a sedation protocol. Restrained patients received more opioids and benzodiazepines. Except for alcohol use, patient characteristics and treatment factors did not predict restraint use.

The aim of this study was to assess the cardiopulmonary effects, the onset time after the administration of a detomidine/ketamine combination, and the recovery from anesthesia of cougars (Puma concolor) anesthetized with detomidine/ketamine and isoflurane or sevoflurane for abdominal ultrasound imaging. Fourteen animals were randomly allocated into two experimental groups: GISO (n=7) and GSEVO (n=7). Chemical restraint was performed using 0.15mg/kg detomidine combined with 5mg/kg ketamine intramuscularly; anesthesia induction was achieved using 2mg/kg propofol intravenously and maintenance with isoflurane (GISO) or sevoflurane (GSEVO). The following parameters were assessed: heart rate, respiratory rate, systolic and diastolic arterial blood pressure, mean arterial blood pressure, oxyhemoglobin saturation, rectal temperature, central venous pressure, and end-tidal carbon dioxide. The time to sternal recumbency (TSR) and time to standing position (TSP) were also determined. There was not statistically significant difference for the cardiopulmonary variables or TSP whereas TSR was significantly shorter in GSEVO. The time to onset of anesthesia was 11.1±1.2 minutes and 11.3±1.8 minutes for GISO and GSEVO, respectively. The anesthesia of cougars with detomidine/ketamine and isoflurane or sevoflurane was conducted with safety, cardiopulmonary stability, and increased time to sternal recumbency in the GISO group.

Tendo em vista que o tratamento nos episódios de crise é parte fundamental do cuidado em saúde mental, objetivou-se caracterizar o manejo da crise psiquiátrica em hospitais de urgência e emergência de Natal/RN. Foram realizadas entrevistas semiestruturadas com 33 profissionais dos quatro hospitais públicos locais responsáveis pelo atendimento às situações de crise. Os resultados revelaram inexistência de leitos adequados ao atendimento psiquiátrico, escassez de psicofármacos, falta de clareza quanto aos critérios diagnósticos utilizados, acolhimento via contenção química e internação como estratégia de cuidado prioritária. Evidenciou-se a fragmentação do processo de trabalho com centralidade do médico no manejo da crise, desarticulação entre hospitais e demais serviços da rede de atenção psicossocial e encaminhamento sistemático para o hospital psiquiátrico. Conclui-se que a configuração da rede hospitalar local não apresenta capacidade satisfatória de resposta às situações de crise e que suas debilidades clínico-institucionais refletem o processo de reforma psiquiátrica em curso na região. Dado que el tratamiento de la crisis psiquiátrica es fundamental en la atención en salud mental, el objetivo fue caracterizar su manejo en hospitales de urgencia y emergencia de Natal/RN. Fueron llevadas a cabo entrevistas semiestructuradas con 33 profesionales de cuatro hospitales locales. Los resultados revelaron inexistencia de espacios de internación adecuados, escasez de psicofármacos, falta de claridad en cuanto a los criterios diagnósticos, tratamiento basado en la contención química y la internación como estrategia de cuidado prioritaria. Fueron evidenciadas fragmentación del proceso de trabajo con centralidad del médico en el manejo de la crisis, desarticulación entre hospitales y demás servicios de la red de atención psicosocial y derivación sistemática para el hospital psiquiátrico. El estudio llegó a la conclusión que el funcionamiento de la red hospitalaria local no presenta capacidad satisfactoria de respuesta a la crisis psiquiátrica por sus debilidades clínico-institucionales, que reflejan problemas en el proceso de reforma psiquiátrica. Since psychiatric crisis treatment is crucial in mental health care, this study aimed to characterize the psychiatric crisis in the hospital emergency services of Natal/RN. Semi-structured interviews were conducted with 33 professionals employed in four local public hospitals. The results revealed the absence of adequate beds for psychiatric conditions, scarcity of psychiatric drugs, lack of clarity regarding diagnostic criteria, treatment based on chemical restraint and inpatient care as a priority strategy. Furthermore, there is fragmentation of the work processes with physician centrality in the management of crisis, disarticulation between hospitals and other services of the psychosocial care network and systematic referrals to psychiatric hospital. We conclude that the configuration of the local hospital network does not present satisfactory responsiveness to psychiatric crisis situations and its clinical and institutional weaknesses reflect the process of psychiatric reform in the region.

