What can be administered intravenously (IV) or intramuscularly (IM) to calm a patient with Acute Kidney Injury (AKI) who is experiencing confusion, irritability, and agitation?

From the Guidelines

I strongly recommend administering lorazepam 1-2 mg IV/IM for acute agitation in this AKI patient, as it is a more recent and evidence-based approach compared to haloperidol. According to the study by 1, lorazepam can be used as a crisis medication in the management of delirious patients with severe agitation and distress, with a suggested starting dose of 1 mg IV/IM. Before administration, a brief assessment should be performed to identify potential causes of the agitation such as pain, hypoxia, or urinary retention. Monitor vital signs and mental status after medication administration. It's also important to note that benzodiazepines may have prolonged effects in patients with AKI, so close monitoring is necessary. Some key points to consider when administering lorazepam include:

• Starting with a lower dose, especially in elderly or frail patients
• Using the medication on a PRN (as needed) basis
• Regularly assessing the patient's response to the medication and adjusting the dose accordingly
• Considering non-pharmacological approaches such as reorientation, family presence, and a quiet environment once the acute agitation is controlled. Additionally, the study by 1 suggests that benzodiazepines, such as lorazepam, can be effective monotherapy for the initial drug treatment of acutely agitated patients in the ED.

From the FDA Drug Label

For the primary purpose of sedation and relief of anxiety, the usual recommended initial dose of lorazepam for intravenous injection is 2 mg total, or 0.02 mg/lb (0. 044 mg/kg), whichever is smaller.

Intramuscular Injection IM lorazepam is not preferred in the treatment of status epilepticus because therapeutic lorazepam levels may not be reached as quickly as with IV administration However, when an intravenous port is not available, the IM route may prove useful

The patient can be given 2 mg of lorazepam IV for sedation and relief of anxiety. If an IV port is not available, IM lorazepam can be considered, but it is not the preferred route. The dose for IM administration is 0.05 mg/kg up to a maximum of 4 mg. However, it's essential to note that the patient's condition, AKI, and potential interactions with other medications should be considered before administering lorazepam 2.

From the Research

Patient Condition

• The patient is experiencing acute kidney injury (AKI) and is becoming increasingly confused and irritable, currently yelling.
• The patient's condition requires immediate attention to prevent further deterioration.

Treatment Options

• According to the study 3, a combination of haloperidol, lorazepam, and diphenhydramine (B52) or a combination of haloperidol and lorazepam (52) can be used to treat acute agitation.
• The study 3 found that both combinations were effective in treating agitation, but the 52 combination resulted in fewer side effects, such as hypotension and oxygen desaturation.
• However, it is essential to consider the patient's underlying condition, AKI, and potential interactions with other medications before administering any treatment.

Considerations for AKI Patients

• The studies 4, 5, 6, and 7 emphasize the importance of careful management of AKI patients, including fluid and electrolyte management, avoidance of nephrotoxic medications, and close monitoring of kidney function.
• The patient's AKI condition may affect the metabolism and excretion of medications, which should be taken into account when selecting a treatment option.
• It is crucial to consult with a nephrologist or other specialists to determine the best course of treatment for the patient's AKI and agitation.