From the FDA Drug Label
THE POTENTIATING ACTION OF HYDROXYZINE MUST BE CONSIDERED WHEN THE DRUG IS USED IN CONJUNCTION WITH CENTRAL NERVOUS SYSTEM DEPRESSANTS SUCH AS NARCOTICS, NON-NARCOTIC ANALGESICS AND BARBITURATES. Sedating drugs may cause confusion and over sedation in the elderly; elderly patients generally should be started on low doses of hydroxyzine and observed closely.
The patient is post-craniotomy, which may involve central nervous system depressants, and is already agitated and confused. Hydroxyzine may exacerbate confusion and sedation.
- It is not explicitly stated in the label that hydroxyzine can be safely used in post-craniotomy patients.
- Caution is recommended when using hydroxyzine, especially in patients with risk factors for QT prolongation.
- The label advises to use low doses and close observation in elderly patients or those with decreased hepatic, renal, or cardiac function. Given the patient's condition and the potential risks, it is not recommended to resume hydroxyzine without careful consideration of the potential benefits and risks, and close monitoring of the patient's condition 1.
From the Research
For post-craniotomy patients experiencing agitation and confusion, cautious pharmacological management is recommended, with low-dose antipsychotics like haloperidol 0.5-1mg IV/PO or quetiapine 25-50mg PO as preferred first-line options for acute agitation. Hydroxyzine (Vistaril) can be resumed but should be used carefully due to its sedative properties which may mask neurological changes 2. Dexmedetomidine (Precedex) 0.2-0.7 mcg/kg/hr IV infusion is also effective without significant respiratory depression. Benzodiazepines like lorazepam should be avoided or used sparingly (0.5-1mg IV/PO) as they can worsen confusion and mask neurological assessment.
Non-Pharmacological Approaches
Non-pharmacological approaches should be implemented first, including:
- Reorientation
- Family presence
- Maintaining day-night cycles
- Minimizing unnecessary stimuli The underlying cause of agitation should be investigated, as it may result from pain, urinary retention, hypoxia, or medication effects. Regular neurological assessments are crucial during any sedative administration to monitor for potential complications or deterioration in neurological status. A study published in 2018 found that bi-frontal pneumocephalus is an independent risk factor for early postoperative agitation in adult patients admitted to intensive care unit after elective craniotomy for brain tumor 2.
Pharmacological Management
Pharmacological management should be tailored to the individual patient's needs, taking into account their medical history, current medications, and potential side effects. The most recent and highest quality study available should guide pharmacological management decisions. In this case, the study by 2 provides valuable insights into the management of post-craniotomy agitation.
Key Considerations
Key considerations in the management of post-craniotomy agitation include:
- Monitoring for potential complications or deterioration in neurological status
- Investigating the underlying cause of agitation
- Implementing non-pharmacological approaches first
- Using low-dose antipsychotics as preferred first-line options for acute agitation
- Avoiding or using benzodiazepines sparingly due to their potential to worsen confusion and mask neurological assessment.