Icu Psychosis

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by traumarns
Oct 4, '02 Views: 4,843 Comments: 14

hi guys,
I have a patient that totally perplexes me.

63 yo man was admitted 3weeks ago for bilat PE's. then found to have an arterial clot in his rle, went emergently to or for embolectomy. the intensivist (genius she is i might add) ordered tee, he was found to have a patent foramen ovalis. pediatric cardio surgeon repaired the foramen, and then cardiologist inserted filter to prevent further emboli. man was intubated sedated on diprivan for a good 8 days. he would totally freak during weaning times, thus unable to wean. they then switched him to fent/versed. he did better, still intubated another week and two days ago extubated.

curently awake oriented, at times. since i have had him he has slept a whole 30 mins on nights, and none on days.

the man has been having intermitt visual hallucinations. sometimes he is totally confused. has short term memory probs. has been found to have full on conversations with the wheelchair. ct head neg. neurologist consult states possible icu psychoses or mild encephalopathy.
the intensivest refuses to order sleepers. i can kind of understand, most have long half lives, and she really wants a good neuro pict of the pt.
he is receiving haldol q6hrs, and i suspect will be off the haldol tonight. we started weaning the haldol yesterday. thought about holding the 4am dose, as i was wondering if the haldol was causing some of the psychosis. he gets much weirder about 1.5 hrs after injection.

other than discharge this man to the floor,where he should get a few hours of uninterrupted "rest" what else can i do to promote sleep. besides he is no longer a candidate for transfer to the floor, last night he went into symptomatic rapid afib. got his rate down to 100-110's. and b/p up to 100's. abg's normal, slightly alk. ph 7.48, co2 36, bicarb 28. he passed his swallow eval, ordered him "comfort food" for dinner. mashed taters, mac/cheese, pudding, chick noodle soup for dinner.

i cant close his curtains, or the doors, as he is 170kg, and has been found to attempt to get oob. i dont want to restrain him, as he is really too "with it" and i think the restraints would agitate him more. i have bathed him, that relaxes him. last night he got 1 bath, one fluff and buff, and on back rub.

this man NEEDS sleep in the worst way. do any of you have any ideas on how to help this guy sleep without the use of anxiolytics, or sleepers.

on a side note, during a lucid moment, i asked him if he has anxiety at home. he said sometimes yes. he said at night he takes ambien 10mg for sleep when he feels anxious. i then asked what do you do to help with your anxiety during the day. his response
"i pick my nose"
I then took his nc off, and said "WELL MY DEAR PICK AWAY"
that too did not help. but his sao2 came up. lol

any advice would be great.
thanx in advance
mel
About traumarns

Joined: Jan '02; Posts: 61; Likes: 37
ed rn

14 Comments

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Oct 4, '02
Occupation: Retired Specialty: 15 year(s) of experience in Corrections, Psych, Med-Surg ; From: US ; Joined: Aug '02; Posts: 2,246; Likes: 48

"Nose-picking as stress management." Gotta love it! I'll have to remember that technique the next time I do a patient education session on the subject.

Last edit by sjoe on Oct 4, '02
Oct 4, '02
Occupation: ed rn Joined: Jan '02; Posts: 61; Likes: 37

Originally posted by sjoe
"Nose-picking as stress management." Gotta love it! I'll have to remember that technique the next time I do a patient education session on the subject.

lmao sjoe,
this was totally confirmed by the family.
gotta love the honesty.
Oct 4, '02
Occupation: RN Joined: Sep '02; Posts: 117; Likes: 6

I have seen a few times where haldol or some other psych med has created the opposite effect such as you described. The last time I had a patient who had those same symptoms it was a reaction to vicodin. Once the med was stopped, the behavior was gone within 24 hours. we are currently trying lavender lotion for patients that can't sleep, good old back rub and a glass of hot milk, so far the results have been promising.

Last edit by longtermcarern on Oct 4, '02
Oct 4, '02
Occupation: RN Joined: May '02; Posts: 1,897; Likes: 2

We have many residents who can't take haldol for the reasons you have specified here. The majority of them experience major hallucinations and psycotic episodes. After med is dc'd it usually takes about 10-15 days before "normalcy" returns.
Shygirl
Oct 4, '02
From: US ; Joined: Oct '01; Posts: 6,238; Likes: 1,829

Sounds to me like he needs to develope some itching around bedtime...a little Atarax or Benedryl might do wonders for him.
Oct 4, '02
Joined: May '02; Posts: 726; Likes: 17

MIL had the same reactions to haldol that you've described here. d/c'd the haldol and about 7 days later she was "normal." we lovingly refer to it as the week she "went on vacation." :chuckle
Oct 4, '02
Occupation: Critical Care Joined: Aug '00; Posts: 2,629; Likes: 20

OMG a nose picker, I think I saw him at a stop light !!!

