max dose for ativan

[skarndghks2017]

had an incident today where this patient in ER jumping and going crazy so doctor decided to give ativan 4mg iv push x4 times
I was kind of scared that patient might undergo respiratory depression but nurse was screaming to verify
hope pt is okay

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[beautifulrobot]

I agree the dose seems excessive, typically we would start someone off with 2 mg iv/im, wait 10-15 minutes, and reassess for another dose or the addition of an antipsychotic (or start off with the good ol "B52" - haldol 5mg, diphenhydramine 50 mg, lorazepam 2 mg).

Technically, agitation is an off-label use for ativan injection, so there is no defined "max dose" determined from clinical trials for this specific indication Different guidelines and standards of practice exist across the country. But, extrapolating from other indications, 4 mg iv push is the conventional max you would give per dose. for status epilepticus, the package insert states that that doses beyond 4 mg iv push x2 with a 10-15 minute delay between doses have not been well studied. Was the order for x4 prn, or to give 4 doses regardless of response? Over what time frame? The other thing that is weird about this order is why are they ordering IV rather than IM, especially in the ED? If the patient is calm enough that you can push an IV med over the course of 1-2 minutes, rather than stick em with an IM shot, it doesn't seem like it would be such a hectic scene that the nurse would have to be yelling at you and you wouldn't have time to question the order.

Also, most EDs have some kind of protocol in place for agitated patients, to avoid this exact situation where you are questioning what to do while there is an emergency and you need to get the patient sedated quickly. Does this ED not have a protocol in place?

 

[skarndghks2017]

it was like 4mg x1: i verified.
few min later another 4mg x1: so i verified
few min later another 4mg x1: i got worried so called the er and the nurse screamed at me that they don't have a choice bc pt is going crazy
few min later another 4mg x1: i was like oh wtf? but nurse calls again
i got worried so i checked the pt few min ago and pt transferred to icu and other rph just put pt with precedex drip
i asked her about ativan and she has no idea either lol
i think pt is okay now. but how long after would you see the resp depression?

 

[beautifulrobot]

thanks for clarifying, that makes more sense. with ativan monotherapy, if respiratory depression were to happen, i would expect to see it within 15-20 minutes from IV dose administration. benzodiazepines by themselves are relatively safe, the issue is if the patient had any alcohol, opiates, or other cns depressants in their system - that's when I would be a lot more cautious about giving multiple high doses of lorazepam in quick succession like what you described. on the reassuring side, with the patient in an ICU, his o2 sats and resp rate should be closely monitored.

 

[beautifulrobot]

also, i don't think it's unreasonable that you called after the first two doses to confirm - nurse was probably really stressed out but it was still inappropriate for her to yell at you. (i know, it happens all that time, still doesn't make it right). does your ED have a protocol for agitation?

 

[skarndghks2017]

also, i don't think it's unreasonable that you called after the first two doses to confirm - nurse was probably really stressed out but it was still inappropriate for her to yell at you. (i know, it happens all that time, still doesn't make it right). does your ED have a protocol for agitation?

I know! It happens all the time. She sounded like she was very stressed but you know we are all working for the same purpose here: trying to help the patients but they don't know how much WE are trying either so whatever
As far as the protocol is concern, there is a protocol. It gives you with a chart with what to give/do, single time dose, max dose whatever. That's why I was concerned. It says 10mg max in 24hour and such but I have seen numerous times where the protocol gets overridden by doctors/hospitalists. I have told the doctors about the protocols but if they don't like it or want something they want, then I just write a note and that's it. Past 3 years at hospital experience taught me not to fight with the doctors lol

 

[beautifulrobot]

as long as you're documenting everything (confirmed md is aware of protocol, md provided rationale for overriding protocol, etc.) and as long as the order is not egregiously wrong, you should be in the clear. with benzos, as long as there are no other cns depressants in the mix (esp. alcohol or opiates), and as long as they are being monitored closely, I wouldn't be too concerned about respiratory depression. it's very rare that someone has a fatal overdose from a pure benzo overdose in the outpatient side (not absolutely unheard of, but rare), so I would be even less concerned if the patient is being monitored in the ICU.

 

[skarndghks2017]

as long as you're documenting everything (confirmed md is aware of protocol, md provided rationale for overriding protocol, etc.) and as long as the order is not egregiously wrong, you should be in the clear. with benzos, as long as there are no other cns depressants in the mix (esp. alcohol or opiates), and as long as they are being monitored closely, I wouldn't be too concerned about respiratory depression. it's very rare that someone has a fatal overdose from a pure benzo overdose in the outpatient side (not absolutely unheard of, but rare), so I would be even less concerned if the patient is being monitored in the ICU.

Thanks that helped alot!
Im new to this forum and wow i learned alot today. Thanks again!

 

[CetiAlphaFive]

had an incident today where this patient in ER jumping and going crazy so doctor decided to give ativan 4mg iv push x4 times
I was kind of scared that patient might undergo respiratory depression but nurse was screaming to verify
hope pt is okay

Soooomebody needs to review Drug Action 1.