Objective To establish an accurate anaesthetic dose for chemical restraint of African mole-rats using ketamine and xylazine. Study design Prospective nonrandomized laboratory study. Animals Sixteen adult Ansell’s mole-rats ( Fukomys anselli ) and eight giant mole-rats ( F. mechowii ). Methods Fukomys anselli of different ages, sexes and reproductive status were systematically anaesthetized starting with an intramuscular injection of ketamine (2.5 mg kg −1 ) and increasing the doses in steps of 0.5 mg kg −1 until loss of the righting reflex (LRR) was observed. Xylazine was added to a constant dose of ketamine, starting at 0.5 mg kg −1 that was increased by 0.5 mg kg −1 in further trials. Once an effective combination was established and evaluated in F. anselli , it was also tested in F. mechowii . Heart and respiratory rates and rectal temperatures were measured during anaesthesia. anova for repeated measures and Student’s t-test were used to compare means. Results Chemical restraint was accomplished at a dose of 6 mg kg −1 ketamine combined with 2.5 mg kg −1 xylazine. LRR lasted on average mean 56 ± SD 19 minutes ( F. anselli ) and 140 ± 41 minutes ( F. mechowii ). Loss of pedal withdrawal reflex (LPR) lasted for 20 ± 15 minutes ( F. anselli ) and for 29 ± 2 minutes ( F. mechowii ), respectively. All animals recovered satisfactorily. Heart and respiratory rates were stable during anaesthesia, but rectal temperature fell significantly in F. mechowii after losing the righting reflex (LRR) from T1 (32.6 ± 0.6 °C) to T3 (30.4 ± 0.9 °C). Conclusions and Clinical relevance African mole-rats (Bathyergidae) live in closed burrow systems under particular conditions (hypercapnia, hypoxia, stable temperature, humidity, darkness) and show several physiological adaptations. Injectable anaesthetics in the dose rates used in other rodents are not appropriate for use in these subterranean species. Here, a reliable protocol for chemical restraint is provided.

Following the Food Drug Administration (FDA) approval of atypical antipsychotics in the late 1990s, the use of antipsychotic medications among nursing home residents increased rapidly over the next 15 years. Many of these residents were receiving antipsychotics to manage behavioral and psychiatric symptoms associated with dementia (Briesacher et al. 2005; Office of Inspector General [OIG] 2011). This led to widespread off-label use of antipsychotics, often viewed as a form of “chemical restraint” (Hughes, Lapane, and Mor 1999). In the mid-2000s, it became evident that these medications could result in significant negative health outcomes in persons with dementia.1 Subsequently, the FDA issued public health advisories cautioning that atypical antipsychotics (2005), and later all antipsychotics (2008), are associated with increased risk of mortality in persons with dementia. Even with the public health advisories of the FDA, the quantity of antipsychotic medication use is still a concern as the national rates of antipsychotic use remain high (Kales et al. 2011). In March of 2012, the Centers for Medicare and Medicaid Services (CMS) launched a national initiative, the Partnership to Improve Dementia Care in Nursing Homes, in an attempt to reduce the unnecessary use of antipsychotic medications, especially for nursing home residents with dementia (CMS 2012, 2013). As part of this initiative, CMS distributed for public comment revised surveyor guidance related to antipsychotics, launched a website (https://www.nhqualitycampaign.org/), and began public reporting new quality measures on antipsychotic medication use on the Nursing Home Compare (NHC) website. The purpose of this initiative, including the public reporting of antipsychotic quality, was to improve behavioral health care practices and reduce inappropriate use of antipsychotics. The focus of this paper is the public reporting of antipsychotic use on the NHC website. Since 2002, NHC has publically reported various measures of nursing home quality, with the intent of allowing consumers to compare the quality of nursing home care in their local area. By logging onto the NHC website, consumers and administrators are able to search nursing homes within a geographic area and compare their quality performance. Quality is currently reported using a 5-star system, but data on specific quality measures are also available, such as number of deficiencies, staffing levels, financial penalties, and a set of resident care quality measures. NHC did not initially include antipsychotic use as a measure of quality. Starting in July of 2012, CMS began publically reporting an antipsychotic quality measure on NHC that attempts to approximate “inappropriate” use.2 This measure is also included in the calculations of the 5-star quality scores of facilities. The public reporting of an antipsychotic quality measure should reduce the use of antipsychotics in nursing homes subject to public reporting. But one of the unintended effects is that nursing homes may substitute other medications that have similar sedating properties for antipsychotics. This paper studies this issue by examining the changes in the use of antipsychotics and other psychoactive medications just prior to and after the period in which NHC began publicly reporting the long-stay antipsychotic quality measure.

Introduction Agitated patients who present a danger to themselves or emergency medical services (EMS) providers may require chemical restraints. Haloperidol is employed for chemical restraint in many EMS services. Recently, ketamine has been introduced as an alternate option for prehospital sedation. On-scene time is a unique metric in prehospital medicine which has been linked to outcomes in multiple patient populations. When used for chemical restraint, the impact of ketamine relative to haloperidol on on-scene time is unknown. Objective To evaluate whether the use of ketamine for chemical restraint was associated with a clinically significant (≥5 minute) increased on-scene time compared to a haloperidol based regimen. Methods Patients who received haloperidol or ketamine for chemical restraint were identified by retrospective chart review. On-scene time was compared between groups using an unadjusted Student t-test powered to 80% to detect a ≥5 minute difference in on-scene time. Results 110 cases were abstracted (Haloperidol = 55; Ketamine = 55). Of the patients receiving haloperidol, 11/55 (20%) were co-administered a benzodiazepine, 4/55 (7%) received diphenhydramine and 34/55 (62%) received the three drugs in combination. There were no demographic differences between the haloperidol and ketamine groups. On-scene time was not statistically different for patients receiving a haloperidol based regimen compared to ketamine (18.2 minutes, [95% CI 15.7-20.8] vs. 17.6 minutes, [95% CI 15.1-20.0]; p = 0.71). Conclusions The use of prehospital ketamine for chemical restraint was not associated with a clinically significant (≥5 minute) increased on-scene time compared to a haloperidol based regimen.

