AtivanGeneric Name:Lorazepam(lor-a´ze-pam)
Brand Name:Ativan
Classifications:central nervous system agent; anxiolytic; sedative-hypnotic; benzodiazepine
Pregnancy Category:D

Availability:
0.5 mg, 1 mg, 2 mg tablets;  2 mg/mL oral solution;  2 mg/mL, 4 mg/mL injection

Actions
Most potent of the available benzodiazepines. Effects (anxiolytic, sedative, hypnotic, and skeletal muscle relaxant) are mediated by the inhibitory neurotransmitter GABA. Action sites: thalamic, hypothalamic, and limbic levels of CNS.

Therapeutic effects
Antianxiety agent that also causes mild suppression of REM sleep, while increasing total sleep time.

Uses   
Management of anxiety disorders and for short-term relief of symptoms of anxiety. Also used for preanesthetic medication to produce sedation and to reduce anxiety and recall of events related to day of surgery; for management of status epilepticus.

Contraindications
Known sensitivity to benzodiazepines; acute narrow-angle glaucoma; primary depressive disorders or psychosis; children <12 y (PO preparation); coma, shock, acute alcohol intoxication; pregnancy (category D), and lactation.

Cautious use
Renal or hepatic impairment; organic brain syndrome; myasthenia gravis; narrow-angle glaucoma; suicidal tendency; GI disorders; older adult and debilitated patients; limited pulmonary reserve.

 

Route & dosage

Antianxiety
adult: PO  2–6 mg/d in divided doses (max: 10 mg/d)
geriatric: PO  0.5–1 mg/d (max: 2 mg/d)
child: PO/IV  0.05 mg/kg q4–8h (max: 2 mg/dose)

Insomnia
adult: PO  2–4 mg at bedtime
geriatric: PO  0.5–1 mg h.s.

Premedication
adult: IM  2–4 mg (0.05 mg/kg) at least 2 h before surgery
IV  0.044 mg/kg up to 2 mg 15–20 min before surgery
child: PO/IV/IM  0.05 mg/kg (range: 0.02–0.09 mg/kg)

Status Epilepticus
adult: IV  4 mg injected slowly at 2 mg/min, may repeat dose once if inadequate response after 10 min
child: IV  0.1 mg/kg slow IV over 2–5 min (max: 4 mg/dose), may repeat with 0.05 mg in 10–15 min if needed
neonate: IV  0.05 mg/kg over 2–5 min, may repeat in 10–15 min

 

Administration

Oral

  • Increase the evening dose when higher oral dosage is required, before increasing daytime doses.

Intramuscular

  • Injected undiluted, deep into a large muscle mass.

Intravenous    


  • IV administration to neonates, infants, children: Verify correct IV concentration and rate of infusion with physician.
  • Patients >50 y may have more profound and prolonged sedation with IV lorazepam (usual max: initial dose of 2 mg).

PREPARE  direct: Prepare lorazepam immediately before use. Dilute with an equal volume of sterile water, D5W, or NS.
ADMINISTER  direct: Inject directly into vein or into IV infusion tubing at rate not to exceed 2 mg/min and with repeated aspiration to confirm IV entry. Take extreme precautions to PREVENT intraarterial injection and perivascular extravasation.
Incompatibilities  Y-site:  Idarubicin, Omeprazole, Ondansetron, Sargramostim, Sufentanil, TPN with Albumin.

  • Keep parenteral preparation in refrigerator; do not freeze.
  • Do not use a discolored solution or one with a precipitate

Adverse effects
BodyWhole:
Usually disappear with continued medication or with reduced dosage.
CNS:Anterograde amnesia, drowsiness, sedation, dizziness, weakness, unsteadiness, disorientation, depression, sleep disturbance, restlessness, confusion, hallucinations.
CV:Hypertension or hypotension.
SpecSenses:Blurred vision, diplopia; depressed hearing.
GI:Nausea, vomiting, abdominal discomfort, anorexia.

Nursing implications  

Assessment & Drug Effects

  • Have equipment for maintaining patent airway immediately available before starting IV administration.
  • IM or IV lorazepam injection of 2–4 mg is usually followed by a depth of drowsiness or sleepiness that permits patient to respond to simple instructions whether patient appears to be asleep or awake.
  • Supervise ambulation of older adult patients for at least 8 h after lorazepam injection to prevent falling and injury.
  • Lab tests: Assess CBC and liver function tests periodically for patients on long-term therapy.
  • Supervise patient who exhibits depression with anxiety closely; the possibility of suicide exists, particularly when there is apparent improvement in mood.

Patient & Family Education

  • Do not drive or engage in other hazardous activities for a least 24–48 h after receiving IM injection of lorazepam.
  • Do not drink large-volumes of coffee. Anxiolytic effects of lorazepam can significantly be altered by caffeine.
  • Do not consume alcoholic beverages for at least 24–48 h after an injection and avoid when taking an oral regimen.
  • Notify physician if daytime psychomotor function is impaired; a change in regimen or drug may be needed.
  • Terminate regimen gradually over a period of several days. Do not stop long-term therapy abruptly; withdrawal may be induced with feelings of panic, tonic–clonic seizures, tremors, abdominal and muscle cramps, sweating, vomiting.
  • Do not self-medicate with OTC drugs; seek physician guidance.
  • Discuss discontinuation of drug with physician if you wish to become pregnant.
  • Do not breast feed while taking this drug.