What is the maximum dose of Haloperidol that can be given?

[elroot]

we frequently use haloperidol in the management of acute disturbance for rapid tranquilisation. There does not seem to be a concenses on the maximum dose of Haloperidol that can be given for a average build young male. Some say it is only 18mg/day. Others quate higher figures. Have any of you guys used higher doses of haloperidol? I know i have because for some patients 18 mg of Haloperidol is not enough.

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[Doc Samson]

we frequently use haloperidol in the management of acute disturbance for rapid tranquilisation. There does not seem to be a concenses on the maximum dose of Haloperidol that can be given for a average build young male. Some say it is only 18mg/day. Others quate higher figures. Have any of you guys used higher doses of haloperidol? I know i have because for some patients 18 mg of Haloperidol is not enough.

Largest single dose I've heard of is 100 mg IV. Largest daily total I've heard of is 2800 mg IV. Personally, I've gone as high as 80 mg IV boluses with a daily total of 1800 mg IV.

 

[Faebinder]

Largest single dose I've heard of is 100 mg IV. Largest daily total I've heard of is 2800 mg IV. Personally, I've gone as high as 80 mg IV boluses with a daily total of 1800 mg IV.

Impressive.

My record is 50 mg in a day and 15 mg IM max 1 dose, although i am quick to ride up to 50 mg... but I stop there.

 

[Doc Samson]

Impressive.

My record is 50 mg in a day and 15 mg IM max 1 dose, although i am quick to ride up to 50 mg... but I stop there.

IM is another story... don't think that I've ever given more than 10 mg doses.

 

[whopper]

Wow!

Most I've heard is100mg, and that's what I gave. I figure at that point, if its not working try something else.

 

[Doc Samson]

I'm talking specifically about delirium here - I'd switch to something else too if I were treating acute mania or psychosis. For years the haldol naysayers have been saying that >90% of D2 receptors are blocked after 10 mg of Haldol, so why use more doses. Research in the past couple of years has found that they butyrophenones (haldol and droperidol) have an idiosyncratic dose responsive action at the sigma receptors that is neuroprotective in conditions of oxidative stress. In other words, in delirium haldol may actually save neurons.

 

[whopper]

Another reason why I am very glad you are on this board. If all of us were superheroes, I think you'd be a Superman or Batman, while I'd be a 2nd or 3rd stringer like Blue Beetle or Green Arrow. (Doc Samson--the handle doesn't do you justice).

No sarcasm meant.

 

[elroot]

Largest single dose I've heard of is 100 mg IV. Largest daily total I've heard of is 2800 mg IV. Personally, I've gone as high as 80 mg IV boluses with a daily total of 1800 mg IV.

Thannks Doc Samson. Very high doses. We almost never give haloperidol IV. Not even in delirium. Every here beleives that haloperidol IV should only be given if you can guarantee close monitering the sort you get with cardiac moniters and so on. Where we work cardiac monitrs are hard to come by and i have only 2 doctors who have given quite small doses IV when the patient was cared in a ICU.

What do you guys think. Is it just hype by the people who dont like haloperidol. Or is there real danger? DOses you have suggested will be considered down right dangerous where i work.

 

[Doc Samson]

Another reason why I am very glad you are on this board. If all of us were superheroes, I think you'd be a Superman or Batman, while I'd be a 2nd or 3rd stringer like Blue Beetle or Green Arrow. (Doc Samson--the handle doesn't do you justice).

No sarcasm meant.

Aw shucks... switching to the Marvel universe, I had you pegged somewhere along the Cyclops or Reed Richards spectrum - certainly not a second or third stringer. I'm happy with the ambivalence of Doc Samson, fits the CL lifestyle for sure - just yesterday had one patient thank me for "saving my life" then the patient in the room right next door told me I treated her "like a stray dog." I like Magneto for similar reasons.

 

[Doc Samson]

Thannks Doc Samson. Very high doses. We almost never give haloperidol IV. Not even in delirium. Every here beleives that haloperidol IV should only be given if you can guarantee close monitering the sort you get with cardiac moniters and so on. Where we work cardiac monitrs are hard to come by and i have only 2 doctors who have given quite small doses IV when the patient was cared in a ICU.

What do you guys think. Is it just hype by the people who dont like haloperidol. Or is there real danger? DOses you have suggested will be considered down right dangerous where i work.

Is there risk with IV Haldol? Sure. Is there risk with untreated delirium? Absolutely. So, you're faced with a risk/benefit calculus of the POTENTIAL risk of IV Haldol vs. the immediate and ACTUAL risk of untreated delirium. Should patients on IV Haldol be closely monitored? Yes, but telemetry is not an absolute requirement. Daily 12 lead EKGs and close monitoring of potassium and magnesium (independent predictors of QTc prolongation) should suffice. You should also remember that Haldol is associated with the lowest prolongation of the QTc per dose equivalent of all the neuroleptics.
Also, the doses listed above are outliers by orders of magnitude over what I typically use in day-to-day practice.