Hint:

Think of how bzd affects the gate

I never thought I'd agree with my professors who said Med Chem is clinically important. Lol

 

[njac]

Are you sure it wasn't for etoh withdrawal?

At one hospital I worked at (with significant alcoholic population) patients didn't have to go to the icu until their lorazepam gtt was at 25 mg per HOUR.

I've seen upwards of 40mg given in patients actively heading towards DTs.


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[skarndghks2017]

Are you sure it wasn't for etoh withdrawal?

At one hospital I worked at (with significant alcoholic population) patients didn't have to go to the icu until their lorazepam gtt was at 25 mg per HOUR.

I've seen upwards of 40mg given in patients actively heading towards DTs.


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I honestly don't know why pt received ativan. We dont know the dx and the reason and i think thats a huge loophole in our hospital's system. I really dont like it.
But 40mg? Wow

 

[confettiflyer]

I'm surprised they didn't just override it and give it without your needing to approve it. We have a limited set of drugs available for this, and Ativan is one of them.

I think I've gone up to like 20-30mg of IV Ativan in a short period of time. In the thick of things, 40mg doesn't sound entirely unreasonable (but still, holy hell)


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[Rockinacoustic]

Like everything in medicine, it depends.

4mg of IV ativan for the patient in the ED or ICU seizing or having DTs? Go right ahead. 4mg of ativan for the 92 year old who is anxious before her MRI? probably not.

I'm also perplexed why IV Ativan is not available on override in your ED. And, if you're just approving it when a nurse calls for it no questions asked, then what's the point?

 

[skarndghks2017]

Like everything in medicine, it depends.

4mg of IV ativan for the patient in the ED or ICU seizing or having DTs? Go right ahead. 4mg of ativan for the 92 year old who is anxious before her MRI? probably not.

I'm also perplexed why IV Ativan is not available on override in your ED. And, if you're just approving it when a nurse calls for it no questions asked, then what's the point?

We usually have ed rph who is on top of everything and verifies. Today is Saturday and the rph doesn't work so everything from ed came to central.

 

[njac]

I'd be far more concerned about those doses of lorazepam on a Med/surg floor than the ED. If the clinical situation requires those escalating dose of benzo, the ED is the place for it as they have the tools and the skillset to intubate if indicated.


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[ldiot]

From what I was told in school it's essentially impossible to overdose on a benzo because they only decrease Km, they don't have any effect on Vmax and GABA must still be present for a benzo to have any effect. So essentially the effect of the benzo will just plateau at a high enough dose because GABA itself becomes the limiting variable. This is unlike phenobarb which actually mimics GABA at high doses and increases Vmax.

With that being said I have no actual clinical experience with any of this and 16mg is certainly high; especially if they were naive to the drug class.

 

[beautifulrobot]

From what I was told in school it's essentially impossible to overdose on a benzo because they only decrease Km, they don't have any effect on Vmax and GABA must still be present for a benzo to have any effect. So essentially the effect of the benzo will just plateau at a high enough dose because GABA itself becomes the limiting variable. This is unlike phenobarb which actually mimics GABA at high doses and increases Vmax.

With that being said I have no actual clinical experience with any of this and 16mg is certainly high; especially if they were naive to the drug class.

This is true. There are some case reports in the literature of fatal overdoses that appear to be pure benzo overdoses, but there could always be some other unknown factor that was not identified in the case report.

The one very important thing to keep in mind is the that if opiates or alcohol are in the patient's system already, the addition of benzos can make thinks go downhill very quickly (or vice versa).

 

[CetiAlphaFive]

From what I was told in school it's essentially impossible to overdose on a benzo because they only decrease Km, they don't have any effect on Vmax and GABA must still be present for a benzo to have any effect. So essentially the effect of the benzo will just plateau at a high enough dose because GABA itself becomes the limiting variable. This is unlike phenobarb which actually mimics GABA at high doses and increases Vmax.

With that being said I have no actual clinical experience with any of this and 16mg is certainly high; especially if they were naive to the drug class.

+++1

Bingo bingo bingo, baby eaten by a dingo.

This is also why Soma is so dangerous in the outpatient setting.
Physicians think of it like flexeril, but one of the active metabolites is actually the very drug that killed Bruce Lee.

Unlike benzos, which just modify the gate and allow GABA to pass through more readily, meprobamate and PBT ram themselves through the gate.

 

[Sparda29]

had an incident today where this patient in ER jumping and going crazy so doctor decided to give ativan 4mg iv push x4 times
I was kind of scared that patient might undergo respiratory depression but nurse was screaming to verify
hope pt is okay

Yup, we had a dude on PCP going nuts, especially after the nurse said "nighty night" as she injected him with ativan. He was a Russian guy so he went "I KNOW WHAT NIGHTY NIGHT MEANS" with this growling Russian accent. After a **** ton of injections, they kept him under by putting him on propofol.