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...
As stated above, the pt could be going thru withdrawal from the ativan. Shouldn't someone on large doses be tapered down? 7mg is probably a taper dose.
Chemical restraint? Are you f-ing kidding me? Sorry, but I withdraw a lot of guys and lorazepam is used for their safety. I can't beleive I have to explain this.....that level of aggitation, the yelling the wigging out - is that not a sign of an overactive nervous system? I'm pretty sure she didn't give the drug with the intent on knocking him cold, but more that she saw a hyperactive state and considered his safety. We do have protocols we follow and certain symptoms get scored and depending on the score - protocol says you push the med. Good grief.....nurses like you made me hate nursing school. Please don't take students.
Try using a precedex drip. It totally works. There's no respiratory depression and it mellows them out big time! You won't need nearly as much ativan or narcs for that matter.
I have a couple points, first of all most DTs follow a time line, but I have seen patients start to DT while still legally intoxicated, and seen them DT for weeks. I worked in Southern Mass. and we had very high alcoholic population, we had an escalating DT protocol that on third level had 12 mg Ativan every 15 minutes when high on the CIWA scale, the we started Propofol drip (which I did not like but it was the protocol). You did the right thing, once DTs are out of control is very hard to get them back down. A lot of alcoholics have two speeds with no in between, patient was breathing, stable???? NP. Also if doc did not want pt to have the med he would not have ordered them.
I saw 30mg pushed before a guy was on a vent. We only ended up tubing this guy so we could give him more ativan. They are HIGHLY tolerant. I think this guy ended up having 50mg IV Ativan pushed in the matter of 2 hours, then placed on a drip once tubed and propofol. Still needed wrist restraints, it was insane.
Ummm, on another note, we don't all cough in our sleep and if we get a few hours of being zonked which is all that nurse was going to get out of him if she is lucky, he isnt going to get pneumonia. We don't....
I dont' see that as a chemical restraint at all. I see it as treatment for agitation and injury prevention. The dose was not excessive. Although acute withdrawal MAY have been finished, that short amount of time doesn't completely rewire their nervous system to eliminate all tolerance within that time period. Coupled with the drip they had been on 7mg sounds very appropriate.
at my hospital it is policy that ativan, haldol, etc. are considered 'chemical restraints' and they cannot be ordered for a patient unless the patient has a documented history of dementia and/or pt is etoh detox (ativan). it's not our call whether or not we can use it; many MD's just won't order it at all. of course they won't order anything.. and expect the seven nurses on my 42-bed telemetry unit to use 'enhanced supervision' to ensure patient safety. we do the best we can.
Try using a precedex drip. It totally works. There's no respiratory depression and it mellows them out big time! You won't need nearly as much ativan or narcs for that matter.
I had a preceptorship in the ICU during school. My first patient was a relapsed ETOHer with pancreatitis on a vent. He was on precedex, versed, insulin, and heparin drips and had SL and IV ativan. (That was the first time I ever saw that many IV pumps and lines. Wow.) 300 pounds and still swinging for the fences every chance he got and they could not wean him off the vent.
The nurse I was working with was hot at the MD for using versed instead of propofol.
Etoh works on GABA. Ativan, versed, propofol, valium work on GABA. Precedex works on Alpha 2 (clonadines big brother). All are acceptable for withdrawl. Fentanyl may help relax the person too, but it is not for the withdrawl and may contract the spincter of oddi (pancreatitis problem, but not at the same degree as morphine). Pancreatitis is severly painful, perhaps this person was having some withdrawl and a lot of pain. Hydromorphone (dilaudid) may have helped this person. I don't know why the nurse you were with was upset with the versed. It does cost more, also does have a shorter duration of action (eliminated quicker).
cargalrn
51 Posts
As stated above, the pt could be going thru withdrawal from the ativan. Shouldn't someone on large doses be tapered down? 7mg is probably a taper dose.