ICU Psychosis ?????

Dinith88 · Mar 15, 2006

Yeah, i hate that. Family asks why grandma is acting so out of her head...and all you can say is"..umm, that just sometimes happens..." They freak out and are convinced gramma had a stroke, and you're an idiot.

These patients invariable get the neuro consult, ct, eeg, etc. ad nauseum...

Nonspecific findings...a diagnosis of 'multifactoral encephalopathy' or something similar (and non-specific)...but we all have to jump through these hoops regardless.

This 'icu head' (which can happen in any hospital room...or any place where you put people in a cage for days)...is usually (99% of the time-i'm making this number up but i'm sure it's close) seen in elderly patients who have 'age related atrophy' (old brain) ct-scans, and/or emerging dementia-type stuff, are given sedatives, narcotics, anesthesia, or any other potentially mind-altering drugs...all on top of being critically ill...kinda tips them over the edge.

Your brain is like any other organ in that we lose a bit of function each year. Luckily we, for the most part, have lots of reserve. When we reach old-age sometimes some of us are nearing the limits of this reserve. Now, add all the insults i listed (on top of all the others i failed to list) and it can tip grandma over the edge. She gets confused and out of her head and tries to fall out of bed and starts pooping herself and (need i continue?) the family is justifiably scared...

and we jump through our hoops for them.

Grandma is usually back to herself in a few days.

JiffyGriff · Mar 15, 2006

What was this patient's normal mental status before they were sedated and put on the vent?? Maybe this is normal for them and you just don't know it because you didn't have them prior to being sedated.....look back in the documentation a bit. If this is a change then it needs to be reported and I have no pity for the nurse that blows a change in mentation off as "ICU Psychosis" and doesn't have the proper steps taken to find out what is causing it. That's the person that will inevitebly lose their license when it ended up being sepsis or VAP that kills that patient. Report it, document it, and follow up on it. It could just be the effects of the sedation still wearing off, it could be that they are delerious because of unfamiliar surroundings, or it could be something serious like VAP, sepsis, inadequate brain perfusion, PE, some type of neuro problem..........the list goes on.........but those nurses shouldn't be blowing it off......that's bad practice.

heartICU · Mar 16, 2006

Just wondering exactly what ICU psychosis is and other's experiences with it.
I would love to hear your thoughts on this, along with some of the personal experiences with it.

ICU psychosis also can be caused from the stimulating environment of the ICU. These patients hear alarms, beeps, buzzers, etc, 24 hours a day. People are constantly talking, and they are constantly being woken up to be assessed, turned, bathed, etc. in addition to being critically ill, often old, and usually receiving a ton of meds. The lights are usually on most of the day and night, and they often get their days and nights reversed. Any ICU nurse who has worked long enough can see the "look" even before the patient exhibits any specific signs...they will start looking at you funny, almost suspiciously, they will start looking at their lines frequently, maybe pick at their dressings, fidgeting in bed, stuff like that. It seems like the men like to take off their clothes more than the women...men will tend to pull up their gowns and show off their family jewels.

But as others have said, you have to rule out anything else - hypoxia is a big one, maybe they threw a clot, etc. Some drugs can cause it - I have had multiple neuro consults for patients taking pepcid. Narcotics can also do it, though I would imagine it is a combination of being in the unit for so long, drugs, constant stimulation, etc.

Dirk · Mar 27, 2006

There is a very good article, written by Kimberley Litton.

This article deals with the ICU delirium (not psychosis, because it is an acute confusion, not a psychiatric disorder) and shows, how you can reach the diagnosis of ICU elirium, and what are ways to treat that in a right way.

Delirium in the Critical Care Patient

CRITICAL CARE NURSING QUARTERLY, 2003, vol 26, no. 3, pp 208-213

Greetings

Dirk

papawjohn · Mar 27, 2006

Hey loricatus!!!

True story--happened last week: Gentleman in his 80s takes home meds including coumadin is visiting the Park in Sarasota and unfortunately takes a ground-level fall. Visits local ER gets NEG CT Scan and sutures. Over the next couple days he develops expressive aphasia. Now he comes to my Hosp's ER and CT shows small SubArachnoid. They decide to put him in my ICU with a few prns for BP control and Q2h neuro checks.

