Amiodarone may be considered for patients with junctional ectopic tachycardia refractory to treatment with sedation, analgesia, cooling, and electrolyte replacements. There are currently no published pediatric data regarding the hemodynamic effects of the newer amiodarone formulation, PM101, devoid of hypotensive agents used in the original amiodarone formulation. We performed a single-center, retrospective, descriptive study from January 2012 to December 2020 in a pediatric ICU. Thirty-three patients were included (22 male and 11 female) between the ages of 1.1 and 1,460 days who developed post-operative junctional ectopic tachycardia or other tachyarrhythmias requiring PM101. Data analysis was performed on hemodynamic parameters (mean arterial pressures and heart rate) and total PM101 (mg/kg) from hour 0 of amiodarone administration to hour 72. Adverse outcomes were defined as Vasoactive-Inotropic Score >20, patients requiring ECMO or CPR, or patient death. There was no statistically significant decrease in mean arterial pressures within the 6 hours of PM101 administration (p > 0.05), but there was a statistically significant therapeutic decrease in heart rate for resolution of tachyarrhythmia (p < 0.05). Patients received up to 25 mg/kg in an 8-hour time for rate control. Average rate control was achieved within 11.91 hours and average rhythm control within 62 hours. There were four adverse events around the time of PM101 administration, with three determined to not be associated with the medication. PM101 is safe and effective in the pediatric cardiac surgical population. Our study demonstrated that PM101 can be used in a more aggressive dosing regimen than previously reported in pediatric literature with the prior formulation.

‘Rapid tranquillisation’ refers to the use of medication to calm highly agitated individuals experiencing mental disorder who have not responded to non-pharmacological approaches. Commonly it is the initial stage in the treatment of severe and enduring illness. Using medication in this way requires particularly robust evidence of efficacy and the management of side-effects. This article attempts to integrate current understanding of the neurochemical mechanisms of underlying illness and drug actions with therapeutic interventions. It distinguishes arousal from agitation, and effects on sedation from tranquillisation. It reviews critically the practice of rapid tranquillisation in the light of new evidence, changes in the NICE guidelines and British National Formulary recommendations and a national audit (POMH-UK). Broader aspects of management, known as ‘restrictive practices’ (such as control and restraint and seclusion), psychological support of team members, incident reporting, risk assessment, monitoring and medico-legal aspects are not covered.

Background: Staff working on psychiatric intensive care units (PICUs) are routinely exposed to aggression or threats of aggression from the patients they care for. This phenomenon is identified as an ongoing factor that influences both work performance as well as staff sickness, and as such requires understanding and management.

Aims & method: This study utilized questionnaires assessing the extent to which PICU staff thought violence was a problem and how safe and supported they felt. Semi-structured interviews were conducted with five nurses to gather in-depth information on the factors involved in perceptions of safety and support.

Results: The analysis indicated that as a whole, staff feel safe and supported by their immediate team. Interview analysis produced two main domains and ten sub-domains of experiences that contribute to managing threats, these being grouped in either personal or systemic factors. It particularly highlighted that although patient aggression is a concern, the perception of threat most directly relates to beliefs about a lack of support from other teams and senior management, not the patients themselves.

Conclusions: More research and attention is needed on systemic factors in the management of threatening patients.

Aims and method: NICE guidelines provide a framework for decision making with regard to the management of disturbed or violent behaviour in inpatient mental health settings, although also point to the fact that there is a limited evidence base for the use of more high risk interventions such as rapid tranquillisation, restraint, and seclusion. The current study sought to elicit the views of a team of PICU staff regarding their preference for management strategies for such behaviour.

Results: Forty-three staff assigned ranks to five intervention options: restraint to administer medication, restraint without medication, seclusion, individual counselling, and offering PRN medication. The results revealed a clear preference for individual counselling as the first choice of intervention, and offering PRN medication as a second choice. The three remaining options could not be statistically separated.

Clinical implications: The results indicate that respondents viewed the choice of intervention beyond counselling and the offer of PRN medication as an issue of clinical judgement, dependent on a range of factors relevant to the presenting clinical situation. As such they offer support for the current NICE guidelines. The results are discussed with reference to the NICE guidelines, and areas for further study are highlighted.

Evidence suggests violence and aggression are key reasons for admission to Psychiatric Intensive Care Units (PICUs). Research and national guidelines highlight the potential benefits of anger management interventions in this setting, however such interventions are often only offered in a minimal number of units. This paper describes the implementation of a two session cognitive behaviour therapy informed anger management intervention within a PICU setting. Twelve service users completed the sessions. There was a statistically significant reduction in the frequency of violent and aggressive incidents instigated by these patients in the two week period post intervention compared to the two weeks prior. It is possible that participation in anger management sessions contributed to the reduction in violence and aggression; however, large scale, longer term research is necessary controlling for other contributing variables, in order to establish the true effectiveness of this approach.

Background: PICUs traditionally manage patients who can display disturbed behaviour. Recent guidance has advocated patient engagement in outlining preferences regarding management strategies should they display such behaviour.

Aim: To audit the use, within one PICU, of a mechanism that formally records individual patient preference in management of episodes of acute disturbed behaviour.

Method: Two sets of fifteen retrospective case note analyses in an audit cycle.

Results: Initial findings revealed that advance statements were completed by eight of the fifteen patients admitted (53%). Patients’ wishes were followed for two thirds of patients following incidents needing interventions. Following changes to practice, although only minimal improvement occurred in patients completing advance statements, they were completed sooner after admission and, despite more incidents needing interventions, patients’ wishes following episodes of disturbed behaviour were followed in two thirds of those who completed an advance statement.