Objective This study’s primary objective was to investigate the prevalence of physical and chemical restraint use in selected elderly hospitalized patients. Results This study was conducted in April 2014 in four major acute care hospitals. Trained data collectors assessed the use of physical and chemical restraint among all admitted elderly patients. There were 287 elderly patients (median age 64 years, 46% women). 32 patients were restrained. The overall prevalence of restraints was 11.1%, with physical restraint use alone at 3.2% and chemical restraints use alone at 7.3%. Restraint use varied by hospital type, with the highest at the private hospital (22.9%) and the lowest at the two university hospitals (

Caring for patients with dementia emerging from general anaesthesia in the recovery room can be very challenging. Sedation is sometimes necessary in order to nurse patients effectively and avoid any negative consequences of poor post-anaesthetic care. No local or national guidelines could be found to suggest best nursing practice in this situation. Three small-scale innovations were introduced into the recovery room in one hospital as part of a quality improvement project to give alternatives to chemical restraint. These were: music and distraction therapy, maximising the use of the ‘About Me’ document and improved access to staff training. The simple innovations were well received by recovery room staff. Further research is needed to quantify the benefits of these innovations and further work is needed to develop use of the carer's passport in recovery.

Safe and effective sedation protocols are important for chemical restraint of birds in clinical and diagnostic procedures, such as clinical evaluations, radiographic positioning, and blood collection. These protocols may reduce stress and ease the management of wild-caught birds, which are susceptible to injury or death when exposed to stressful situations. We compare the sedative effect of intranasal midazolam in wild-caught blue-fronted (Amazona aestiva) and orange-winged (Amazona amazonica) Amazon parrots. Ten adult parrots of each species (n = 20), of unknown sex, weighing 0.337 ± 0.04 (blue-fronted) and 0.390 ± 0.03 kg (orange-winged), kg were used. Midazolam (2 mg/kg) was administered intranasally and the total volume of the drug was divided equally between the 2 nostrils. Onset time and total sedation time were assessed. Satisfactory sedation for clinical evaluation was induced in all birds. Onset time and total sedation times were similar in both species: 5.36 ± 1.16 and 25.40 ± 5.72 minutes, respectively, for blue-fronted Amazons and 5.09 ± 0.89 and 27.10 ± 3.73 minutes, respectively, for orange-winged Amazons. A total of 15 animals showed absence of vocalization, with moderate muscle relaxation and wing movement upon handling, and 2 animals presented with lateral recumbence, with intense muscle relaxation and no wing movement, requiring no restraint. Three blue-fronted Amazons had no effective sedation. Intranasally administered midazolam at a dose of 2 mg/kg effectively promoted sedative effects with a short latency time and fast recovery in wild-caught parrots.

Ocular diseases reported in frogs include uveitis and glaucoma, which are associated with changes in intraocular pressure (IOP). The objectives of this study were to characterize the normal IOP for White's tree frogs ( Litoria caerulea ) using two types of rebound tonometers, and to assess whether time of day or method of restraint affected IOP. Eighteen conscious, unrestrained, ophthalmologically normal frogs were used to measure IOP using TonoVet® and TonoLab® tonometers, at three time points during the day. In a subset of 12 frogs, IOP was measured while under manual restraint using the TonoVet. Anesthesia was induced in 9 frogs using two different concentrations of MS-222 (0.5 g/L and 2 g/L) in order to evaluate for changes in IOP with the TonoVet. Mean (± SD) IOP values for the TonoLab (16.8 ± 3.9 mm Hg) were significantly higher than TonoVet values (14.7 ± 1.6 mm Hg; P0.01). TonoVet IOP values did not significantly change with time of day. TonoLab values were significantly lower in the evening (1600-1800; 14.5 ± 3.1 mm Hg), compared with morning and midday measurements (0800-1000 and 1200-1400; 18.0 ± 3.8 mm Hg; P0.01). Manually restrained frogs had significantly lower IOP (13.4 ± 1.5 mm Hg) compared with unrestrained frogs (15.3 ± 1.2 mm Hg; P0.01). Chemical restraint did not cause significant changes in IOP. Intraocular pressure can be measured with both types of rebound tonometers in White's tree frogs, but time of day and manual restraint can affect IOP values.

