What is the recommended intravenous (IV) management for acute anxiety?

IV Management for Acute Anxiety

Routine pharmacological anxiolytics are neither necessary nor recommended for acute anxiety; psychological support and reassurance should be the primary intervention, with IV benzodiazepines (lorazepam 2-4 mg or diazepam) reserved only for severe, refractory cases where the patient becomes excessively disturbed. 1

Primary Approach: Non-Pharmacological Management

• Psychological support and reassurance are the first-line interventions for acute anxiety in medical settings 1
• Studies demonstrate that anxiety, blood pressure, heart rate, and chest discomfort were no different in patients treated with diazepam compared to placebo 1
• Conversely, psychological support provided during hospitalization has been shown to decrease anxiety and depression immediately and for up to 6 months 1
• Opioids (morphine) are frequently all that is required when anxiety accompanies pain 1

When IV Anxiolytics Are Indicated

Use IV benzodiazepines only in selected patients who become excessively disturbed despite reassurance and supportive measures. 1

IV Lorazepam (Preferred Agent)

• Dose: 2 mg IV initially (or 0.02 mg/kg, whichever is smaller) 2
• Administer slowly at a rate not exceeding 2 mg per minute 2
• Must be diluted with an equal volume of compatible solution (sterile water, normal saline, or 5% dextrose) immediately prior to IV use 2
• Additional 2 mg doses may be given at 5-minute intervals if needed 2
• Maximum initial dose should not exceed 2 mg in patients over 50 years of age 2

Alternative: IV Diazepam

• Can be used for acute anxiety, though evidence shows no superiority over placebo in cardiac patients 1
• Proper use is dependent on thorough understanding of pharmacokinetics and pharmacodynamic properties 1

Critical Caveats and Pitfalls

Avoid Routine Use

• The routine use of pharmacological anxiolytics is neither necessary nor recommended in most clinical scenarios 1
• Benzodiazepines are not recommended for routine use in anxiety management 3, 4

Drug-Specific Warnings

• Lorazepam may cause sedation, respiratory suppression, and hypotension 1
• Rapid IV administration may precipitate seizures 1
• All doses may cause paradoxical excitement or agitation 1
• Avoid concomitant use with other CNS depressants without careful monitoring 2, 5

Special Populations

• Elderly patients and those with hepatic disease: No dosage adjustment needed for acute administration 2
• Renal disease: Caution with frequent doses over short periods 2
• Drug interactions: Reduce lorazepam dose by 50% when coadministered with probenecid or valproate 2

Agitation vs. Anxiety

For severe agitation (not simple anxiety), IV haloperidol is preferred over benzodiazepines:

• Intravenous haloperidol is a rapidly acting neuroleptic that can be given safely and effectively to cardiac patients with agitation 1
• Rarely produces hypotension or requires assisted ventilation 1
• Particularly useful in CCU settings for agitation and delirium 1

Procedure-Related Anxiety

For procedure-related anxiety, anxiolytics should be given preemptively when feasible 1

• Interventions should be multimodal, including both pharmacologic and nonpharmacologic approaches 1
• Supplemental doses of analgesics should be given in anticipation of procedure-related pain 1

Long-Term Considerations

• IV administration of antidepressants does not show increased efficacy over oral administration for anxiety disorders, though there are suggestions of faster onset 6
• For ongoing anxiety disorders, SSRIs and SNRIs remain first-line pharmacotherapy 3, 4
• Cognitive behavioral therapy has the highest level of evidence for anxiety disorders 3, 4