I thought this editorial encapsulated the argument nicely:

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

 

[elroot]

Is there risk with IV Haldol? Sure. Is there risk with untreated delirium? Absolutely. So, you're faced with a risk/benefit calculus of the POTENTIAL risk of IV Haldol vs. the immediate and ACTUAL risk of untreated delirium. Should patients on IV Haldol be closely monitored? Yes, but telemetry is not an absolute requirement. Daily 12 lead EKGs and close monitoring of potassium and magnesium (independent predictors of QTc prolongation) should suffice. You should also remember that Haldol is associated with the lowest prolongation of the QTc per dose equivalent of all the neuroleptics.
Also, the doses listed above are outliers by orders of magnitude over what I typically use in day-to-day practice.

I thought this editorial encapsulated the argument nicely:

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

We treat delerium with IM haloperidol and upto now we have not ahd problems. I agree with you with the risk benefit thing 100%. How do you manage acute disturbed behavior in bipolar or schizophrenia when de-escalatio tecniques have failed.

We give IM haloperidol and IM midazolam 5mg each and some patients do get sedated. (All my patients asians by the way)

 

[Piaget]

Awesome man , I had come across this today itself and its discussed here. Well, I got called from ICU staff about a 60 year old guy with stroke currently delirious and agitated last night. The other on call resident started him on iv haldol 5-10 mg q 4 h prn and that helped in controlling his agitation overnight. I saw this patient today however I looked at his EKG as he also have some cardiac problems, his EKG revealed QTc of 524 ms and the patient was again very agitated. Now I was in a fix to whether use further iv haldol, as far as i remember if patient have > 500 QTc its not safe to use any antipsychotic especially convential and geodon. I tried to look in the literature but I didnt get any straight guidlines about use of antipsychotic meds with patients of prolonger QTc due to risk of TDP. I called pharmacy in my hospital and they suggested zyprexa i.m., I was not very convinced with there recommendation however I had a back up to support my decision and we used zyprexa along with close monitoring of potassium and mg , so far its working for him. That said, I think even zyprexa have risk of causing QT prolongation.

Guys epecially our CL experts what are your suggestions on scenario like this ? and any literature to support this ?

 

[kugel]

Should patients on IV Haldol be closely monitored? Yes, but telemetry is not an absolute requirement. Daily 12 lead EKGs and close monitoring of potassium and magnesium (independent predictors of QTc prolongation) should suffice.

1) Many hospitals have instituted policies that "absolutely" prohibit the use of IV Haldol unless there is constant cardiac monitoring. Be sure to know your hospital's policy. If your hospital is the only one in the region that does NOT have such a policy, and there's a bad outcome, you could be in for a "community standard" problem. I'm not saying policies dictate everything about patient care (I'm in trouble at least 1x/month for violating someone's interpretation of policy), but you should KNOW when you're doing it.

2) Even the psych consultant should be helping the primary team find the CAUSE of the delirium. Many will say "it goes without saying," but experience shows it doesn't. I've seen way too many times the Primary Team believed they had adequately treated the pt, "except for this pesky delirium."
DELIRIUM IS A SYMPTOM of serious medical illness.
(okay, I'm down off the soapbox)

Sometimes the "delirium" is caused by the use of PRN antipsychotics and BZD's. One shift gives 6 PRN's, and the next finds the pt over-sedated and gives none, so the next shift finds the pt agitated, and so on.

 

[Doc Samson]

Awesome man , I had come across this today itself and its discussed here. Well, I got called from ICU staff about a 60 year old guy with stroke currently delirious and agitated last night. The other on call resident started him on iv haldol 5-10 mg q 4 h prn and that helped in controlling his agitation overnight. I saw this patient today however I looked at his EKG as he also have some cardiac problems, his EKG revealed QTc of 524 ms and the patient was again very agitated. Now I was in a fix to whether use further iv haldol, as far as i remember if patient have > 500 QTc its not safe to use any antipsychotic especially convential and geodon. I tried to look in the literature but I didnt get any straight guidlines about use of antipsychotic meds with patients of prolonger QTc due to risk of TDP. I called pharmacy in my hospital and they suggested zyprexa i.m., I was not very convinced with there recommendation however I had a back up to support my decision and we used zyprexa along with close monitoring of potassium and mg , so far its working for him. That said, I think even zyprexa have risk of causing QT prolongation.

Guys epecially our CL experts what are your suggestions on scenario like this ? and any literature to support this ?

A few points here:

1) Zyprexa causes the second lowest per dose equivalent prolongation of the QTc after Haldol (something like 6 ms rather than 4 ms - compared to >20 for Geodon).