RESUMO: Um exemplar de rato-do-bambu (Dactylomys dactylinus) subadulto saudável do sexo feminino, de vida livre, com massa corporal de 0,32 kg, recebeu por via intramuscular, em uma única injeção, doses de tiletamina, zolazepam, xilazina e atropina calculadas por meio de extrapolação alométrica interespecífica, a partir das recomendações usuais para o cão doméstico de 10,0 kg (tiletamina/zolazepam - 5,0mg/kg, xilazina - 1,0mg/kg) e atropina - 0,05mg/kg). O rato perdeu a reação postural de endireitamento em 2,3 minutos pós-injeção (MPI) e recuperou a capacidade de deambular normalmente em 135 MPI. A frequência cardíaca variou de 360 a 188 bpm (226±62), a frequência respiratória de 128 a 112mpm (120±5), e a temperatura retal de 36,2 a 33,5°C (34,4±1,0). A analgesia e o miorrelaxamento foram considerados bons para a realização de procedimentos indolores ou pouco dolorosos de curta duração, como exame físico, colheita de material biológico, biometria, exames de imagem e marcação. A associação de fármacos permitiu a manipulação segura do animal por 63 MPI. A recuperação foi considerada satisfatória, porém prolongada. Destaca-se que este é primeiro registro de ocorrência da espécie na Região Sul do Brasil, e o primeiro relato de contenção farmacológica desse roedor neotropical. ABSTRACT: One subadult healthy free-living female Amazon Bamboo Rat (Dactylomys dactylinus), weighting 0.32 kg, received tiletamine HCl, zolazepam HCl, xilazine HCl and atropine sulfate, combined in a single intramuscular injection. All doses were calculated by interspecific allometric scaling, using as model a 10.0 kg domestic dog (tiletamine/zolazepam -5.0mg/kg), xylazine -1.0mg/kg), and atropine - 0.05mg/kg). Immobilization occurred in 2.3 minutes after injection (MAI) and returno to normal ambulation was observed in 135 MAI. Heart rate remained between 360 and 188 beats/minute (226±62), respiratory rate between 128 and 112 breaths/minute (120±5), and body temperature ranged from 36.2 to 33.5°C (34.4±1.0). Analgesia and myorelaxation were considered good for painless or mild painful fast procedures as physical examination, biological sampling, biometrics, imaging tests and tagging. The proposed anesthetic protocol was safe and effective, allowing safe manipulation of the animal during 63 MAI. The recovery was satisfactory, but prolonged. This is the first record of the species in Southern Brazil and the first report on its chemical restraint.

Recently, ketamine has seen increased use among emergency medical services in the prehospital setting as a first-line means of chemical restraint for agitated patients. In this case report, we explore an instance in which ketamine administration for nonpsychotic agitation before emergency department (ED) evaluation may have caused unexpected psychotic symptoms leading to a complicated ED course necessitating admission. As ketamine gains widespread use in the prehospital setting, the safety profile deserves reevaluation. In the following report, we review relevant literature and discuss important factors to consider regarding the use of prehospital ketamine, including psychiatric and substance abuse history.

Purpose The present study investigated the association between nurse staffing and health outcomes among psychiatric inpatients in Korea by assessing National Health Insurance claims data. Methods The dataset included 70,136 patients aged 19 years who were inpatients in psychiatric wards for at least two days in 2016 and treated for mental and behavioral disorders due to use of alcohol; schizophrenia, schizotypal and delusional disorders; and mood disorders across 453 hospitals. Nurse staffing levels were measured in three ways: registered nurse-to-inpatient ratio, registered nurse-to-adjusted inpatient ratio, and nursing staff-to-adjusted inpatient ratio. Patient outcomes included length of stay, readmission within 30 days, psychiatric emergency treatment, use of injected psycholeptics for chemical restraint, and hypnotics use. Relationships between nurse staffing levels and patient outcomes were analyzed considering both patient and system characteristics using multilevel modeling. Results Multilevel analyses revealed that more inpatients per registered nurse, adjusted inpatients per registered nurse, and adjusted inpatients per nursing staff were associated with longer lengths of stay as well as a higher risk of readmission. More adjusted inpatients per registered nurse and adjusted inpatients per nursing staff were also associated with increased hypnotics use but a lower risk of psychiatric emergency treatment. Nurse staffing levels were not significantly associated with the use of injected psycholeptics for chemical restraint. Conclusion Lower nurse staffing levels are associated with negative health outcomes of psychiatric inpatients. Policies for improving nurse staffing toward an optimal level should be enacted to facilitate better outcomes for psychiatric inpatients in Korea.

