psychosis in icu after heart surgery can someone explain what happened to me

RedBait · Sep 8, 2004

I wanted to ask a few questions about a personal experience that I had with my mother, that has actually been the reason why I am in school for nursing. My mother had a quadruple bypass in July of this year. My mother did live a very sedentary lifestyle that unfortunately involved alot of alcohol consumption. We brought her into the ER because she actually had a slight stroke which after cat scans and her cardiac cath they found that she was pretty much completely blocked and scheduled her for her bypass immediately. Everything went fine with her surgery, but approximately 24 hrs post-op she became very paranoid which I initially didn't think much of, I figured she is pretty drugged up it will go away. Needless to say it didn't. Within a few hours she was completely insane, she was fighting with the nurses (she actually injured one of them) and said that they were trying to kill her and all of our family that was there for her. This went on for about 24 hours and subsided once they took her out of ICU. I know you have probably seen all of this before, but this was my mother and I was devastated and didn't and still don't understand what happened. We came and sat with her and the nurses called her doctor. I am confused and still don't understand it, the doctor seemed to think it was alcohol withdraw, even though she had already been in the hospital for 6 days without a drink and didn't have any of these symptoms. I don't believe that was what it was. Then a nurse suggested something called ICU psychosis. I tried to research it but it seems there isn't much out there that I could find. Have any of you experienced this and could you maybe explain some of it to me.
As a foot note to this all of the nurses that took care of my mother and our family from the beginning to the end (even in the bad times) were wonderful and I think that all nurses are amazing people and should be recognized for the great things they do with their patients and I truly mean that. They truly inspired me.

Look for information on delirium in the ICU (ICU psychosis is a sort of slang). A Google search is a good place to start, Medscape and Pubmed should be next. The librarian in your closest medical library will be most helpful. This has been a particularly hot topic these last few years with much data pouring forth. Post cardiotomy patients are very often the group studied, although any critically ill patient may suffer this syndrome.

It has been my experience that anesthesia will send patients into "alcohol" withdrawal, no matter how many days they are from the last drink. It is a liver thing, I opine. But alcohol withdrawal looks very different from ICU delirium. It is treated very differently, as well.

angle71054 · Sep 25, 2004

I wanted to ask a few questions about a personal experience that I had with my mother, that has actually been the reason why I am in school for nursing. My mother had a quadruple bypass in July of this year. My mother did live a very sedentary lifestyle that unfortunately involved alot of alcohol consumption. We brought her into the ER because she actually had a slight stroke which after cat scans and her cardiac cath they found that she was pretty much completely blocked and scheduled her for her bypass immediately. Everything went fine with her surgery, but approximately 24 hrs post-op she became very paranoid which I initially didn't think much of, I figured she is pretty drugged up it will go away. Needless to say it didn't. Within a few hours she was completely insane, she was fighting with the nurses (she actually injured one of them) and said that they were trying to kill her and all of our family that was there for her. This went on for about 24 hours and subsided once they took her out of ICU. I know you have probably seen all of this before, but this was my mother and I was devastated and didn't and still don't understand what happened. We came and sat with her and the nurses called her doctor. I am confused and still don't understand it, the doctor seemed to think it was alcohol withdraw, even though she had already been in the hospital for 6 days without a drink and didn't have any of these symptoms. I don't believe that was what it was. Then a nurse suggested something called ICU psychosis. I tried to research it but it seems there isn't much out there that I could find. Have any of you experienced this and could you maybe explain some of it to me.
As a foot note to this all of the nurses that took care of my mother and our family from the beginning to the end (even in the bad times) were wonderful and I think that all nurses are amazing people and should be recognized for the great things they do with their patients and I truly mean that. They truly inspired me.

I am a cardiac nurse on the floor not the unit, so I don't really deal with the ICU psychosis, but I do see the after effects once they leave the unit. If you think about the environment of an ICU, it usually is very loud with many beeps and alarms. People coming in waking you up at all hours of the night and day. You have had a major life change/experience that is difficult to comphrened and deal with. Not to mention all the drugs (pain meds) and anethesisia. All of these factors come together to aid in ICU psychosis. It isn't her fault, and the best treatment sometimes is to get the pt. out of the situation. My experience once a pt. gets out to the floor, the confusion and other symptoms slowly stop. I have had pts. that come out on the floor in the evening confused and showing signs of ICU psychosis, but by morning when they wake up they are already more alert, and feeling better.

