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detoxing in ICU setting

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I am soliciting the much needed help of all of your seasoned psych nurses. :yeah:

I work in a busy medical/surgical/trauma ICU. We see all kind of patients with drug problems:

1) The saturday night alcohol/drug indulger who gets intubated for various reasons. They usually are extubated the next day. Some leave AMA. For a few, it is a one-time event. The staff and their families are supportive and they leave having learned a hard lesson.

2) The adolescent/young adult whose will is broken by 10 strong males and a few screaming doctors and nurses.

3) The long-term (10+ years) drug/alcohol abuser who ends up in the unit for either a severe medical or trauma-related issue. I assume that many, but not all, have some sort of underlying behavioral or psych issue. They are often heavily sedated in the beginning of their stay with benzos and opiates. (It takes large hourly doses of drugs to keep these patients down.) As they get better and are extubated, they become difficult to handle. They are not well enough to be transferred to a step-down unit and thus I am left trying to manage their behavior and treat their medical issues. And it is their behavior (and that of their families) that is driving me insane! Families expect us to force the patient to be compliant with medical care.

I've seen small doses of benzos/opiates have a rebound effect on some of these patients. This leaves them either in a stupor or agitated/anxious. It becomes hard to separate the psych issues from the medical issues. I guess we are underdosing some patients and others are just a puzzle. Confrontations happen and has little therapeutic effect. We do not have a psych unit in our hospital. We can consult psych, but they don't address withdrawal and don't give us much relief when it comes to the behavioral issues. Sometimes it takes the whole unit to manage these patients.

Is there a public or private resource somewhere that can help us? Some of my worst nights have been with detoxing patients. Our rooms are not set up for safety and it is hard to get one-on-one observation unless the patient is suicidal. :loveya:

Classicaldreams

Jules A, MSN

Specializes in Family Nurse Practitioner.

The hardcore addicts are rough on us all. I really appreciate your writing because so many times I feel as if ICU is trying to pawn them off on us as soon as the hemorrhage slows to a trickle. You really should have a detox protocol and someone who will write scripts for psych meds for patients that have a history of mental illness in addition to addiction which is probably most of them. Detoxing can be life threatening and should be addressed. Having them put back on their psych medications should really help also. Very often the patients I get from ICU have been pumped fulll of benzos and pain meds round the clock so when they come to us they are wd-ing from even more than what they came in with. This makes an already irritable, entitled population even more oppositional to deal with on the psych floor. I know how difficult they are and fwiw the psych unit is even lower on the list for 1:1 staff because we are supposed to know how to handle these patients. :o I hope you get a decent response here and again thank you for writing.

The hardcore addicts are rough on us all. I really appreciate your writing because so many times I feel as if ICU is trying to pawn them off on us as soon as the hemorrhage slows to a trickle. You really should have a detox protocol and someone who will write scripts for psych meds for patients that have a history of mental illness in addition to addiction which is probably most of them. Detoxing can be life threatening and should be addressed. Having them put back on their psych medications should really help also. Very often the patients I get from ICU have been pumped fulll of benzos and pain meds round the clock so when they come to us they are wd-ing from even more than what they came in with. This makes an already irritable, entitled population even more oppositional to deal with on the psych floor. I know how difficult they are and fwiw the psych unit is even lower on the list for 1:1 staff because we are supposed to know how to handle these patients. :o I hope you get a decent response here and again thank you for writing.

Jules A:

Thanks so much for responding. Yes, we are guilty of pawning, I'm afraid. Your instincts are correct.

Some of us do try to address the issue before they come to you. Sometimes, though, it is difficult to assess whether their behaviorial issues are psych related or related to some medical issue. (Change in mental status is one of the key indicators that something medically is impending.) I've spent countless hours soliciting help, but only so much can happen in 12 hours. I've advocated that they stay in the unit until they are both more behaviorally and medically stable, but that doesn't happen, of course.

It is somewhat easier if they have a psych diagnosis, but many times that isn't so. I think they probably are functional enough that they haven't had the need for psychiatric help prior to the illness/trauma. Then whatever coping mechanisms they used in the past don't work when under such severe stress.

And those who have psychiatric diagnoses do not receive their psych meds when so critically unstable. I had no idea going into the ICU how much disfunctionality I would encounter. I think in general, most nurses are pretty resourceful, so we forget or don't understand those who have so little in reserve.

I've done a little research on finding a detox protocol, but haven't found much. If you know of one, please let me know.

Perhaps this is an inner city problem that will spread and get more attention in the future.

Thanks again for responding.

Classicaldreams

Whispera, MSN, RN

Specializes in psych, addictions, hospice, education.