Delirium can be associated with behavioural manifestations such as agitation, inappropriate be haviours, delusions, and hallucinations, which can be distressing to patients and to their families. Moreover, these symptoms can make patients diffi cult to provide care for and are a source of burden and stress for both health-care workers and informal carers. Largely to address these behavioural symptoms, the fi eld of delirium prevention and treatment has come to focus on clinical trials of antipsychotic drugs. 2,3 A search of the PubMed database shows that the annual number of studies of antipsychotic drugs for prevention or treatment of delirium has grown substantially in the past 20 years, from two studies published in 1990 to more than 40 in 2013. This necessitates an urgent call for caution in the use of antipsychotic drugs for the management of patients with delirium. The use of antipsychotics might be regarded as counterintuitive because these drugs can all cause confusion or delirium as side-eff ects. However, powerful incentives in our health-care systems promote prescription of antipsychotics for patients with delirium, and have led to the frequent use of these drugs. Antipsychotics may have appeal as a potential quick fi x compared with non-pharmacological approaches, but clinicians might not fully realise that their attempt to make patients more manageable and less distressed can result in worsened clinical outcomes. In essence, these drugs can be regarded to be a form of chemical restraint, and concern exists that the use of drugs such as haloperidol and atypical antipsychotics for treatment of delirium might often be serving the interests of the providers rather than the patients. The marketing and promotion by the pharmaceutical industry of off -label use of antipsychotics for treatment of agitation in cognitively impaired patients 4

Evaluation of dental abnormalities were carried out on a group of 74 polo horses with history of colic (colicky group) and another group of 70 randomly selected polo horses with no history of colic (non-colicky group) under similar environmental and management condition at Lagos Polo Club, Lagos, Nigeria in order to investigate probable correlation between dental abnormalities, routine dental care and predisposition to colic. Visual examination of the horses’ oral/dental status was carried out after adequate physical and chemical restraint with intravenous administration of 2% xylazine hydrochloride at dose rate of 1.1 mg/kg body weight. Structured interview of handlers and review of dental health records where available were carried out to investigate routine dental care. One-way analysis of variance (ANOVA), Pearson correlation and linear multiple regression analysis were used to find out associations between dental abnormalities, routine dental care and colic. Thirty-eight (38) horses (51.4%) among the colicky group had dental abnormalities ranging from overjet (4.8%) to dental attrition (26.2%), while twenty-two (22) horses (29.7%) among the non-colicky group had dental abnormalities. Dental caries and sharp enamel point had significant difference (p < 0.05) on colic in horses and were positively correlated with colic. There were also positive significant correlation between fractured tooth and overjet (r = 0.908) and malposition and overjet (r = 0.944), respectively. Age and sex had no significant correlation with dental abnormalities and predisposition to colic, while local breeds were found to be more predisposed to colic due to dental abnormalities (p < 0.05). There was also a significant difference (p < 0.05) in horses that had no routine dental care and colic. In conclusion, this study indicates that dental caries and sharp enamel points are predisposing factors for colic in horses. Although not all forms of dental abnormalities predispose horses to colic, routine dental examination and care would be beneficial for early diagnosis and prevention of dental abnormalities that may predispose to colic. Key words: Colic, horses, dental abnormalities, predisposed to colic.

The need to manage otariid populations has necessitated the development of a wide range of capture methods. Chemical restraint by remote drug delivery (i.e., darting) is a highly selective method that can be used to facilitate otariid capture in a range of scenarios, when other methods may be impracticable. However, the risks associated with darting otariids are not widely known and guidelines necessary to promote and refine best practice do not exist. We review the risks associated with darting and in light of our findings, develop darting guidelines to help practitioners assess and minimize risks during capture, anesthesia and recovery. Published studies reveal that mortalities associated with darting predominantly result from complications during anesthetic maintenance (e.g., prolonged respiratory depression, apnea, or hyperthermia), rather than from complications during capture or recovery. In addition to monitoring vital signs and proper intervention, the risk of irreversible complications during anesthesia can be reduced by administering drug doses that are sufficient to enable the capture and masking of animals, after which anesthetic depth can be regulated using gas anesthesia.

Introduction: The incidence of respiratory depression in patients who are chemically sedated in the emergency department (ED) is not well understood. As the drugs used for chemical restraint are respiratory depressants, improving respiratory monitoring practice in the ED may be warranted. The objective of this study is to describe the incidence of respiratory depression in patients chemically sedated for violent behavior and psychomotor agitation in the ED. Methods: Adult patients who met eligibility criteria with psychomotor agitation and violent behavior who were chemically sedated were eligible. SpO2 and ETCO2 (end-tidal CO2) was recorded and saved every 5 seconds. Demographic data, history of drug or alcohol abuse, medical and psychiatric history, HR and BP every 5 minutes, any physician intervention for hypoxia or respiratory depression, or adverse events were also recorded. We defined respiratory depression as an ETCO2 of >50 mmHg, a change of 10% above or below baseline, or a loss of waveform for >15 seconds. Hypoxia was defined as a SpO2 of 15 seconds. Results: We enrolled 59 patients, and excluded 9 because of >35% data loss. Twenty-eight (28/50) patients developed respiratory depression at least once during their chemical restraint (56%, 95% CI 42-69%); the median number of events was 2 (range 1-6). Twenty-one (21/50) patients had at least one hypoxic event during their chemical restraint (42%, 95% CI 29-55%); the median number of events was 2 (range 1-5). Nineteen (19/21) (90%, 95% CI 71-97%) of the patients that developed hypoxia had a corresponding ETCO2 change. Fifteen (15/19) (79%, 95% CI 56-91%) patients who became hypoxic met criteria for respiratory depression before the onset of hypoxia. The sensitivity of ETCO2 to predict the onset of a hypoxic event was 90.48% (95% CI: 68-98%) and specificity 69% (95% CI: 49-84%). Five patients received respiratory interventions from the healthcare team to improve respiration [Airway repositioning: (2), Verbal stimulation: (3)]. Thirty-seven patients had a history of concurrent drug or alcohol abuse and 24 had a concurrent psychiatric history. None of these patients had a major adverse event. Conclusion: About half of the patients in this study exhibited respiratory depression. Many of these patients went on to have a hypoxic event, and most of the incidences of hypoxia were preceded by respiratory depression. Few of these events were recognized by their treating physicians. [West J Emerg Med. 2014;15(4):430-437.]