Conclusion: Use of advance statements regarding management of disturbed behaviour can be introduced in PICUs and this should be advocated.

This commentary aims to explore the benefits of having a designated, specialised clinical lead on the psychiatric intensive care unit (PICU). It discusses the problems, disadvantages and risks of not having such leadership, especially where a multiple consultant psychiatrist model is employed. The impact of clinical leadership on specific aspects of work on the PICU is examined including multidisciplinary team working, patients’ clinical time and safety, decision making, resource expertise, delayed discharges, and staff stress levels. Reference is made to standards in the literature which show that departure from designated leadership on the PICU is unsatisfactory.

Objective: A paucity of research exists on the types of patients admitted to psychiatric intensive care units (PICUs), which is important in terms of identifying patient needs, training and service provision. Questions have also been raised as to whether or not ethnic minorities are overrepresented in these units.

Method: A literature review using MeSH headings from a wealth of databases was performed to identify such studies. In addition studies on ethnic minority overrepresentation in psychiatric care were also identified.

Results: Under a dozen studies were identified, mainly from the UK and Australia. Study designs tended to be basic and heterogeneous, but this was reflected in the nature of the study and the data gained. A typical PICU patient emerged, namely a young schizophrenic detained male, belonging to an ethnic minority (if in an inner city), known to mental health services with previous informal, detained and PICU admissions, admitted due to violence and often possessing a forensic history. If a complex need existed, it was usually substance misuse. The inpatient stay tended to be for less than two months and discharge was usually to an acute ward. Ethnic minorities were overrepresented in PICU care.

Conclusions: The literature review highlighted a paucity of good-quality studies in this field. The establishment of a national association of intensive care units as well as national guidelines can only improve services. The reason for ethnic minority over-representation on these units is still far from clear.

Problems in the acute sector of psychiatric care are not unique to the Netherlands and at an international level appear to be linked to problems that are significant for big cities. The search for an “acute bed” had become more difficult and patients were being placed and transported through the whole country. The three mental health care institutions in Amsterdam joined forces and opened a gateway facility in order to confront the pressure on admissions. The object??ive of this facility was to create a buffer for the relief of acute compulsory admissions and thus reduce the period that patients had to stay in police cells and decrease the number of placements outside the Amsterdam region.

In this article the goals, patient groups and achievements of this interim facility, called the Temporary Admission Unit (TOA), are described.

The TOA has proved to be able to fulfil its promise to function as a buffer towards the secure admission units in Amsterdam. For a small group of patients (13%) a short admission period on the TOA is sufficient and they can be discharged immediately. The average occupancy rate of the beds of 5 (out of 8 beds) means that the TOA can usually guarantee availability of beds for acute admissions. Between 2000 and 2002 the number of guest placements outside Amsterdam has drastically lowered, along with a gradual rise in the number of compulsory admissions. Finally, the waiting time in the police stations has been diminished considerably.

The advantages of the TOA are clear. Expensive (nocturnal) ambulance transport can be avoided. The stay in the police cell is reduced and the patient arrives in a facility where psychiatric care is available with greater speed. Contact with a regular therapist and therefore continuity of care guarantees a better situation than when the patient is admitted in a distant facility. The same holds good for family contacts.

Background: The principle that patients should be cared for under conditions of no greater security than is justified is well established and applies to patients cared for on psychiatric intensive care units.

Aims: This audit aimed to establish: (1) the characteristics of patients admitted to a PICU, (2) whether patients experienced delays in discharge to care in lower levels of security and (3) the characteristics of patients who experienced a delayed discharge.

Method: An audit survey of the case notes of patients discharged from an inner city PICU in 2005 to establish compliance with the standards described.

Results: Of 109 patients discharged from the PICU, 88 were included in the survey. 51.1% of patients experienced a delay in discharge from the PICU. The characteristics of the patients discharged from the PICU are described, and compared with those experiencing a delay in discharge.

Conclusions: Patients often experience a delay in discharge to clinically appropriate levels of security from a typical PICU. The source of referral of patients and diagnosis are associated with a delay in discharge. The findings warrant wider study.

Background: The role of psychiatric intensive care units is well established for the general adult psychiatric population, but these units are often less suitable for the elderly psychiatric population. An increase in the number of behaviourally challenging demented male patients in the elderly psychiatric admission wards of one Scottish health region created an opportunity to develop a psychiatric intensive care unit for elders with these problems (PICUe).

Method: Prospective survey of activity in the PICUe during 2005, using routinely collected data.

Results: 14 male patients, mean age 70 years, were admitted to the PICUe on 17 occasions during 2005, with 76% detained under the Mental Health (Scotland) Act, 1984. The majority (43%) of patients had a primary diagnosis of Alzheimer's dementia, 21% with vascular dementia. The main transfer reason was resistive behaviours, with persistent physical aggression being the next most common reason. The average mini-mental state score was 14/30, and the mean duration of patient stay in the PICUe was 46 days, with 71% of admissions discharged from the unit during the evaluation period. Benefits were noted for referring clinical teams and for patients.

Conclusions: The results suggest that a regionally-based psychiatric intensive care unit for older adults can serve a useful function in the management of disturbed elders who are otherwise difficult to manage within the current hospital-based elderly psychiatric care facilities.

This paper highlights the many complex psychological needs of paediatric patients in intensive care. The literature on the experience of children in intensive care and their relatives is reviewed and related to the work of a paediatric psychologist. Case examples are given of direct work with children and suggestions are made of ways in which the psychologist can work in a consultation/liaison capacity. The personal impact of this work is addressed, as is the need to disseminate information to other health professionals. Further research is called for, both on the child's experience and on the development of appropriate psychological interventions.