Help me out: what are the possible causes for my patient's agitation?(Sorry long one)

Specialties MICU

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I am a 4th year nursing student. Currently I am doing my preceptorship at ICU.

Here is the patient's profile (has been modified for patient's confidentiality):

Patient X, male, 50 years old.

Dx: Hypertensive Emergency

Medical history: GIST (GI Stromal Tumor), metastatic to liver, lungs, and spine. Surgery in 2004 &2005. Pt. used morphine for pain control at home. Patient was on PO chemo trial since last month. One week ago, pt was brought to ER for increased BP (200/110), increased HR, altered LOC. Patient C/O loss of vision and increasingly confused during waiting period at ER. MRI revealed bilateral parietal and occipital edema. Pt was intubated and transferred to ICU for BP control.

At my shift:

Pt was extubated 5 days ago. Night nurse reported that pt. had an episode of coughingà BradyàSaO2 dropped to 86%, was put on 100% O2, SaO2 returned to 96% after. ABG showed PCO2=63. Pt was on 33% FiO2 when we start our shift. We drew another ABG 0730: PH=7.43, PCO2=52, PO2=80, HCO3=35. SaO2=96%.

During assessment, pt is not fully oriented, but follows commands, moving all ext., no pain. Pt is only on Diludid infusion for pain control, no sedation.

Pt's BP remains stable (MAP at 90's) while sleeping. But once pt is awake, he is agitated, tries to get off from bed, MAP shoot to 130 to 140, SaO2 drops to low 90's. We tried to re-orient the pt, get him on the chair, relaxation music, distraction..., but nothing worked. Pt. has to be restrained to keep him pulling all the lines and tubes. Family said he is never an aggressive person. During our shift, we had to give him a lot of Propofol and versed bolus to calm him.

My questions:

What are the possible causes for the agitation?

My interpretation of the ABG: Metabolic alkalosis with respiratory acidosis (I know the PH is fine, but the numbers are abnormal, right?) . But which one is compensating which one? Are the kidneys trying to compensate the respiratory acidosis?

Thank you for reading this long posting. I am just curious to know:heartbeat

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Specializes in CCU/CVU/ICU.

A VERY good guess is that He has/had to poop.

(before you write this off as a joke, it's not.)

He just couldnt communicate it...and was doing everything in his power to not poop the bed.

Any other answer to your 'why is he agitated' question will be a guess.

Mines as good as any.

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Specializes in MICU, SICU, CRRT,.

That was what i was thinking as well. I have a similar situation with a patient now..no BM for about 3 weeks, High doses of narcs, long term vent dependant, extremely agitated, maxed on diprovan, restrained..and still pulling at vent lines. Has lots of gas, and is obviously VERY constipated. Waiting on a GI consult, because primary doc does not want to try to clear out the impaction becuse of a few things in her history (that i am not very familiar with)...

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This reminded me. I did have this patient 3 days ago, and he had not had BM for 3 days at that time, we gave him senna. Maybe I can check it out on the chart next week to see when his last BM was.

Good point. any thoughts about his ABG?

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Specializes in CCU/CVU/ICU.

Good point. any thoughts about his ABG?

At first glance the ABGs look like a chronic CO2 retainer's. (high CO2, high HCo3, normal pH) Does he have Hx of Smoking? COPD? I know you mentioned he has lung mets...

Keep in mind that the body takes weeks/months to compensate for chronic CO2 retention...so when you see this normal pH in combination with high HCO3 it's always a good guess. It's likely not an acute compensation.

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A fellow student here... anybody take a second look at his head?

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Anyone think of ICU psychosis, or UTI or constipation. I never know these situations unless I look at the patient myself.

If he was on propofol I am guessing he was tubed and how do you know he is more confused??

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According to those ABG results, you patient has compensated Metabolic Acidosis. The pH was high originally due to elevated HCO3, the lungs then compensated by decreasing the respiratory rate and conserving CO2 in the blood.... this lowered the pH back into an acceptable range. Hydrogen was also moved out of the cells to lower the pH as well, but when this happens then potassium and calcium have to move out of the blood and into the cell to keep the cell electrically neutral.

The decrease of potassium and calcium in the blood results in serum hypocalcemia and hypokalemia. The signs and symptoms of these two conditions include:

Neuromuscular- muscle cramping, twitching, hyperactive reflexes. and tetany.

and

And an overexcitement of the CNS and PNS- lightheadedness, agitation, confusion, seizures

Hope this helps :)

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***Edit***

Can't figure out how to edit my post..................

I wrote the wrong word in the post about. I meant to say that your patient has COMPENSATED METABOLIC ALKALOSIS.

Sorry for any confusion.

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Specializes in CCU/CVU/ICU.
***Edit***

Can't figure out how to edit my post..................

I wrote the wrong word in the post about. I meant to say that your patient has COMPENSATED METABOLIC ALKALOSIS.

Sorry for any confusion.

Nope. Compensated respiratory acidosis. Chronic.

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Specializes in CCU/CVU/ICU.
Nope. Compensated respiratory acidosis. Chronic.

To continue on with this point...perhaps to help you better understand...

1) To hypoventilate to the point that your pCO2 is 52, you'd have a (dramatic) low pO2 as well...and OP's pt is only on 33% FiO2

2) OP mentions patient receiving propofol and versed...which means patient is likely intubated. If this is the case the ventilator would prevent any 'compensatory hypoventilation'.

3) a 'true' metabolic alkylosis is very rare. If you were correct in your diagnosis, the patient is in a PROFOUND metabolic alkylosis (as it requires a pCO2 of 52 to 'compensate'). What in the pt's description leads you to even suspect a metabolic alkylosis???

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Specializes in ICU, PACU, Cath Lab.

Am I the only one that noticed that we are all saying that since the pt is getting diprivan they would be inutubated, however after re-reading the OP it clearly states that they are giving diprivan and versed in what appears fairly large doses and this pt had been extubated 5 days prior! I would have to think that alone could be causing some of the issues at hand with confusion and aggitation.

OP watch your back here many states prohibit RN pushing diprivan and giving it to a patient that is not ventilated is a disaster waiting to happen...at least in my opinion.

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