Os répteis possuem um sistema porta-renal, o qual pode desviar parte do sangue proveniente das porções caudais do corpo aos rins antes que a mesma atinja a circulação sistêmica. Em vista disto, vem sendo aconselhada a administração de medicamentos injetáveis nos membros torácicos, para que se evite a filtração imediata pelo parênquima renal, causando redução do efeito esperado. O objetivo do presente estudo foi comparar aspectos qualitativos e quantitativos da associação de cetamina (30 mg/kg) e xilazina (1 mg/kg), injetada no membro torácico ou pélvico, em jacarés-do-papo-amarelo (Caiman latirostris) juvenis. Oito animais machos com peso médio (±DP) de 1,3 (±0,3) kg e, aproximadamente, dois anos de idade foram anestesiados em duas ocasiões distintas com intervalo de sete dias. Em cada ocasião, os animais receberam, de forma aleatória, a associação anestésica por via intramuscular em membro torácico (tratamento MT) ou pélvico (tratamento MP). Foram avaliados os intervalos de tempo entre a administração do tratamento e a perda do reflexo de endireitamento (período de indução), entre a perda e o retorno desse reflexo (duração do efeito clínico importante) e entre o retorno do reflexo de endireitamento e os primeiros movimentos de deambulação (duração do efeito residual), as frequências cardíaca e respiratória e as temperaturas ambiental e cloacal. Os escores de sedação/anestesia foram avaliados através de uma escala com variação de 0 (alerta/consciente) a 10 (anestesia profunda/sobredosagem). No tratamento MP, dois animais não apresentaram perda de reflexo de endireitamento. Considerando somente aqueles que apresentaram a perda desse reflexo, o tempo de indução (21±9 e 17±5 minutos) e a duração do efeito clínico importante (35±19 e 43±21 minutos) e residual (28±31 e 12±11 minutos) foram similares entre os tratamentos MT e MP (média±desvio padrão). O escore de sedação foi significativamente maior que o basal de 20 a 50 minutos nos dois tratamentos e, aos 30 minutos (pico de efeito), o escore mediano (interquartil) foi 3,5(2,3-4,0) no tratamento MT e 3,0(2,0-4,0) no tratamento MP. Assim como nos escores de sedação, diferenças entre tratamentos nas variáveis fisiológicas não foram observadas. Em ambos os tratamentos, o reflexo de retirada de membro ao pinçamento digital não foi abolido. A administração da associação de xilazina e cetamina em membro pélvico ou torácico de jacarés-do-papo-amarelo juvenis promove efeitos similares, sugerindo que a influência do sistema porta-renal não é clinicamente relevante. Nas doses empregadas, tal protocolo não promove anestesia cirúrgica e a imobilidade/contenção farmacológica é imprevisível e de curta duração. Reptiles possess a renal portal system which can divert part of the blood from the caudal portions of the body to the kidney before it reaches the systemic circulation. In view of this, it has been recommended the administration of injectable medications in the forelimbs, in order to avoid immediate glomerular filtration, which might result in a reduction of the expected effect. The aim of this study was to compare qualitative and quantitative aspects of the pharmacological restraint provided by the combination of ketamine (30mg/kg) and xylazine (1mg/kg), injected into the forelimb or hindlimb, in broad-snouted caiman juveniles (Caiman latirostris). Eight male animals, with a mean weight (±SD) of 1.3 (±0.3) kg, and aged about 2 years old, were anesthetized on two separate occasions with an interval of 7 days. On each occasion, the animals were randomly assigned to receive the anesthetic combination intramuscularly into the forelimb (FL treatment) or hindlimb (HL treatment). The time intervals between administration of treatment and loss of the righting reflex (induction time), between the loss and return of this reflex (duration of important clinical effect), and between the return of the righting reflex and first movements of ambulation (duration of residual effect) were measured as well as heart and respiratory rates and cloacal and environmental temperatures. Sedation/anesthesia scores were evaluated using a scale ranging from 0 (alert/conscious) to 10 (deep anesthesia/overdose). In the HL treatment, loss of righting reflex was not observed in two animals. Considering only those animals whose loss of righting reflex was observed, the induction time (21±9 and 17±5 minutes), the duration of important clinical effect (35±19 and 43±21 minutes), and the duration of residual effect (28±31 and 12±11 minutes) were similar between the FL and HL treatments, respectively (mean±SD). Sedation/anesthesia scores were significantly higher than at baseline from 20 to 50 minutes in both treatments and, at 30 minutes (peak sedative effect), the median score (interquartile range) was 3.5(2.3-4.0) in the FL treatment and 3.0(2.0-4.0) in the HL treatment. Differences between treatments in physiological variables were not observed. In both treatments, withdrawal reflex in response to digital clamping was not absent at any timepoint. The administration of xylazine-ketamine combination in the forelimb or hindlimb of broad-snouted caiman juveniles provides similar effects, suggesting that the influence of the renal portal system is not clinically relevant. At the doses used, such combination does not induce surgical anesthesia and the immobility/pharmacological restraint is unpredictable and of short duration.

