Verced In Anxiety-Induced Hyperventilation

clearblueskies said:
it has absolutely nothing to do with slowing down of the patients respiratory rate causing the problem here. The problem is biochemical in nature and results from the confirmation change that the versed isomer goes through when introduced into an alcolotic environment. IE. the known alcolosis of a patient who is severly hyperventilating. It can (but does not always) precipitate a further deepening alcolosis by causing a further release of bicarb by the kidneys. This can cause a whole host of problems when trying to reverse it later on, not the least of which is the potassium suddenly becoming artificially low. This reaction doesnt occur with the other benzos. and no one is sure why. It has been detrimental enough that our facility and many i know have protocols against administration of versed to a known alcolotic patient unless there are no other options. It has also been taught to us in the classes im taking for my CRNA license. Ive had three different anastesiologists warn against this in school . One of them actually said it took a week to get his patient turned around in the ICU after giving it. I know i won't chance it after learning about it.
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But wasn't the biochemical problem caused by the increased respiratory rate? And by slowing down the respiratory rate would not not prevent a worsening of the alkolosis?

Also do you have a link to any information about benzos in alkolosis? I can't find anything in my pharm book or in google
 
ChaseZ33 said:
But wasn't the biochemical problem caused by the increased respiratory rate? And by slowing down the respiratory rate would not not prevent a worsening of the alkolosis?

Also do you have a link to any information about benzos in alkolosis? I can't find anything in my pharm book or in google
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This is the book it is in, I looked tried to access it from the internet but haven't figured out how as of yet.

You are right decreasing the respiratory should prevent a worsening alkolosis..... IF something else doesn't help it along. This is where I was going with the versed issue. It has been known to cause an already known alkolosis to get worse.

http://books.google.com/books/about/Textbook_of_Anesthesia_for_Postgraduates.html?id=f2YOpCMNFD4C
 
Did the patient have a real medical condition?
Were the symptoms serious enough to warrant treatment?
Did you have the ability to provide that treatment?

If yes to all of the above (and I think they're all yes, based on what you've told), then I'd say you were absolutely justified in treating the patient's anxiety.

Clearblueskies is right to say that we should not provide treatment just because we can; but likewise, we should not withhold treatments when it's indicated just because we can either. Especially with something like pain.
 
That is what I said, I personally do not treat this exact particular condition in my practice I have decided after doing this for a long time and gaining some extra education that I don't feel as though it is necessary. That being said I would not fault someone if they wanted to do so. I was simply discussing that versed would by no means by my personal choice to treat it and have discussed why. I just posted the book where it came out of on here, and am frankly getting tired of defending the info. I would just tell anyone out there that continues to wonder about it, to continue your research and seek out further education on your drugs. I have had some real eye openers from my continued schooling. As medics we are taught just enough in many cases to be dangerous when it comes to medications. This even happens at the advanced levels of medic education such as CCEMT-P and FP-C, both of which I have. I am just suprised at how much I wasn't taught about some of the "simple" and supposedly benign drugs that we give on the street, in the aircraft etc.
Bieber said:
Did the patient have a real medical condition?
Were the symptoms serious enough to warrant treatment?
Did you have the ability to provide that treatment?

If yes to all of the above (and I think they're all yes, based on what you've told), then I'd say you were absolutely justified in treating the patient's anxiety.

Clearblueskies is right to say that we should not provide treatment just because we can; but likewise, we should not withhold treatments when it's indicated just because we can either. Especially with something like pain.
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Hyperventilating? Nothing that a pillow and duct tape can't solve! LOL

I have used benadryl with success several times to reduce anxiety reactions. 25-50 mg IV, dimming the lights and talking in my "soothing baritone" generally works. And although I haven't ever done it myself, I have seen the low-flow NRB trick work like a charm. I generally reserve versed for when I need to put someone down NOW, like psych patients, and although hyperventilation may cause painful spasms, it's not life threatening. Plus breaking out the narcs always means more paperwork. I know, I know, extra paperwork isn't a good excuse for not giving a med, but I know that I always sigh inwardly when I have to get out the lock box.
 
clearblueskies said:
it has absolutely nothing to do with slowing down of the patients respiratory rate causing the problem here. The problem is biochemical in nature and results from the confirmation change that the versed isomer goes through when introduced into an alcolotic environment. IE. the known alcolosis of a patient who is severly hyperventilating.
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[citation needed]
http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=Midazolam+alkalosis gives nothing relevant and Epocrates doesn't mention it.

I did find an unsourced comment:
One other little example: midazolam is a benzodiazepine sedative drug. It is stored at an acidic pH to keep it water soluble. When it enters the bloodstream, the slightly basic pH induces a conformational change which makes it lipid soluble and easily capable of penetrating the brain-really pretty slick.
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which is cool, but not actually relevant. I also remember reading a case report of a guy who got so much Ativan the propylene glycol diluent ended up killing him.
 
