The expert consensus guideline series. Treatment of behavioral emergencies 2005.
The expert consensus guideline series. Treatment of behavioral emergencies 2005.
复制标题
DOI：
10.1097/00131746-200511001-00002
复制
发表时间：
2005-11-01
影响因子：
1.9
通讯作者：
Docherty, John P
中科院分区：
文献类型：
--
作者：
Allen, Michael H;Currier, Glenn W;Docherty, John P
目标：由于紧急情况下研究的固有危险和障碍，很少有数据可以指导临床医生如何最好地管理行为紧急情况。诸如搅动之类的关键结构定义不明确。由于缺乏经验数据，我们对专家意见进行了调查，调查结果发表在 2001 年《行为紧急情况治疗专家共识指南》中。几种第二代（非典型）抗精神病药（SGA）现在有用于治疗行为紧急情况的新配方（例如肌内注射奥氮平和齐拉西酮；奥氮平和利培酮快速溶解片剂）。该领域面临着关键问题。 SGA 与 FGA 以及彼此之间显着不同，并且尚未像 FGA 那样在未经选择的患者中进行研究。 SGA 是否可以被视为一类药物？所有抗精神病药物在不同条件下是否都具有类似的抗躁动作用？如果同样有效，它们的安全性可能会受到哪些限制？是否应该更具体地使用抗精神病药物来治疗精神病，而单独使用苯二氮卓类药物 (BNZ) 来治疗精神病？关于 SGA 和 BNZ 组合的可用数据很少，并且有关氟哌啶醇加 BNZ 传统组合的研究结果可能与 SGA 组合无关。这种文化也在不断发展，更加强调患者参与治疗决策。国际上已经形成共识，即行为紧急干预的适当终点是镇静而不是镇静。我们进行了一项新的专家意见调查，以更新先前调查的建议。方法：将包含 61 个问题（1,020 个选项）的书面调查邮寄给该领域的 50 名专家，其中 48 名 (96%) 完成了调查。该调查旨在确定紧急干预措施适宜的躁动程度、根据紧急程度和患者合作能力而定的评估范围、选择干预措施的指导原则，以及针对各种临时诊断和复杂情况在不同诊断置信水平下的适当物理和药物治疗策略。兰德公司用于评估医疗决策适当性的 9 分制量表的修改版本用于对大多数选项进行评分。共识被定义为通过卡方“拟合优度”检验得出的分数的非随机分布。我们根据平均值周围的 95% 置信区间为每个选项分配了分类排名（第一行/首选、第二行/备用、第三行/通常不合适）。评级用于制定关键临床情况下首选策略的指南。这项研究得到了多个赞助商的财政支持，小组对赞助商保持不知情，以减少可能的偏见。药物评级仅基于那些对每种药物有直接经验的受访者的反应。在报告实践模式时，专家小组被要求根据实际数据而不是估计做出回应。 结果：专家小组对 9 分制评分选项中的 78% 达成了共识。这些答复表明，医生可以有一定的信心做出临时诊断，并根据诊断和其他显着的人口统计和医学特征来区别选择药物和非药物干预措施。当没有可用数据、没有具体治疗方法（例如人格障碍）或可能具有特定益处（例如中毒）时，建议使用 BNZ。没有任何一种 SGA 可以作为氟哌啶醇的非特异性替代品；相反，根据当前的证据，在不同的情况下会首选不同的 SGA。就氟哌啶醇的推荐程度而言，它几乎总是与 BNZ 联合使用；仅在健康状况不佳的情况下才优选单独使用氟哌啶醇。相比之下，SGA 通常建议单独使用，并且专家组会避免将 BNZ 与某些 SGA 结合使用。单独口服利培酮或与 BNZ 联合使用在多种情况下都得到了大力支持。口服奥氮平的评级与利培酮非常相似，在已研究的情况下（例如精神分裂症、躁狂症），其评级略高于利培酮，而在尚未研究或安全性可能令人担忧的情况下，评级略低；对于口服奥氮平与 BNZ 联合用药的支持较少。对于与精神分裂症或躁狂相关的躁动的口服治疗，单用奥氮平、单用利培酮或与 BNZ 联用、氟哌啶醇加 BNZ 是一线药物，也强烈支持将双丙戊酸与抗精神病药物联用治疗疑似躁狂症。在大多数情况下，口服齐拉西酮和喹硫平通常获得相似的二线评级。如果需要注射剂，请立即联系。仅奥氮平一项就获得了比我更多的支持。单独使用齐拉西酮；然而，i.m. 得到了更多的支持。单独使用齐拉西酮或与 BNZ 联合使用比肌内注射更有效。奥氮平加 BNZ，可能反映了安全问题。例如，对于精神分裂症的临时诊断，一线肠外注射选择是肌内注射。单独使用奥氮平或齐拉西酮或肌内注射氟哌啶醇或齐拉西酮与 BNZ 联用。当没有可用数据或诊断涉及医疗合并症或中毒时，这两种新的肠胃外制剂都没有得到像传统药物（即 BNZ、即氟哌啶醇）那样多的支持。当使用利培酮、齐拉西酮或氟哌啶醇进行初步干预不成功时，专家组建议在抗精神病药物中添加 BZD。然而，当奥氮平或喹硫平初始治疗不成功时，建议增加剂量。奋乃静始终被评为二线药物，氟哌利多和氯丙嗪始终被评为三线药物。结论：在专家意见的范围内，并预计未来的研究数据将优先，这些指南表明，SGA 现在是治疗原发性精神疾病躁动的首选药物，但在其他情况下，BNZ 是首选。
OBJECTIVES: Due to inherent dangers and barriers to research in emergency settings, few data are available to guide clinicians about how best to manage behavioral emergencies. Key constructs such as agitation are poorly defined. This lack of empirical data led us to undertake a survey of expert opinion, results of which were published in the 2001 Expert Consensus Guidelines on the Treatment of Behavioral Emergencies. Several second-generation (atypical) antipsychotics (SGAs) are now available in new formulations for treating behavioral emergencies (e.g., intramuscular [i.m.] olanzapine and ziprasidone; rapidly dissolving tablets of olanzapine and risperidone). Critical questions face the field. The SGAs are significantly different from the FGAs and from each other and have not been studied in unselected patients as were the FGAs. Can the SGAs can be thought of as a class, do all antipsychotics have similar anti-agitation effects in different conditions, and, if equally effective, what limits might their safety profiles impose? Should antipsychotics be used more specifically to treat psychotic conditions, while benzodiazepines (BNZs) alone are used nonspecifically? Few data are available concerning combinations of SGAs and BNZs, and findings concerning the traditional combination of haloperidol plus a BNZ may not be relevant to combinations with SGAs. The culture is also evolving with more emphasis on patient involvement in treatment decisions. An international consensus has been developing that calming rather than sedation is the appropriate endpoint of behavioral emergency interventions. We undertook a new survey of expert opinion to update recommendations from the earlier survey.METHOD: A written survey of 61 questions (1,020 options) was mailed to 50 experts in the field, 48 (96%) of whom completed it. The survey sought to define level of agitation at which emergency