Antidepressants in Sedated/Comatose Patients

[blondy2061h, MSN, RN]

I'm wonder what experiences people have had with this. What do you do with patients who have been on long term antidepressants and are now unable to swallow due to being unconscious or sedated and intubated? I am particularly thinking of patients who have already had some type of entral tube placed for either other critical medications or feeding. I seem to see two trains of thought on this. The first is that if a patient is expected to make a recovery in a relatively short period of time (say more than 3 or 4 days where holding the med might not make a difference but less than 2-3 weeks), holding the med means they could take weeks to become therapeutic on a med again, or could cause physiological withdraw symptoms, therefore, if possible, give it.

The other train of thought is of course that they won't be symptomatic emotionally of depression while sedated/comatose, and fewer meds is better, especially when considering that a patient in this situation would be on tons of meds anyway.

So what have you been seeing? Anyone else have any rationales to add?

[blondy2061h, MSN, RN]

Anybody have an experience with this? Maybe this would be better in critical care nursing?

[WillyNilly]

I would continue to give because most psych meds require a step down approach unless the dr wishes to dc them. I always give psych meds and heart meds first then follow up with the others. What happens if they wake up and are unmedicated or delirious? It may be harder to control s/s.

[sapphire18]

Just wrote a long post that got lost. Yes I think they should be continued unless there's a very good reason not to. Some doctors say "they don't need them" while some make every effort to continue them. The only one that's hard is cymbalta bc it can't be crushed or opened.

[blondy2061h, MSN, RN]

Thanks for your responses! That's my thought too, unless they're so critically ill that they're not expected to recover or having kidney/liver issues.

[Here.I.Stand, BSN, RN]

Almost all of our pt's have a route to give pills--NJ, PEG tube, etc. We crush the antidepressant (assuming it's not a CR, etc.) and give it per tube, just like we give them any other med that is not available as an elixir or not favorable IV. If they are not expected to recover and the family has decided to do comfort care (which we see often b/c of our SICU includes neuro), then all meds are d/c'ed except ones that promote comfort--our palliative dr's like Ativan, morphine, atropine/scopalomine for secretions.

So short answer, if we can we give them.

1.) They might be intubated/sedated for a matter of days. If it looks like they will need longer-term ventilatory support they will get a trach and then *generally* not be sedated. 2.) Wherever possible, we do a daily "sedation vacation" where they have the sedation held. This is to assess their need for vent settings and to decrease the likelihood of delirium. In both these cases, we would hate for these people to have rebound sx after suddenly d/c'ing a psych med.

3.) Being sedated doesn't mean they can't feel. Unless they are under *deep* sedation, they will wake up sometimes, like during cares. Even if they look like they're asleep, I like to remember that they're not asleep in the sense that we sleep at the end of our day. We can't know with absolute certainty what they are experiencing. We pay attention to what we say in the pt's room, right? Treat their pain even though it looks like they're sleeping, right?

Hope this helps!

[Here.I.Stand, BSN, RN]

*Sorry, I'd stepped away overnight and for some reason was thinking I was on the student board...I've replied on some posts there b/c I love students but am WAY too terrified of public speaking to ever consider teaching when I grow up. lol! I was thinking "advanced student doing a capstone in an ICU." Anyway, that's why I explained stuff as I went. I didn't mean to talk down to a working ICU RN.

[blondy2061h, MSN, RN]

*Sorry, I'd stepped away overnight and for some reason was thinking I was on the student board...I've replied on some posts there b/c I love students but am WAY too terrified of public speaking to ever consider teaching when I grow up. lol! I was thinking "advanced student doing a capstone in an ICU." Anyway, that's why I explained stuff as I went. I didn't mean to talk down to a working ICU RN.

I appreciate your thoughts, thank you! I don't have a lot of experience with intubated patients, but I do see patients that aren't able to swallow pills for a variety of reasons, and I'm seeing these meds held a lot. It's good to hear others' experiences.

[applewhitern, BSN, RN]

Not all antidepressants are given strictly for depression; some people take them for anxiety, OCD, etc. Some antidepressants, like Paxil for instance, should not be stopped abruptly, but need to be weaned off. If it were up to me, I would continue them, but our doctors usually discontinue them.