Guys, It's been bugging me...last night in the ICU...I had a guy who was weaned off the ventilator on the 5th of August...he had awful Alcohol withdrawal and DTs the previous 2 weeks which made him be on an Ativan GTT...so last night he was on Alcohol withdrawal protocol...this guy was climbing out of the bed yelling, VSS, and I ended up giving the guy 2 mg IV Ativan...one hour later 3mg, 2 hours later 2 mg of Ativan so a total of 7...he was breathing fine but definitely zonked in the AM and the dayshift nurse was like, "Whoa, 7 mg of Ativan IV, Geez he's gonna be back on the vent because he might get pneumonia because he can't effectively cough!" I was like, "you should have been there last night and I felt he needed it..."...Is this too much in your honest opinion...to me, I asked several nurses in the ICU if this was too much and they said, "absolutely not due to his history of DTs the last couple of weeks and his being on an Ativan GTT a few days earlier in his hospitalization...
Heck no! For any other non-intubated patient, it might be too much but for the patient in DTs (especially at night when everyone gets nuts) 7mg is not too much. I've even had non-intubated patients on Ativan DRIPS before.
Ativan doesn't really affect breathing too greatly...other than it might slow it down if the patient is hyperventilating d/t anxiety or withdrawl. 7mg is really not that much. I have seen patients on 50-60mg per hour on a drip and not intubated. It is basicallly used to prevent seizures and control the withdrawl from alcohol/other substances.
One other point: One of the risks of ETOH w/d is seizure - and what drug do we commonly give for seizures? Ativan, which is also considered an anti-convulsant.
considering he had been on an ativan gtt for detox, he likely built a tolerance.
compound that with his agitation, his threshhold was even higher.
think of it this way:
those few hrs that he was yelling, those lungs of his were being expanded and was working those secretions...
decreasing his risk for pneumonia.:)
but since the acuity of his detox s/b over, it's time to consider meds for the long term, including one that addresses probable, forthcoming agitation- if he stays off the booze.
you're fine.
he's fine.
it's all good.
leslie
I agree last nite I gave 4 mg (PRN) IVP of ativan for bad agitation and then 4 hrs later my preceptor had me give 4 mg more he was yelling hollering and fighting but then before the end of the shift I found out the 2 doses I gave were suppose to be IM not IVP I checked the pt all night after giving it and all it did was let him sleep for a couple of hrs and then he would start all over again--he was an alcoholic prior to coming into hospital I finally called the doc and got wrist restraints but it still bothered me that I gave it IVP rather than IM although there is no way I could have given it IM he would not have let me---he pulled out 3 IVs that had to be replaced he sure wasn't about to let me give an IM so it just kinda bothered me
Asked a MD why we don't give Haldol to DT patients and was told it increases the chance of seizure.
Had a patient who had serious DTs, was getting Ativan for 72HRs 2mg oral Q2H and 1mg IM Q3H. Didn't sleep a wink for 3 days kept on trying to get OOB (he fell once) and was on restraints for about 36 of those 72hrs. Plus when he would fight on restraints or try to get OOB he'd go from 110-120bpm to 160-180bpm.
I don't know if you guys use the WAS protocol at all, but I've had patients where I'm giving 12 mg every hour. Keep in mind that these patients are usually on the vent. However, I have even given that much to non-vented patients who are having bad DTs.
Asked a MD why we don't give Haldol to DT patients and was told it increases the chance of seizure.
Had a patient who had serious DTs, was getting Ativan for 72HRs 2mg oral Q2H and 1mg IM Q3H. Didn't sleep a wink for 3 days kept on trying to get OOB (he fell once) and was on restraints for about 36 of those 72hrs. Plus when he would fight on restraints or try to get OOB he'd go from 110-120bpm to 160-180bpm.
I also have a pt similiar but would not recommend Haldol either b/c haldol makes a bad,situation worse I'd recommend Geodon unless co traindicated
First of all, it was pretty crappy for those dumb nurses to try to make you feel bad about a decision you made...
And 7 mg of ativan for a detoxer is NOTHING!! Ive seen a guy get 30 once, and it still didnt touch him.
I was taught that 2 mg of Ativan = 1 drink... So you figure if that person is used to drinking 1 drink per hour (which I highly doubt they drink that little) you can give 2 mg per hour and be ok... In my hospital we never skimp on the Vitamin A...
It all depends on the situation. I've had a guy with DT's on an ativan drip at 6/hr and multiple 5mg boluses. In 8 hours he had be given over 150mg and was still very agitated and trying to tear off restraints. On the other hand, I've had people going thru w/d but not dt's and they got pretty sedated from 4mg in 2hours.
Also a possibility is that he was in benz withdrawl - we see this quite a bit when docs turn off versed gtts that have been running at like 5 mg/hr for days.
I don't think 7 mg is anywhere a huge dose, but I've given acute DT'ers somewhere in the neighbourhood of 40 mg of Valium and they still keep on ticking.
Im sitting here shaking my head at the nurses referring to Ativan as a chemical restraint and too scared to use it.. You think you're advocating for the patient by not "restraining" them.. by allowing them to be anxious, agitated and confused, putting them at risk for injury and arrythmias, not to mention the horrifying hallucinations and everything else that comes along with it... Hellooooooo its not about you or your beliefs, its about the patient and what's best for them...
We had a DT pt. just last night that was on 10mg/hr Ativan gtt. Our CCU has also had pt's going thru DTs on an Ativan & Diprivn gtt simutaneously the whole time still talking .
ccuCCRN
7 Posts
Heck no! For any other non-intubated patient, it might be too much but for the patient in DTs (especially at night when everyone gets nuts) 7mg is not too much. I've even had non-intubated patients on Ativan DRIPS before.