Next day, he's been neuro stable (stumbles over words but can spell everything he can't say--isn't that peculiar) and is totally symmetrical except a small R facial droop. A repeat CT shows SubArrachnoid is stable. Order is written Transfer to Tele.

However--no Tele beds available. So he spends a full weekend in ICU still with close Neurochecks (I did let him sleep as much as possible). Sat night he started deteriorating--the 1000meter stare, the inapprop emotions, the ataxia, started drooling from the R side of his mouth.

By Monday AM, he's got the entire ICU panoply of PoseyVest, WristRestraints and PRN Ativan. His CT is still unchanged.

So what's going on? 1--Worst case: An evolving stroke from the original traumatic bleed. 2--Intermediate case: Encephalothy from inflammation of the cerebral tissues and blood in ventricles. 3--ICU Psychosis.

Turns out he slept about 48hrs straight when he got out to Tele and his family could stay with him then woke up with just a little expressive aphasia.

If only we'd been able to get him a room when the order was written--what a bad time and waste of time we'd have saved.

Papaw John

pricklypear · Mar 28, 2006

It's an absolute FACT. Anybody who has spent any time working (nights especially) in ICU can attest to it. Personally, I think it all stems from the cummulative effects of sleep deprivation. Think about it, we are SUPPOSED to sleep UNINTURRUPTED for 6-8 hours at a time. What patient in ICU ever sleeps more than 4 between assessments (those would be the lucky ones)? How much time do they spent in REM sleep? If they don't get enough REM, it doesn't even count as sleep. And that's for a normal, healthy person. What about someone sick enough to be in ICU? Receiving unfamiliar drugs, at unfamiliar doses, by unfamiliar people, at 2 am. As heartICU points out, the stimulation in ICU is constant. Hey, I have ICU psychosis, and I just WORK there!

MommyandRN · Mar 29, 2006

Yep I've seen it. They don't get any sleep. Some people just go nuts. I've seen it happen mostly to older people. They say try to keep the lights dim at night, minimize sleep disruptions etc.

2berliners · Jan 8, 2010

Re: ICU Psychosis. Am "frequent flier" to ICU: HIV/COPD/ARDS/DVT. When I was hospitalized for ARDS I was on a vent for SIX weeks. Was discharged for 2 weeks, then decompensation - readmit to 2nd hospital for 3 weeks - was not a stranger there either. History of bipolar disorder. Was put on "drug quarantine" (with psychiatric drugs inclusive) to determine best way of handling C. Difficile infection. Okay now you have history. Now about ICU Psychosis. On decomp. admit could not sleep for 60+ hours at a time; usually got about 3 hours in between manic cycles - of 60+ hours sleep deprivation. I was only allowed to use "real" toilet with my "minder" constantly watching me.

Now my psychosis manifested as believing as true, as reality - various horrible scenarios that would re-occur in EPISODIC cycles: I thought hospital staff were poisoning me and kept asking staff to stop messing around and "be quick and merciful." I believed I was taken to an adjoining "secret room" next to my own which had only a elevator, dental chair,and a transexual CNA whose "job" was to "mess [me] up" if I tried anything. Outside the secret room were a gang of hoods and a 2nd set of elevators. I thought I was in prison: there were a variety of prison-related sub-plots happening. I believed a whole wing of the hospital which housed only myself and another guy whose face I never saw because his bed was so close to the floor was controlled by nursing staff RNs who supplied methamphetamine for my side-wing of the hospital. CNAs were always on the lookout eyeing me so I wouldn't try to escape. At various times when I was close to escaping, one of the CNAs would start a fire in the wing to get rid of me and my roommate. They punished my roommate at times by throwing caustic stuff on him while he was poseyed to his bed. I would scream: "Fire! fire!" and no one would hear me.

Plenty of people heard me when I would regain a conscious sensiblility. I was treated to my own "Tales of Outer Space" given by, especially given by the staff of the 2nd facility where I was admitted for decompensation. I didn't recognize the faces of the Staff, both CNAs, RNs, and physicians who gave various comments like: "Nice to have you back," "Boy were you flying high Saturday night, we had a three point hold on you," "You kicked (at least 2) staff in the stomach and spit at so-and-so in the face but apologized later," (At least I apologized!)

