Icu Psychosis

[traumarns]

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

[fedupnurse]

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!

[traumarns]

nimbex, I have heard that before about the haldol and inapsine dosing. remember how inapsine was dosed weird, something like 0.125-0.25 CC'S instead of ordering it by mgs. i vaguely remember reading something about pts getting more eps with the smaller dosages of inapsine. something about the way it is broken down. but when given in the higher dosages, and i cannot honestly remember what the mg/cc was, that the incidence of eps was much smaller.

oh well they took inapsine off the market.

haldol is relatively new to me. i have given it rarely before. this was my first pt on it as a routine med. i know inapsine and haldol are two different meds, but they are in the same family. vitamin I worked wonders for our psychotic pts when i worked er.

I still kinda wonder if the haldol was not contributing in part to his craziness. i have seen people get totally whacked on ativan and benadryl.

We have one doctor that orders 0.5mg of haldol iv Q8hrs prn. i laughed the first time i got that order. repeated it back to him like 3 times. "are you sure that is all you want????" I did not even waste my time giving it to that particular pt. i just camped out in his room. (this was for a different pt, one who was baseline demented with ptsd), waiting for perm pacer/aicd placement. required 100% transcutan. pacing.

we were thinking my latest psychotic pt might have been possibly withdrawing from versed. he was on a drip for about a week or more. and they stopped it cold turkey. the fentanyl was slowly weaned off.

we usually wean the dip slowly, unless of course it drops their b/p and wham we take them off. You know come to think of it i dont wean dip 5mcg/kg/min. i usuall take them down by 2-5cc/hr. by 0700 they are on a full blown vent wean. i refuse to take them completely off the dip during wean times as sometimes a little sniff of dip is enough to keep them relaxed enough to not buck the vent, or gag on the ett.

per the wife and the pt, he only took the ambien rarely. he was already in the icu for several weeks without any.

it is possible that he could have a micro emboli, he was in a rapid, however he was already on heparin at 3200u/hr. ptts stable in the 60's for a good week before his run of afib. and he was started on coumadin. the night before he went into afib.

no neuro deficits that i could find. cranial nerves intact.(well the ones i checked,:) ) mae's equally except is rle slightly weaker. i suspect that leg weaker as that was where he had his fasciotomy and embolectomy.

ok, i just called the floor. I never ever ever call to see how a pt is doing when i am off. but i had to find out.

he slept last night and most of today. WOO HOO. has had no hallucinations, and is not confused. they are thinking of dcing the sitter tomorrow. the one thing that concerned me, the nurse said the pt has a flat affect. he was not flat when i had him. who knows. i just hope that he remains stable enough to go home to florida.

well i go back to work tues night, praying for 2 vented and well sedated pts.

thanks for the suggestions.

take care

mel

[farmmom]

sorry but all of you working as nurses( going to school for it now)

as a CNA in a very short staffed institution for the mentally ill I had a lot of on hand meds for them Halidol is for very bad residents.Nose picking is a comfort or security blanket,your resident is looking for a resession that will help him slow down to leave his thought process. You need to teach him how to relax breathe and take breaths count and stretch his body from his toes take a breath stretch your toes breathe and stretch your calves and so forth .Unless he is showing signs of psychosis he does not need halidol or signs of schizophrenia that is not the drug of choice.Is he a violent resident.