O potencial evocado auditivo de tronco encefálico (Brainstem Auditory Evoked Potential - BAEP) avalia a atividade elétrica do sistema auditivo, desde a cóclea até o tronco encefálico, permitindo diagnóstico de surdez em cães. Como alguns animais não permitem a obtenção do BAEP sem contenção química, o objetivo deste trabalho foi analisar a influência da sedação com morfina e acepromazinano BAEP de 16 cães com audição normal. Os potenciais foram obtidos antes e durante a sedação com administração intramuscular de morfina (0,5mgkg-1) e acepromazina (0,05mgkg-1). O protocolo de sedação utilizado permitiu contenção efetiva e segurança dos animais. A sedação causou prolongamento nas latências das ondas II, III e intervalos I-III e I-V, mas não dificultou as suas identificações. O uso deste protocolo de sedação não interferiu com a interpretação do potencial evocado e pode ser útil em cães. Pelo que se pode observar na literatura compilada, este é o primeiro estudo avaliando a influência da sedação no BAEP em cães no Brasil. Brainstem auditory evoked potential (BAEP) reflects the electrical activity along the auditory pathway, from the cochlea to the brainstem, and contributes for the diagnosis of deafness in dogs. BAEP recording may require chemical restraint in some cases, so this study was designed to analyze the impact of sedation with morphine and acepromazine on the BAEP recordings of 16 dogs with normal hearing. BAEPs were recorded before and during sedation with a combination of morphine (0.5mgkg-1) and acepromazine (0.05mgkg-1) given intramuscularly. The protocol employed allowed safe and effective animal restraint. Sedation increased the latency of waves II and III and intervals I-III and I-V but did not interfere with wave identification. and showed to be safe in the dogs tested. Based on the current literature this is the first study which assessed the impact of sedation on BAEPs in dogs in Brazil.

Low-stress handling is important for the safety of the veterinary staff and for the welfare of the patient. The commitment to ensuring the emotional well-being of the patient should be equal to that shown toward the physical well-being of the animals under a veterinarian’s care. Before handling animals it is essential to assess the environment and the patient’s response to it. Taking the time to create a behavior handling plan makes future visits easier and bonds clients to the practice. Understanding how and when to use handling tools is key to making patient visits safer, more humane, and more efficient.

The European hedgehogs may require the use of chemical restraint for clinical examination because of their tendency to roll up as a defensive behaviour. This study evaluated the effects of alfaxalone combined with dexmedetomidine for restraint of hedgehogs undergoing pre-release health checks and atipamezole for recovery.Twenty hedgehogs received alfaxalone 2 mg/kg and dexmedetomidine 0.05 mg/kg intramuscularly in the quadriceps. If the righting reflex was still present, both drugs were administered at half of the initial doses. A semiquantitative scale scored sedation; clinical variables evaluated included pulse rate, respiratory rate, arterial haemoglobin oxygen saturation, end-tidal CO2 and body temperature.The righting reflex disappeared between 141 and 880 seconds. Overweight animals required one additional injection to achieve adequate relaxation. Pulse rate decreased during the procedure and increased after atipamezole administration. Respiratory rate and end-tidal CO2 did not change statistically throughout the procedure but one hedgehog showed haemoglobin oxygen saturation lower than 90%. Recovery after atipamezole was smooth and complete. Body temperature decreased over time.The sedation protocol may represent an effective combination to restrain European hedgehogs and atipamezole provides a rapid antagonism. Additional sedatives administration may be required in overweight animals and an external source of oxygen should be available.