interventions are appropriate, scope of assessment depending on urgency and patients' ability to cooperate, guiding principles for selecting interventions, and appropriate physical and medication strategies at different levels of diagnostic confidence for a variety of provisional diagnoses and complicating conditions. A modified version of the RAND Corporation's 9-point scale for rating appropriateness of medical decisions was used to score most options. Consensus was defined as a non-random distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred, second line/alternate, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean. Ratings were used to develop guidelines for preferred strategies in key clinical situations. This study received financial support from multiple sponsors, with the panel kept blind to sponsorship to reduce possible bias. Medication ratings were based on responses of only those respondents with direct experience with each drug. In reporting practice patterns, the panel was asked to respond based on actual data rather than estimates.RESULTS: The expert panel reached consensus on 78% of the options rated on the 9-point scale. The responses suggest that physicians can make provisional diagnoses with some confidence and that pharmacological and nonpharmacological interventions are selected differentially based on diagnosis and other salient demographic and medical features. BNZs are recommended when no data are available, when there is no specific treatment (e.g., personality disorder), or when they may have specific benefits (e.g., intoxication). No single SGA emerges as a nonspecific replacement for haloperidol; instead, different SGAs are preferred in various circumstances consistent with current evidence. To the degree that haloperidol is recommended, it is almost always in combination with a BNZ; haloperidol alone is preferred only in the medically compromised. In contrast, the SGAs are more often recommended for use alone, and the panel would avoid combining BNZs with some SGAs. Oral risperidone alone or combined with a BNZ receives strong support in a variety of situations. Oral olanzapine was rated very similarly to risperidone, with slightly higher ratings than risperidone in situations where it has been studied (e.g., schizophrenia, mania) and slightly lower ratings where it has not been studied or safety may be a concern; there was less support for combining oral olanzapine with a BNZ. For oral treatment of agitation related to schizophrenia or mania, olanzapine alone, risperidone alone or combined with a BNZ, and haloperidol plus a BNZ are first line, with strong support also for combining divalproex with the antipsychotic for presumed mania. Oral ziprasidone and quetiapine generally received similar second-line ratings in most situations. If a parenteral agent is needed, i.m. olanzapine alone received somewhat more support than i.m. ziprasidone alone; however, there was more support for i.m. ziprasidone alone or combined with a BNZ than for i.m. olanzapine plus a BNZ, probably reflecting safety concerns. For example, for a provisional diagnosis of schizophrenia, first-line parenteral options are i.m. olanzapine or ziprasidone alone or i.m. haloperidol or ziprasidone combined with a BNZ. Neither of the new parenteral formulations received as much support as traditional agents (i.m. BNZs, i.m. haloperidol) when no data are available or the diagnosis involves medical comorbidity or intoxication. When initial intervention with risperidone, ziprasidone, or haloperidol is unsuccessful, the panel recommended adding a BZD to the antipsychotic. However, when initial treatment with olanzapine or quetiapine is unsuccessful, increasing the dosage is recommended. Perphenazine was consistently rated second line and droperidol and chlorpromazine received third-line ratings throughout.CONCLUSIONS: Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines suggest that the SGAs are now preferred for agitation in the setting of primary psychiatric illnesses but that BNZs are preferred in other situations.