There is a tool called the CIWA that I've used in the past. There's one for alcohol and one for other drugs. I did a quick search and came up with this site, but there were many more listed. I've also used the alcohol CIWA to assess symptoms of other-drug withdrawal. It's important to be able to assess changes as they happen, so you can treat symptoms before you get to full-blown DTs.

http://images2.clinicaltools.com/images/pdf/ciwa-ar.pdf

I've seen over and over again, that psychiatric patients don't get their psych meds while they're hospitalized unless someone points it out to the doctor, and sometimes not even then. There's a withdrawal factor to some of these meds (not getting serotonin reuptake inhibitors for depression can lead to intense GI symptoms). Also, if a psych patient doesn't get his or her meds while hospitalized, there's a HUGE risk that the psych symptoms will be back as bad as they were before the patient began taking the meds in 3-7 days. Full blown schizophrenia or bipolar disorder symptoms are a definite complication in a patient recovering from medical problems. The nurse has to be aware and advocate for the patient in this.

There is a tool called the CIWA that I've used in the past. There's one for alcohol and one for other drugs. I did a quick search and came up with this site, but there were many more listed. I've also used the alcohol CIWA to assess symptoms of other-drug withdrawal. It's important to be able to assess changes as they happen, so you can treat symptoms before you get to full-blown DTs.

http://images2.clinicaltools.com/images/pdf/ciwa-ar.pdf

Thanks for the link. I've seen this on the internet. Do you know of an accompanying med dosage that goes along with the scale?

I've seen over and over again, that psychiatric patients don't get their psych meds while they're hospitalized unless someone points it out to the doctor, and sometimes not even then. There's a withdrawal factor to some of these meds (not getting serotonin reuptake inhibitors for depression can lead to intense GI symptoms). Also, if a psych patient doesn't get his or her meds while hospitalized, there's a HUGE risk that the psych symptoms will be back as bad as they were before the patient began taking the meds in 3-7 days. Full blown schizophrenia or bipolar disorder symptoms are a definite complication in a patient recovering from medical problems. The nurse has to be aware and advocate for the patient in this.

I agree my unit needs education on this whole matter. Because some of the meds can have a sedating effect, I think our hospitalist/intensivists tend not to give them at all. Much easier to just not give them, rather than to think about when and how these meds will interact with the sedation currently ordered. Does your unit consult psychiatry on day 1 and are they helpful?

Thanks for the response.

Classicaldreams

Whispera, MSN, RN

Specializes in psych, addictions, hospice, education.

In my last hospital job I was the clinical nurse specialist of a behavioral health resource team. Doctors on medical units did not consult us. We made rounds of all the units and asked the nurses if they needed us to help them. We'd make recommendations for the nurses to discuss with the doctors and charted in the doctors' notes so the docs could see we'd been there, and they could choose to use our recommendations or not. Some did and some didn't. The nurses, for the most part were glad for the help, but often they didn't call us or tell us about a potential problem until it was an actual problem. We'd get involved with the addict was tearing his room apart or the alcoholic was hallucinating sometimes, but not before that.

Psychiatric services were seldom consulted (the doctorly type) for patients on medical floors unless they were obviously psychiatrically challenged, suicidal, or out of control, and sometimes not even then.

Incidentally, my team was eliminated a few years ago because it was generally felt that we weren't needed. Then a doctor took over psych duties in the overall hospital, found it was too intense, and the team was restarted...but I'd moved on.

In my last hospital job I was the clinical nurse specialist of a behavioral health resource team. Doctors on medical units did not consult us. We made rounds of all the units and asked the nurses if they needed us to help them. We'd make recommendations for the nurses to discuss with the doctors and charted in the doctors' notes so the docs could see we'd been there, and they could choose to use our recommendations or not. Some did and some didn't. The nurses, for the most part were glad for the help, but often they didn't call us or tell us about a potential problem until it was an actual problem. We'd get involved with the addict was tearing his room apart or the alcoholic was hallucinating sometimes, but not before that.

Psychiatric services were seldom consulted (the doctorly type) for patients on medical floors unless they were obviously psychiatrically challenged, suicidal, or out of control, and sometimes not even then.

Incidentally, my team was eliminated a few years ago because it was generally felt that we weren't needed. Then a doctor took over psych duties in the overall hospital, found it was too intense, and the team was restarted...but I'd moved on.

Thanks for the reply. I googled the term "behavioral health resource team" and actually received a few useful links. If you know of any resources, please let me know.

Classicaldreams

Whispera, MSN, RN

Specializes in psych, addictions, hospice, education.

Sometimes med/surg hospitals have a psychiatric liaison who is someone who does what the behavioral health resource team did where I worked. It's just another term for it. You might google that.

What Whispera is referring to is typically referred to as "psychiatric consultation-liaison" (team, or service, or whatever). I've done that type of work, also, and part of our job was managing medical detox on the medical center's medical units, including the ICU (the medical center's policy was that detox was a medical issue, not a psychiatric issue, so all detox clients were admitted to medical beds -- if they needed psychiatric tx, they were transferred after they completed the detox and were medically stable. I wish all facilities would take that approach!!) We used the CIWA protocol with "sliding scale" benzos for ETOH, benzo tapers for benzo withdrawal, and the standard protocol for opiate withdrawal (we also referred people to ongoing inpt or outpt drug/alcohol treatment at discharge, if they were willing). In my experience, the physicians and staff were delighted to have our services available to them, and the physicians v. rarely disagreed with our recommendations.