Ok, sorry, I think one of the reasons your patient has difficulty sleeping besides anxiety is sleep deprivation. If he was on steroids for a while it can cause insomnia. With all the sedation that your patient received it is no wonder that he is a little goofy, that stuff sticks in your system for quite a while.
Oct 4, '02
Joined: Dec '01; Posts: 3,165; Likes: 59

I had a pt. go completely bonkers on the third dose of IV Tequin once....took 8 people to hold her, and she was still kicking like a wildwoman 10 minutes later.

She was previously a/oX3. It took about a week to get her straight. She doesn't remember a thing, but she was accusing us of stealing her dishes, talking to dead people, and refusing any treatments (couldn't take her BP even!), meds, po food/fluids for >4 days.

That an anitbiotic could do that! was what blew me away.

Last edit by Sleepyeyes on Oct 4, '02
Oct 5, '02
Joined: May '00; Posts: 2,065; Likes: 8

But aren't these reactuins very typical for the "Durchgangsyndrom" or as I just looked up in the dictionary: symptomatic transitory psychotic syndrom.
I've seen it a lot on people after big operations, long stays at ICu or CCU.
Or after bigger accidents.
Even see it in LTC, when the old clients first come to live there, they don't know what's going on, have seen the sweetest old lady going beserk.
Take care, Renee
PS: i would have translated the German word for this syndrom into "passageway-syndrom"
Oct 5, '02
Occupation: ed rn Joined: Jan '02; Posts: 61; Likes: 37

wow thanks for all the suggestions.

i KNEW i should have held that 0400 haldol. but coworkers suggested no.

he never got steroids. i truly dont believe he ever had any resp issues, cept his weight on his diaphragm. and his agitation.

i have seen many larger people unable to wean with ett. but once we trach them, they are off the vent within a couple days. we have one intensevist/pulmo who just pulls the tubes. no weaning param. or anything. her pts mostly do awesome. she also puts them on bipap right away. i think this guy would have done much better had the docs gone that route. but whos to say.

anyway here is an update on the man

walk on the unit at 1900. day nurse and cardio are chemically cardioverting the pt with covert. apparently he continued to have rapid afib rate 140's-170's with a bp in the 80's. was on dilt gtt maxed. got all his dig boluses.
anyway approx 15mins after covert given pt went into a sinus rhythm YEAH!
got orders to hold in icu for 4hrs. dc dilt gtt. start amiodorone 400mg po at 2300.(remember this dude is 170 kg) then transfer to tele if pt stable, and stays out of fib.

so he was pretty darn stable. transfered him to the floor at 2330 with a sitter.

im sorry to say, i dont know how the rest of his night went. i suspect he will still be in the hospital when i go back to work weds, i will try to find out if he started sleeping, or had more lucidity.

thanks for all the information.
i totally forgot about the warm milk. used to do that when i worked ltc many ago. we also have chammomile (sp?) and sleepy time teas on the unit. totally spaced those as well.

the first night i had him and called the doc about his nutsy-kookooness i asked for benadryl. the doc would not order it. she told me to put him in restraints if i had too. UGH.

well after we intubated and lined my heroin withdrawal dude, and the immodium kicked in for my other pt who had 7 bouts of diarrhea in 2 hrs. and got this gentlemen to the floor. it was 0200. i was able to get my charting done and my other pts bathed and looking and smelling pretty again by 0500. i actually got a chance to pee, and drink a cup of joe. and sit at the desk and stare off into space for a whopping 15 mins.

i think i will take some of these suggestions and use them on myself right now. lol.

thanks once again for all the great advice.
mel
Oct 6, '02
Occupation: rn supervisor Joined: Jul '02; Posts: 472; Likes: 10

It may or may not be the haldol, we have an aggressive halodol protocol where you keep giving 5mg IV push, Q 15 until effect, or at 50 mg, you start a IV drip.

haldol usually fails DUE TO INCORRECT LOW DOSING. Our cardiac surgeons use this with all ICU crazyness and when given in appropriate doses works almost all the time,

Q 6 hours is inadequate.

I also worked geriatric psyc, where we would IM 10 mg, q 30 minutes until effect. (no IV's there).

The only time I have seen haldol NOT work is with DT's, we had to start an ethanol drip.

so , take this with a grain of salt, my facility is "haldol happy", but if given in good doses, it works, so I'm biased. Talking general doc's into using this is an act of god.
Oct 6, '02
Joined: May '02; Posts: 1,022; Likes: 64

I agree Nimbex, Our docs order 1 mg haldol. I said are you nuttier than the patient? Without a serum level, you won't see any benefical effects. As far as the problem with weaning while on Diprvan, was his dose decreased by 5 mcg/kg/min q 5 minutes? Anything faster than that can lead to severe agaitaion and even violence. SInce he had a history of anxiety, a longer actine sedative was a good idea. Could it also be that he was goign thru ambien withdrawl? The first thing that hit me when I read the intial post was that maybe he had micro emboli that a CT scan is not picking up. ICU psychosis is a real problem and we see it on a regular basis but if this guy had PE's he could easily have had a teeny tiny clot or two shoot up to his brain. The afib didn't help either. He sounds like he is an absolute mess!
Good luck!

Icu Psychosis

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