2 friends who visited me - one on the phone, one in the room- both told me the story about me screaming "Fire, fire," with the added twist that the first one started the story, and the second one finished the story (I told my friend Chris to put on his motorcycle helmet and run.) I am sure once I transmit and close that more remembered scenarios will pop up in my head.

On the brighter side, one morning I thought I was President Woodrow Wilson and had my own cook who called me "Mister President" and who made me pancakes and brought in fresh cold milk. Life wasn't all strawberries and ice cream though: My Presidential Minder made it his job to check my temperature with an old fashioned thermometer both rectally and orally. I'd ask him when we could stop "taking readings" and he'd would comment to me and a CNA I think was there silently in the background that there was always a 1/2 degree difference in these readings: I think he told me the rectal was the higher one. My Presidential Suite was a belvedere full of sunshine, light and airy with a cobblestone courtyard and grass diagonals below and just the cure for my previously mentioned bad benders.

All of these scenarios I felt real and no dream!

And another thing: Once I was on the vent, there were times I could hear everything, everything conversation-wise that was going on. Do not treat your patients on vent like cadavers/pieces of meat/a recurring joke Call the person my his/her name and please hold their hand and tell them "to wake up now," "it's ok, don't worry about the oxygen," or when necessary "So-and-so, they are going to turn off the o2 just to see that you can breathe on your own." When that is done, hold their hand and tell them to breathe as if they were giving birth.

For me the "drug quarantine," sleep deprivation of 60+ hour CYCLES, being on the vent, and the drugs given for the vent, being kooked up in a bed without being able to walk about, have any one (besides my imaginary tormentors) to speak to, all of the foregoing were enough to trigger ICU Psychosis on a grand baroque scale. By the way, the use of Haldol as an antipsychotic can of itself trigger (in me) psychotic episodes along with tardive dyskinesia.

There! Now have a first person primer on ICU Psychosis.

detroitdano · Jan 8, 2010

Wow, good read!

ICU psychosis is definitely real. You sit in one place, 24 hours a day, someone bugs you every hour or two, noise from your own alarms, other alarms, etc. That right there is enough to make a sane person lose it. Add in infections, side effects from a billion medications, etc.

blueheaven · Jan 8, 2010

OMG, how anyone (including pts-) gets out of the ICU without being totally nus is beyond me!! The lights, noise from alarms, loud noisy nurses! The docs will order haldol and most of the time it seems to make them worse or develop TD.

There are a couple of things that really bug the heck out of me though:

1) Your patient has been on anxiolytics and or analgesics for weeks and his/her physcian in their "great wisdom and knowledge" all of a sudden stops them without thinking about the patient having acute withdrawal from them. They need to be tapered down.

2) Psych meds. I can understand why they may need to be stopped sometimes, but it seems that many times they should be continued even while on the vent. You can get withdrawal syndromes from those too.

Dinith88 · Jan 8, 2010

Now my psychosis manifested as believing as true, as reality - various horrible scenarios that would re-occur in EPISODIC cycles: I thought hospital staff were poisoning me and kept asking staff to stop messing around and "be quick and merciful." I believed I was taken to an adjoining "secret room" next to my own which had only a elevator, dental chair,and a transexual CNA whose "job" was to "mess [me] up" if I tried anything. Outside the secret room were a gang of hoods and a 2nd set of elevators. I thought I was in prison: there were a variety of prison-related sub-plots happening. I believed a whole wing of the hospital which housed only myself and another guy whose face I never saw because his bed was so close to the floor was controlled by nursing staff RNs who supplied methamphetamine for my side-wing of the hospital. CNAs were always on the lookout eyeing me so I wouldn't try to escape. At various times when I was close to escaping, one of the CNAs would start a fire in the wing to get rid of me and my roommate. They punished my roommate at times by throwing caustic stuff on him while he was poseyed to his bed. I would scream: "Fire! fire!" and no one would hear me.
.

Wow...i felt like i was reading excerpts from Burrough's, 'Naked Lunch'...

Your story is both frightening...and (more than a little) funny (for a quasi-burnt-out-nurse...please accept my apology if that insults you).

Break-out the Haldol and four-points... I'm goin on break!

*wine