There is plenty of "how to" literature available out there.

My hospital has psych liaison nurses. I page one of them, tell her what is going on (someone who may be difficult to handle or maybe isn't coping well) and she comes up to see the patient. She is able to spend time with the patient and then make recommendations either for me to talk to the doctor about or often she just talks to the doctor himself/herself. I love having this resource available. I wonder how many hospitals across the nation have this kind of resource available.

I wonder how many hospitals across the nation have this kind of resource available.

Not enough -- any time since then that I've described my former PCLN position, everyone I've talked to has oooh'd and ahhhh'd and said, "Wow, I really wish we had something like that here!!!"

Lots of places have psych services available where a physician can order a psych eval of a client and a psychologist or SW comes to see them, but that's v. different from a true consultation-liaison service. My favorite way to describe my old job was, "Whenever there's some big, ugly problem anywhere in the medical center that no one else knows what to do about, the answer is to call us and ask us to please come fix it." (And we did! :))

Edited by elkpark

Elkpark, you are so right! I really appreciate our psych consult nurses and all they do!

SlightlyMental_RN

Specializes in chemical dependency detox/psych.

As someone that works in a free-standing (hospital-associated) detox facility, I'm glad to read of someone in ICU that is trying to understand the medical difficulties posed by detox. Here the main scales that you should be using:

CIWA--for alcohol withdrawal. Our facility's standing orders are: CIWA 8-11 1 mg lorazapam, CIWA 12+ 2 mg lorazapam. May repeat hourly. Other standing orders include clonidine 0.1 mg available for b/p > 150/100 and metoprolol for HR > 110. We use vistaril 50 mg to combat nausea/vomiting (use IM or PO) and for anxiety and sleep. Additionally, patients generally need an IM of thiamine on admit to stave off Wernicke-Korsakoff syndrome--followed by PO administrations.

COWS--for opioid withdrawal. We alternate clonidine and tramadol for scales. Additionally, we have meds available for diarrhea, stomach cramping.

Benzodiazapine withdrawal scale--we use this with phenobarbital available for high scales--mainly we worry about seizures from this withdrawal.

SWS--for stimulants.

I would recommend that you have a MD that is familiar with these scales to set up standing orders so that you can deal more effectively with these types of patients. They aren't easy, I know!:D

Just wanted to thank everyone for your replies.

We do have psych for consult, but they don't get involved in our detoxing patients. In fact, rarely do they get involved at all, unfortunately.

I'll do more research on the scales and try to initiate some sort of protocol.

Classicaldreams

JenTNRN

Specializes in Oncology and Psych. Has 2 years experience.

My Psych hospital has a inpatient 5-7 day detox unit. Etoh detox protocols we use are Ativan 2mg or Librium 50mg every hour for Ciwa scales >10. Using the Ciwa, we assess every four hours under 10. If initial assessment is 10 or greater, then assess 1 hour after medication thereafter until you get it under a 10. CIWA assessment assesses for the following s/s and you score them accordingly.I would grab a CIWA and read over it. Is the pt nauseaus, dry heaving, vomiting, mild-severe tremors present, level of orientation, mild-severe anxiety, HA or head fullness, mild to severe agitation present, sweaty palms or drenching sweats, is the pt hearing, seeing, or feeling things not there. This can be as mild as lights hurting their eyes, numbness or pins needles in fingers, sounds seeming too loud. Or the A/V/T hallucinations can be as severe as hearing/seeing things not there or feeling bugs crawling on them. If they are having severe A/V/T hallucinations and do not normally have them, then they are most likely heading for deliurium. The assessment is subjective and objective. I use VS as a tool, but if they have hypertension or cardiac hx, it makes it difficult to tell, but most people detoxing from ETOH, will have elevated BP and HR. Also, we give vitamins. Every pt detoxing from ETOH gets an initial Thiamine 100 mg IM, then thiamine 100mg po, pyrioxidine 100mg po, and a MVT daily for 7 days. A lot of pts detoxing from ETOH will not have any s/s until 24-48 hours after last drink. I always ask how much they drink daily and for how long and when last drink was. The ones I generally worry about are the ones that drink 12-24 beers or generous amt of liquor daily for long period of months or years, or that amount 4 days or more a week. Opiate addicts detoxing are not a medical emergency, but they are uncomfortable. They will have severe cravings, stomach cramps, leg cramps, diarrhea, increased anxiety and agitation, dilated pupils, piloerection, and mood lability and verbal aggression. Also, if you have someone that's been on benzos for awhile are at risk for seizures and it is dangerous to be cut off all at once on their benzos. We usually titrate them down for 5-7 days and monitor for withdrawals like increased anxiety, agitation, elevated BP. The hallmark with them is tachycardia. Hope this helps! Good luck!