2) Scheduled IMs are cruel and likely to reinforce any paranoia the patient has.

3) Adding a second neuroleptic further increases the risk of QTc prolongation since they bind to different sites on the delayed rectifier K channel.

4) What was this man's baseline QTc? Is the 524 elevated only after the Haldol or was it already prolonged. If it's elevated at baseline and remains stable after Haldol, I'd continue with the Haldol (I've personally given Haldol IV to a patient with a QTc > 590 - again it's the risk/benefit calculus).

5) Any other QTc prolonging drugs on board? I'd look for fluoroquinolone antibiotics, calcium channel blockers, and methadone to name a few.

6) Don't forget to monitor (and replete to high normal range) the magnesium as well as the postassium

 

[surftheiop]

I dont want to hijack the thread, but reading this made me wonder about something.

what are the "ethics" about letting stuff you read a semi-anonymous online forum play into your clinical decision making?

 

[worriedwell]

My understanding was that IV Haldol has different risks of sudden death than PO or IM Haldol and that IV Haldol will confer more risk than other neuroleptics regarding rhythm disturbances because it is IV. Thus the comparison of Zyprexa to Haldol might be true for PO or IM but when you compare IV, you are now in apples and oranges comparison....

Do you, Doc Samson, have different information?

 

[Doc Samson]

My understanding was that IV Haldol has different risks of sudden death than PO or IM Haldol and that IV Haldol will confer more risk than other neuroleptics regarding rhythm disturbances because it is IV. Thus the comparison of Zyprexa to Haldol might be true for PO or IM but when you compare IV, you are now in apples and oranges comparison....

Do you, Doc Samson, have different information?

I'm not aware of any study that's specifically looked at differences in QTc prolongation of PO vs. IM. vs. IV formulations - though we don't get all bent out of shape when we decide whether to administer Levaquin PO or IV and that carries just as much risk of prolonging the QTc.

 

[Regnvejr]

I dont want to hijack the thread, but reading this made me wonder about something.

what are the "ethics" about letting stuff you read a semi-anonymous online forum play into your clinical decision making?

Always double-check. You are right, when your license is on the line "I got it on the internet" won't give you any points. But it is a good place to get themes for your lit search. Not to mention that the info here does follow best evidences closely.

 

[Regnvejr]

The body can handle a lot of haldol, but I have also been called to the ER for a consult after the attending gave 3 * 10 mg haldol im, and the guy was stiff as a board and barely could move his mouth to talk. He had been agitated and threatened the doctor, however, so he was strapped down and pumped full of stuff. I could just get his mouth open enough for stuffing a cogentin in him and waited. He was REALLY happy to make it to the psychiatric floor instead. Not really happy with the ER after that (he was one of our frequent flyers, but he was a bit more careful about coming into the ER after that).

My max dose has been about 300 mg iv over a few hrs back in residency. Since then, I haven't used much IV, and am a bit more careful with im/po.

Agitated patients coming into the ER are generally suffering an exacerbation of psychotic disorders (relatively easy to manage) or drug addicts with a serious overdose. Those I strap down and give narcan (make sure they are strapped down, they're not real happy being robbed of their high). Then it is easier to see how much haldol they need.

Thankfully, my patients are less severe than Doc Samson's, by far. Good work Doc.

 

[elroot]

T

Those I strap down and give narcan (make sure they are strapped down, they're not real happy being robbed of their high). Then it is easier to see how much haldol they need.

When you strap down do you mean to 'mechanically restrain'? Where i work it is illegal to mechanically restrain . It is only chemical restraint that is allowed. We do have hard time. And some times we wish we could restrain them for a period. We give haloperidol with out any form of mechanical restraint, which might be why we need higher doses. Any thoughts?

 

[Regnvejr]

When you strap down do you mean to 'mechanically restrain'? Where i work it is illegal to mechanically restrain . It is only chemical restraint that is allowed. We do have hard time. And some times we wish we could restrain them for a period. We give haloperidol with out any form of mechanical restraint, which might be why we need higher doses. Any thoughts?

Safety issue. If they are not restrained, then they can hurt you or themselves. As physician, you get to decide whether there is an idication for restraint. Go visit an adolescent psychiatric inpatient unit, and you will notice the existence of restraints, holds and all sorts of stuff. In fact, if they train you right, you will learn various ways of bodily restrain someone out of control before you go onto the unit.

And there normally are policies in place for physical restraints, and several forms to fill oiut as well. There almost certainly is some form of mechanical restraint allowed unless you use a dart-gun f.ex. I have 4-point restrained a person in order to get a blood sugar before, f.ex. 14-year old angry, homicidal boys tend to not let you get near with the meter if they are upset.