Sedation for Acute Agitation in Emergency Department Patients: Targeting Adverse Events (SIESTA)

The aim is to determine the nature and incidence of adverse events associated with parenteral sedation medication administered to acutely agitated patients in the ED, and to determine the risk factors for these adverse events.

Grant ID: EMTR-101R23-2015

Project Summary

Acutely agitated patients are commonly seen in the emergency department (ED). As these patients may cause harm to themselves or others, a large proportion need to be managed with injectable sedative medications such as benzodiazepines (eg midazlolam) and/ or antipsychotics (e.g droperidol).

Unfortunately, these medications may precipitate life threatening events (e.g hypoventilation). Safety data related to the use of these medications for the management of acute agitation in the ED setting are scant. Acute agitation in the ED setting is usually caused by mental health issues or substance abuse, again little is known about which sedative medications are best suited for different groups of acutely agitated patients.

The aim of this study is to determine the nature and incidence of adverse events associated with parenteral sedation medication administered to acutely agitated patients in the ED and to determine the risk factors for these adverse events. It is a multicentre national observational study, aiming to recruit 2000 patients over the age of 18, over a 2 year period. It is hoped that the evidence this study generates will define the risk of AE in this population and may guide clinicians in future treatment choices in sedating this challenging group of patients, hopefully reducing future AE.

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Outcomes

Overall the research team found that current practices, including Queensland clinical guidelines, used for sedating patients experience acute behavioural disturbances are safe.

The research team undertook a prospective observational study and a clinical trial of parenteral sedation for the management of acute agitation. They included 904 agitated adult patients who required parenteral sedation from 2014 to 2017 in twelve Australian EDs, They found sedation‐related adverse emergencies was 13.5%. Elderly patients, sedation with multiple sedatives within 60 minutes, and alcohol intoxication increased the risk.

In a second study, the team looked at how patients were being sedated. Approximately half the patients required mechanical restraint and parenteral sedation to manage their behaviour. Intramuscular monotherapy was administered in most cases. The main sedative medications used as monotherapy were droperidol, midazolam and olanzapine. The most common combination therapy was midazolam + droperidol.

No deaths or irreversible adverse events were reported.

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Leveraged Funds

- In-kind: $86,588

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Dissemination

Yap, C.Y., Taylor, D.M., Kong, D.C., Knott, J.C., Taylor, S.E., Graudins, A., Keijzers, G., Kulawickrama, S., Thom, O., Lawton, L. and Furyk, J., 2019. Management of behavioural emergencies: a prospective observational study in Australian emergency departments. Journal of Pharmacy Practice and Research, 49(4), pp.341-348.

Yap, C.Y., Taylor, D.M., Kong, D.C., Knott, J.C., Taylor, S.E. and Sedation for Acute Agitation in Emergency Department Patients: Targeting Adverse Events (SIESTA) Collaborative Study Group, 2019. Risk Factors for Sedation‐related Events During Acute Agitation Management in the Emergency Department. Academic Emergency Medicine, 26(10), pp.1135-1143.

Conference
- Yap C.Y.L., Taylor DM, Kong DCM, Knott JC, Taylor SE, Graudins A, Keijzers G, Kulawickrama S, Thom O, Lawton L, Furyk J, Finucci D, Watkins G, Jordan P, Phillips G, Karro J., "Sedation for Acute Agitation in Emergency Department Patients: Targeting Adverse Events (SIESTA)", 34th Annual Scientific Meeting of the Australasian College for Emergency Medicine, 19-23 November 2017, Sydney (Oral presentation).

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