Surviving Sedation Guidelines 2016 update


Authorship : Dr Minh Le Cong

Peer reviewers: Dr Amit Maini,  Dr George Douros, Dr Tim Leeuwenberg

Intended target audience for this guideline:

  • The occasional sedationist e.g rural health provider, medical resident on ward
  • Those who encounter acutely agitated patients in low resource settings such as rural clinics/hospitals i.e no formal security team response

Summary of 2016 update to guideline:

  • No  major changes to guideline have been made after review of latest relevant medical literature
  • The reference list has been updated to reflect a few significant studies published, that lend support to the current guideline


Comments to 2016 uopdate:

  1. Since 2015 guideline , new published papers from Australia and USA support use of ketamine for acute behavioural disturbance in both emergency department and prehospital use.
  2. One systematic review suggests benzodiazepines associated with more adverse events for acute sedation of agitation, further supporting the current guideline emphasis on droperidol and ketamine
  3. In Australia, trend toward adoption of evidence based sedation guidelines utilising droperidol first line with ketamine as second line for severe agitation. New South Wales Health department guidelines published in August 2015, will be likely adopted by Queensland Health in 2017. South Australia state guidelines in draft with similar sedation recommendations.
  4. One RCT from Melbourne suggesting midazolam & droperidol IV sedation superior to monotherapy was reviewed and discounted. The main issues cited by our reviewers are that IV route not always available initially for acute management and RCT sample size was smaller than DORM studies. Also the  midazolam/droperidol group were noted to have more airway and respiratory adverse events than droperidol alone, consistent with other literature on midazolam sedation. Therefore the guideline will continue to not support use of midazolam sedation for acute behavioural disturbance





Reference List:

JC Chevrolet, P Jolliet. Clinical review: agitation and delirium in the critically ill –significance and management. Critical Care 2007, 11:214

SP Keenan. Sedation in the ICU. Critical care Rounds 2000, 1 (3); Canadian Critical society.

J Shen. Sedation and Analgesia in the Intensive care unit. Hong Kong Medical Diary 2009, 14(9).

Calver LA1, Stokes B, Isbister GK.Sedation assessment tool to score acute behavioural disturbance in the emergency department.Emerg Med Australas. 2011 Dec;23(6):732-40.

EL Bahn, KR Holt. Procedural sedation and analgesia: a review and new concepts. Emerg Med Clin N Am 2003, 23:503-517.

Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures, ANZCA Professional standard Jul 2014, viewed on 20th August 2014 at

SA Godwin, DA Caro, SJ Wolf, AS Jagoda, R Charles, BE Marett, J Moore. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Ann Emerg Med 2005, 45:177-196.

Spain D1, Crilly J, Whyte I, Jenner L, Carr V, Baker A.Safety and effectiveness of high-dose midazolam for severe behavioural disturbance in an emergency department with suspected psychostimulant-affected patients.Emerg Med Australas. 2008 Apr;20(2):112-20.

Leonie A Calver,corresponding author1,2 Michael A Downes,1,2,3 Colin B Page,2,4 Jenni L Bryant,1,5 and Geoffrey K Isbister1. The impact of a standardised intramuscular sedation protocol for acute behavioural disturbance in the emergency department.BMC Emerg Med. 2010; 10: 14.

Leonie Calver,1,2 Vincent Drinkwater,3 and Geoffrey K Isbister.A prospective study of high dose sedation for rapid tranquilisation of acute behavioural disturbance in an acute mental health unit.BMC Psychiatry. 2013; 13: 225.

G Isbister et al. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010 Oct;56(4):392-401

E Chan et al. Intravenous Droperidol or Olanzapine as an Adjunct to Midazolam for the Acutely Agitated Patient: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Ann Emerg Med, 2013, 61(1) :72-81

M Wilson et al. The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. WJEM, 2012, 13(1) :26-34

R Berman et al. Antidepressant effects of ketamine in depressed patients. Biol Psych, 2000,47(4): 351- 354

R Price et al. Effects of Intravenous ketamine on Explicit and Implicit Measures of Suicidality in Treatment-Resistant Depression. Biol Psychiatry. Sep 1, 2009; 66(5):522-526.

C Harihar et al. Intramuscular ketamine in acute depression: A report on two cases. IndJPsych, 2013, 55 (2): 186-188

Special Panel Review of Excited Delirium Less-Lethal Devices Technology working Group NIJ Weapons and Protective Systems Technologies Center.

M Le Cong, B Gynther, E Hunter, P Schuller. Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval. Emerg Med J doi:10.1136/emj.2010.107946

C Parsch, W Emmerton. Ketamine use in retrieval of psychiatric patients. MedSTAR, 2012


Michael P Wilson, MD, PhD,* David Pepper, MD, Glenn W Currier, MD, MPH, Garland H Holloman, Jr, MD, PhD,§ and David Feifel, MD, PhD.The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup.West J Emerg Med. 2012 Feb; 13(1): 26–34.

Ho et al. Successful management of excited delirium syndrome with prehospital ketamine: two case examples. Prehosp Emerg Care, 2013 Apr-Jun;17(2):274-9

A Pritchard, M Le Cong. Ketamine sedation during air medical retrieval of an agitated patient. 2014, 33(2):76-77

D Keseg. Vitamin K or KO ? Outcomes of EMS Ketamine Use. NAEMSP 2014 ANNUAL MEETING.

M Le Cong, E Finn, C Parsch. Management of the acutely agitated patient in a remote location. Med J Aust 2015; 202 (4): 182-183

Calver L1, Drinkwater V1, Gupta R1, Page CB1, Isbister GK1 .Droperidol v. haloperidol for sedation of aggressive behaviour in acute mental health: randomised controlled trial.Br J Psychiatry. 2015 Mar;206(3):223-8.

Leonie Calver; Colin B. Page, MBChB; Michael A. Downes, MBBS; Betty Chan, MBBS, PhD; Frances Kinnear, MBBS; Luke Wheatley, MBBS; David Spain, MBBS; Geoffrey Kennedy Isbister, MD, BS. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department (DORM II study). Ann Emerg Med. 2015;-:1-9

2016 update additional references:

Management of patients with Acute Severe Behavioural Disturbance in Emergency Departments, New South Wales Health department guidelines, August 2015


Clinical Toxicology Vol. 54 , Iss. 7,2016

Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department
Isbister, Geoffrey Kennedy et al.
Annals of Emergency Medicine , Volume 67 , Issue 5 , 581 – 587.e1


Chemical agents for the sedation of agitated patients in the ED: a systematic reviewKorczak, Viola et al. The American Journal of Emergency Medicine, 2016 (Article in Press)


Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial.Taylor, David McD. et al.Annals of Emergency Medicine, 2016 (Article in Press)


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