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Could it be something about the pH of the metabolized byproduct or isomer of the Versed?

Biochem is pretty over my head, need to go back to school.
 
clearblueskies said:
it has absolutely nothing to do with slowing down of the patients respiratory rate causing the problem here. The problem is biochemical in nature and results from the confirmation change that the versed isomer goes through when introduced into an alcolotic environment. IE. the known alcolosis of a patient who is severly hyperventilating. It can (but does not always) precipitate a further deepening alcolosis by causing a further release of bicarb by the kidneys. This can cause a whole host of problems when trying to reverse it later on, not the least of which is the potassium suddenly becoming artificially low. This reaction doesnt occur with the other benzos. and no one is sure why. It has been detrimental enough that our facility and many i know have protocols against administration of versed to a known alcolotic patient unless there are no other options. It has also been taught to us in the classes im taking for my CRNA license. Ive had three different anastesiologists warn against this in school . One of them actually said it took a week to get his patient turned around in the ICU after giving it. I know i won't chance it after learning about it.
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I think you're confusing longer-term alkalosis (metabolic or respiratory) with the short-term acute respiratory alkalosis from hyperventilation. Surely at this stage of your anesthesia training you understand how quickly you can change the EtCO2/PaCO2.

I was using Versed even before it was released into the marketplace more than 25 years ago, in all sorts of critically ill patients. Anecdotal evidence, as well as obscure foreign anesthesia texts, just don't do it for me. We'll have to agree to disagree. I'll take midaz over Ativan any day.
 
I had to take a special interest in this topic.

I give out midazolam like candy. It is my favorite benzo and I am very comfortable using it.

When presented with this new information on alkalosis, I had to take time to research it.

I checked my sources.

I found nothing at all about this in The Pharmacological Basis of Theraputics.

I found nothing at all about this in Miller's Anesthesia

I found nothing at all about it in The textbook of Critical Care

Nothing in my anesthesia pocket guide either.

In a pubmed and medscape search of both versed and midazolam + alkalosis I got one hit.

A case study of milk alkali syndrome.

I can find nothing outside of the cited textbook here that supports these assertations.

I am going to continue to use and support the case for midazolam.
 
I don't exactly share the same level of experience and pharmacological knowledge as most of you, but I would be hard pressed to believe that 1cc of a medication, 5mg, would have the power to induce a metabolic acidosis.

We use 1mEq/kg of Bucarb to correct acidosis... If the effect of versed is that potent then why even use bicarb. (not serious)
 
The Benadryl treatment seems interesting too, at the risk of burying the problem and taking hours to go away. I'd have considered it downrange as a 68W with no benzos, but here, I think midazolam is a better option.
 
Rocketmedic40 said:
The Benadryl treatment seems interesting too, at the risk of burying the problem and taking hours to go away. I'd have considered it downrange as a 68W with no benzos, but here, I think midazolam is a better option.
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Personally, I myself have never had IM or IV benadryl before so I can't vouch for the onset or sedative properties but if it is anything similar to the pills, it wouldn't touch me. 50mg PO does very little to knock me out and im only 180lbs. It also takes a good while to kick in. I really wouldn't be turning to it for sedative effects pre-hospital, when I have benzos at my disposal.
 
I have found promethazine is a much more potent sedative than benadryl
 
Veneficus said:
I have found promethazine is a much more potent sedative than benadryl
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Unfortunately we don't carry promethazine where we are...

IV benadryl has a little more kick than taking it PO, and I generally see the sedation or anti-emetic effects kick in within 5 mins or so. Not that I don't like versed, but benadryl is my go to for mild sedation, I generally reserve versed for the quick 'boom, lights-out' situations.
 
Merck said:
A couple things. First I probably wouldn't treat this patient but rather she would go with a BLS crew to the hospital. Midaz can be funny sometimes. 5mg in one can be quite different than 5 in another pt. This girl is likely going to be fine.
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WTF!! Are things that different up there? A patient with a respiratory problem that is acute and severe would get turfed down to a BLS crew? Is that something that passes muster with the physicians? This wouldn't happen in any system I've been around here in the States.
 
The PT isn't having a respiratory emergency. She is having a panic attack.
 
Breathing just fine, Eli.
 
Eli said:
WTF!! Are things that different up there? A patient with a respiratory problem that is acute and severe would get turfed down to a BLS crew? Is that something that passes muster with the physicians? This wouldn't happen in any system I've been around here in the States.
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Our bls is quite different from your bls. And as stated the pt was having an anxiety attack.
 
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