PHARM Podcast 163 Better Dead than VerSed Or How We ditched Midazoslam in Queensland for chemical restraint

Pronounced VER – SED (propietary name of Midazolam)

Hi folks

on todays episode, I discuss the case to ditch midazolam for acute sedation of behavioural disturbance.  Here are the four deaths I refer to in the podcast.

The 2007 death of David Lee(pg70) was due to excessive sedation from midazolam infusion in Port Hedland hospital. He suffered from Schizophrenia and was under the involuntary status of the mental health act. A followup report here (pg13) concludes lack of adequate staffing should not be justification to use excessive chemical restraint measures.

A very similar case of chemical restraint related death was noted here in 2009 in Western Australia(pg22) , whereby an Aboriginal man with schizophrenia was excessively sedated with midazolam infusion yet again. The cause of death was pulmonary embolus but it is likely this was a result of prolonged immobilisation as a result of the excessive sedation , its resultant pulmonary aspiration syndrome and need for ICU level admission.

In 2010, in Townsville, Lyji Vaggs died after chemical restraint with olanzapine and then midazolam was administered for acute agitation in the mental health unit of the main hospital.

In 2015, David Dungay died in the psychiatric unit of the Long Bay prison after being physically restrained then administered midazolam via injection. He had been diagnosed with schizophrenia whilst in prison and was improving on appropriate medication. The coronial inquest into his unnatural death is still pending.

Here in my state of Queensland, we ditched midazolam from emergency department guidelines for acute severe behavioural disturbance in November 2016 : 

Management of patients with Acute Severe Behavioural Disturbance in Emergency Departments (Qld Health , 2016) (parenteral sedation first line choice is droperidol)

Podcast ( available here and on iTunes)

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2 thoughts on “PHARM Podcast 163 Better Dead than VerSed Or How We ditched Midazoslam in Queensland for chemical restraint

  1. Sadly midazolam is STILL part of the recommendations for acute psych sedation in rural hospitals here in South Australia – whilst I concede it may have a role to get rapid control of a patient and is readily available, it makes me nervous that we are still emphasising it’s use in the rural environment

    Moreover, ne guidelines don’t emphasis the value of an assessment of anaesthetic risk

    Current SA guidelines are along the lines of:

    First line – oral Benz or Anti-psychotic agent
    (typically lorazepam/diazepam or olanzapine)

    Second line – IM droperidol preferred over IV droperidol
    (typically droperidol 5-10mg IM to max 20mg – IV only by ‘experienced practitioners’)
    OR IM olazapine

    Third line – IV midazolam or IM zuclopenthixol
    (midazolam 2.5-5mg titrated to max 20mg or Zuclopenthixol 100-150mg IM)

    Fourth line – ONLY when first/second line tried and failed and ONLY in conjunction with psychiatrist and retrieval service

    Interestingly the need for experienced airway support is only acknowledged for level IV (use of ketamine) and not mentioned when rural practitioners are encouraged to use IV midazolam

    I find this (only considering anaesthetic issues at level IV) and the requirement to consult both retrieval service AND on call psychiatrist as a prerequisite to use of ketamine to be at odds with guidelines developed by rural and emergency clinicians elsewhere

    Ho hum

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