What is the treatment for post-injection delirium/sedation syndrome, also known as Post-Injection Delirium/Sedation (PIDS) syndrome?

From the Guidelines

The treatment for post-injection delirium/sedation syndrome (PIDS) primarily involves discontinuing the precipitating agent and providing supportive care, which may include treatment of agitation, amelioration of hyperthermia, and management of autonomic instability. When PIDS occurs, patients should be placed in a reclining position and continuously monitored for vital signs, oxygen saturation, and level of consciousness.

Key Considerations

• Supplemental oxygen should be provided if oxygen saturation drops below 90% 1.
• Intravenous fluids may be necessary to maintain hydration.
• Airway management, including potential intubation in severe cases, should be considered if respiratory depression occurs.
• Continuous cardiac monitoring is recommended, especially in patients with pre-existing cardiovascular conditions.
• Benzodiazepines may be cautiously administered for severe agitation, but respiratory status must be closely monitored 1.

Management of PIDS

PIDS occurs due to inadvertent intravascular injection of long-acting antipsychotics, particularly those that cause rapid drug release into circulation. After an episode, clinicians should reevaluate the risk-benefit ratio of continuing the medication and consider alternatives. Patients should be observed for at least 3 hours after receiving injections of medications associated with PIDS risk, and they should not drive or operate machinery for 24 hours post-injection.

Treatment of Agitation

• Administration of olanzapine may offer benefit in the symptomatic management of delirium 1.
• Administration of quetiapine may offer benefit in the symptomatic management of delirium 1.
• Benzodiazepines are effective at providing sedation and potentially anxiolysis in the acute management of severe symptomatic distress associated with delirium 1.

Important Considerations

• The use of pharmacological interventions in the management of delirium in adults should be limited to patients who have distressing delirium symptoms or if there are safety concerns where the patient is a potential risk to themselves or others 1.
• Medications should be used in the lowest effective dose and for a short period of time only 1.

From the FDA Drug Label

The administration of flumazenil can precipitate benzodiazepine withdrawal in animals and man This has been seen in healthy volunteers treated with therapeutic doses of oral lorazepam for up to 2 weeks who exhibited effects such as hot flushes, agitation and tremor when treated with cumulative doses of up to 3 mg doses of flumazenil. Similar adverse experiences suggestive of flumazenil precipitation of benzodiazepine withdrawal have occurred in some adult patients in clinical trials Such patients had a short-lived syndrome characterized by dizziness, mild confusion, emotional lability, agitation (with signs and symptoms of anxiety), and mild sensory distortions. This response was dose-related, most common at doses above 1 mg, rarely required treatment other than reassurance and was usually short lived When required, these patients (5 to 10 cases) were successfully treated with usual doses of a barbiturate, a benzodiazepine, or other sedative drug

The treatment for post-injection delirium/sedation syndrome, also known as Post-Injection Delirium/Sedation (PIDS) syndrome, may involve:

• Reassurance
• Benzodiazepines or other sedative drugs at usual doses
• Barbiturates at usual doses However, the optimal treatment is not explicitly stated in the label. 2

From the Research

Treatment for Post-Injection Delirium/Sedation Syndrome (PIDS)

The treatment for PIDS syndrome is primarily focused on supportive care and managing symptoms. According to the studies, the following treatments have been used:

• Supportive care without any pharmacological intervention 3
• Benzodiazepine 3
• Benztropine 3
• Bromocriptine and physostigmine followed by oral rivastigmine to manage antidopaminergic and anticholinergic symptoms respectively 3

Key Aspects of Managing PIDS Syndrome

The management of PIDS syndrome involves:

• Observing patients for three hours after receiving the injection, measuring vitals and referring to medical care if necessary 4, 5
• Being aware of the symptoms of PIDS, including sedation, delirium, dysarthria, ataxia, extrapyramidal symptoms, agitation, dizziness, or seizure 4
• Using pharmacological interventions, such as benzodiazepine and benztropine, to manage symptoms 3
• Considering the use of bromocriptine and physostigmine followed by oral rivastigmine to manage antidopaminergic and anticholinergic symptoms respectively 3

Practical Guidelines for Diagnosis and Management

Practical guidelines for the diagnosis and management of PIDS syndrome include:

• Understanding the pharmacological background of olanzapine long-acting injection 6
• Recognizing the common symptoms of PIDS, including delirium and sedation 6
• Using diagnostic criteria to identify PIDS syndrome 6
• Implementing therapeutic options, such as supportive care and pharmacological interventions, to manage symptoms 6