ICU Psychosis/Delirium & precipitating withdrawal

[NMA851]

First, I am new to this forum and I am VERY happy to be part of a group of my peers who can talk amongst ourselves. We all need a place to 'get it out of our systems' as well as seek some advice/opinions. Please bear with me as I "learn the ropes" here. :):):)

I'm noticing an increasing rate of PT's experiencing ICU psychosis "syndrome" lately in my CCU. I put "syndrome" in quotes for a reason as a few of us (for OT reasons) have picked up a few night shifts to avoid OT. Furthermore, there have been quite a few rotation changes and 'general' changes supposedly for the "good of the PT care" :). We all know what this means - $$ saving attempts....

Anyway, the situations with psychosis are on the rise lately without much explanation. Until the handful of us days started picking up the nights, we would not have seen the difference in protocols. Last night in particular, after briefings and reading charts/MAR's/etc., the 4 PT's I took over were charted as confused/disoriented, refused oral meds, incoherent, etc. I found this odd given 2 of the 4 PT's have been mine on days for at least 2 weeks; and I had yet to see any real noticeable deterioration in function, particularly psych function. I'll just stick with these 2 particular PT's for the sake of this discussion as well. Anyway, their MAR's showed quite a few IVP's of Ativan, some up to 8MG's, Halidol, etc. These are PT's that, while there are PRN's for Ativan, have NEVER needed more than 4MG/day thus far. Further in the charts I see one of my PT's ended up in 4-points and missing restraint logs. I brought this to the attention of my CN who simply advised "It was evidently necessary"... OK - well, that does not answer my inquiries - especially whenever the 2 PT's never got to these extents and such a rapid deterioration, in a 12 hour period, had me pretty disturbed and in fact worried.

Upon further investigation, MAR showed DC'd oral's, IV only ordered. Then I see the pain meds used on BOTH patients was IVP Fentanyl, 25MCG, then both started on infusions of 5MCG/hr with NO titration over the course of the shift. It's almost like they were "left to deal with it".... PT "A" was on Oxycontin 80MG Q12H with 15MG IR's Q4-6PRN; PT "B" was on Morphine CR 100MG Q12H with 30MG IR's Q6H. IMO, I believe this caused a precipitated withdrawal due to the changes in medications without PROPER consideration of the conversion factors nor consideration of titration of the Fentanyl. Once the CR's started wearing off, withdrawals had to set in as I've seen this before. I may not have double-digit years under my belt, however ANYONE who is on a high-dose chronic opioid therapy should ALWAYS have this be the #1 consideration after ensuring vitals are stable. This, too, was the case (both PTs stable).

I did not like the CN's response so I paged the MD. Was told there is NO connection between withdrawals and the psychosis despite me KNOWING these 2 PT's for their entire duration of stay thus far. I further believe the withdrawals were masked a bit by (go figure) increased need of Ativan IVP's. I had two pretty coherent PT's that were now completely in la-la land with a different MD this week as well as a different CN - ALL of which did not seem to find any merit behind my theory. The other RN's with me agreed - particularly the seasoned ones - but since the PT's were now unable to take any meds PO, the choices were [now] IV/IVP.... Quite irritating to say the least - not to mention 2 PT's unable to voice their pain levels or anything else for that matter. I finally was able to consult with another MD who agreed to titrate to effect; after 6 hours, and I capped the infusion 150MCG/hr as the PT began to become lucid. PT "B" had a different MD at the time who denied my requested titration. PT "B" remained FAR from coherent, completely combative, and physically/chemically restrained.

I am attempting to provide as much background as possible to gain some opinions as to this withdrawal theory throwing the PT's into the dreaded ICU psychosis states - especially to the points of needing 4-points?? NOT good... Of course, being one of the lesser-experienced, who am I to question. I counter that statement with our licenses are on the line everyday we walk through those doors so EVERY decision we make is one that must be in the best interest of the PT as well as following orders. Given PT "A"'s response once titration became an effective dose, I cannot understand why PT "B" could not have the same. Finally, PT "A" was DC'd off Fentanyl once he was able to resume PO meds - original meds at that - and the episode was overwith....

The final VERY ODD situation that occurred with a colleague the day before the 2 PT's went into these states was my request to witness multiple wastes on the exact same meds that these 2 PT's were taking PO.. She alleged they both refused ANY meds PO - but didn't set off any 'bells' given if they refused PO, they were already dispensed, they had to be wasted. Given withdrawal (especially with a long-acting) would take at least 12 hours to set in, I'm now speculating that the "waste" may not have truly been destroyed... I HATE to go down that road, but many pieces of the puzzle(s) are starting to fit if you get my drift... This WILL be the FIRST TIME I will be dealing with a problem of this nature, i.e. diversion, however I am unsure of how to proceed at this stage.

Please feel free to ask ANY questions or clarifications; I'm new to this forum, I'm hoping this is a good start in a new place, and will return the favor as I am able down the road!!! Thank you to all in advance for your opinions/advice in these situations. I truly apologize for the length of this once again but I appreciate it more than I can say!!

NMA