Zoo and wildlife practitioners are constantly exposed to persistent dangers during physical restraint of wild animals. Chemical immobilization in reptiles is unpredictable due to their ectothermic nature. This study aims to determine a safe and effective anesthetic protocol for immobilization in chelonians and other reptiles. Varied doses of diazepam ketamine combinations were administered and evaluated in 16 healthy land tortoises ( Testudo graeca ). The tortoises were divided into four groups (4 per group) labeled DK-1 through DK-4. DK-1 had a combination of 44mg/kg of ketamine with 0.25mg/kg of diazepam. DK-2 had 22mg/kg of ketamine with 0.25mg/kg of diazepam. DK-3 had 44mg/kg of ketamine with 0.5mg/kg diazepam while DK-4 had 22mg/kg of ketamine with 0.5mg/kg of diazepam. Anesthetic effects were monitored to determine the duration required for partial extension of the head and limbs, full extension of limbs, and complete recovery from anesthesia. These visual inspection of partial recovery and full extension were adapted as surface and deep anaesthesia respectively in describing the depth of anaesthesia. All the time intervals were recorded in minutes, and summarized as mean and standard deviation. ANOVA was used to test for significance across the groups. Full extension of head and limbs was achieved within mean periods of 10, 15.5 and 13 minutes in DK-1, DK-3 and DK-4 respectively. Tortoises in DK-2, which were only sedated, demonstrated only surface depth of anaesthesia. Complete recovery occurred in mean periods of 128, 25, 158 (p < 0.05) and 132 minutes for groups DK-1, DK-2, DK-3, and DK-4 respectively. Diazepam-Ketamine anaesthetic cocktail provides a safe protocol for chemical restraint in tortoises. A higher dose of diazepam produced a longer duration of complete recovery. Keywords : Anaesthesia, Diazepam, Immobilization, Ketamine, Testudo graeca

This communication briefly describes the use of tricaine methanesulfonate (MS222) to induce chemical restraint/general anesthesia of a Mexican axolotl (Ambystoma mexicanum) for the endoscopic retrieval of a gastric foreign body. There is very little published scientific literature concerning the anesthesia of Mexican axolotls. The anesthesia used in this case was an immersion bath of tricaine methanesulfonate where the concentration of tricaine methanesulfonate was gradually increased to 500 mg/L (ppm) over a 15-min period. A loss of righting reflex was observed within 3 min of attaining the final concentration of the anesthetic bath. The first voluntary movements following the transfer to a freshwater bath occurred within 7 min. The recovery was uneventful. Tricaine methanesulfonate in this case proved to be an effective anesthetic agent for a short, minimally invasive procedure.

Very little is known about the use of restrictive interventions on children and young people with disabilities and challenging behaviours who receive respite. This study examines the use of restrictive interventions in an Australian jurisdiction where there is mandatory reporting of these practices in government-funded services. The characteristics of those subject to restrictive interventions and the types of restraint and seclusion used in respite are compared with those in people who do not receive respite. Approximately 28% (n = 578) of the total number of people with disabilities subjected to restrictive interventions were from respite services. They were generally male, younger (average age 21 years old) and reported to have a diagnosis of autism. The majority were subject to chemical restraint. The use of restrictive interventions in respite services requires further investigation and monitoring. There are policy and practice implications for respite service delivery.

Using a prospective, randomized study design we demonstrate that midazolam sedation minimizes acidosis compared with physical restraint in captive juvenile estuarine crocodiles during handling or noninvasive procedures at preferred body temperature. A dose of midazolam (5.0 mg/kg) was administered intramuscularly into the forelimb of 20 male estuarine crocodiles weighing 2-3.5 kg. Their heart and respiratory rate and degree of sedation were monitored until recovery and then daily for 7 subsequent days. Blood samples were taken at 30, 60, 90, 180, and 360 min. We recorded lactate, partial pressure of carbon dioxide (CO2), hematocrit, glucose, and blood pH. A second group (1.9-2.6 kg) was physically restrained for 5 min and the same parameters recorded. Physically restrained animals demonstrated elevated heart rate, respiratory rate, glucose, lactate, and anion gap compared with the midazolam-treated group. Physically restrained animals had lower pH, bicarbonate, and partial pressure of CO2 compared with the midazolam-treated group. Behavior in the physically restrained group in the days following the study was disrupted, with reluctance to feed and bask, compared with midazolam-treated animals whose behavior was normal. We conclude that midazolam administered in the forelimb of captive estuarine crocodiles of 2-3.5 kg provides predictable onset and duration of sedation enabling physical examination, sample collection, and translocation of the animals with minimal disturbance to lactate, pH, and CO2. Behavior following recovery appears normal.

Appropriate stabilization of the critically ill animal before sedation or anesthesia is imperative to minimize anesthetic complications. Problems should be anticipated and an appropriate and efficient therapeutic plan should be formulated before anesthetic induction. Use of a balanced anesthesia technique should be considered to minimize potential deleterious effects of single-use drug therapy. Using a combination of different classes of analgesics may be more effective in treating established pain than using a single agent. The critically ill animal should have drugs titrated to effect to minimize the amount of drug needed and lessen potential side effects.