Another related psychosis is hosp. psychosis. An alert and oriented person at any age or health problem can come into the hospital, and they can become very confused. They may loose track of the days and whether it is night and day. They can try and get up and fall because they are in a strange environment. It usually effects older people, but not always. The best thing you can do is try and reorient them, be patient, and give them time. They seem to come out of it on their own. And the best thing is to get them back to their own home and bed.

I hope this was helpful, if you have anyother questions just holler.

Woodufish2 · Sep 28, 2004

Another factor that can sometimes add to this psychosis is "Sundowner's Syndrome". This happens many times to older patients at "sundown" and they become very confused. It is hard to say what may have contributed to your mother's pyschosis, but could very well be a combination of many things.

I am hoping the nursing staff tried to educate you on what may be happening. I work on an Open Heart Step Down Unit and we actually have a written education form for family members prior to surgery & is again presented once the patient comes from the recovery room that we give called "When your loved one becomes confused". That helps them to understand and or remind them that this behavior may occur.

Hope this helps.

sargent · Sep 29, 2004

The phenomena that you describe is probably something that we refer to as post-pump psychosis. It is still poorly understood but is thought to be a temporary psychosis that occurs as a result of micro air emboli that remain following a period on cardio-pulmonary bypass during cardiac surgery.

Anecdotely the effects usually kick in at about 24-48 hours and last about 24 hours. Often requiring large doses of haloperidol to prevent the patient harming themselves (they may still have chest drains in at this stage).

It is hard to predict who will have this problem, limited research is available due to it relative rarity (approx 1 in 1000 cases), but it has been suggested that some patients are predisposed to the psychosis. these people are those with a history of depression or alcohol use.

hope that helps

Andrew (UK)

CHATSDALE · Sep 29, 2004

i use to work on a step down unit and we got almost all post cab pts they would frequently be readmit due to family concern of possible stroke because behavior changes...one woman i saw later said that she had given her husband the keys to her car to take to work with him because she had found herself about 25 miles from home and no memory of how she got there or the reason that she had left home....i don't know if this is the same thing because she was alert and aware at all other times while in hospital body and mind are intertwined much more than we realize...

Dinith88 · Sep 29, 2004

I wanted to ask a few questions about a personal experience that I had with my mother, that has actually been the reason why I am in school for nursing. My mother had a quadruple bypass in July of this year. My mother did live a very sedentary lifestyle that unfortunately involved alot of alcohol consumption. We brought her into the ER because she actually had a slight stroke which after cat scans and her cardiac cath they found that she was pretty much completely blocked and scheduled her for her bypass immediately. Everything went fine with her surgery, but approximately 24 hrs post-op she became very paranoid which I initially didn't think much of, I figured she is pretty drugged up it will go away. Needless to say it didn't. Within a few hours she was completely insane, she was fighting with the nurses (she actually injured one of them) and said that they were trying to kill her and all of our family that was there for her. This went on for about 24 hours and subsided once they took her out of ICU. I know you have probably seen all of this before, but this was my mother and I was devastated and didn't and still don't understand what happened. We came and sat with her and the nurses called her doctor. I am confused and still don't understand it, the doctor seemed to think it was alcohol withdraw, even though she had already been in the hospital for 6 days without a drink and didn't have any of these symptoms. I don't believe that was what it was. Then a nurse suggested something called ICU psychosis. I tried to research it but it seems there isn't much out there that I could find. Have any of you experienced this and could you maybe explain some of it to me.
A few things you mention make me suspicious that it WAS alcohol withdrawal/DT's. If you're a daily alcoholic for several years and are rushed in to an emergent CABG, you're bound to have some sort of withdrawal. DT's can happen around 4-7 days after sudden withdrawal. If the behavior stopped seemingly abruptly, (just prior to arrival on the floor) she was probably getting valium (or something similar) to control her DT's/withdrawal and was thus seemigly 'better'. The reason i suspect this is because the Dr told you he was thinking in this direction...he surely was treating with something??.If she were acutely confused/paranoid/dangerous she shouldn't/wouldn't have left the icu (hopefully!). Another thing to consider is that heavy drinkers usually have fragile livers to begin with, which can exacerbate an encephalopathy (withrawal induced or otherwise). Surely her situation was multi-factoral, but the Md was probably right that her alcoholism was a(the) major contributor to the off-the-wall behavior you witnessed.
edited to add:when i mention "d/t's, i dont mean soley the shaking/trembling, but also withrdawal induced psychosis type stuff...

chris_at_lucas_RN, RN · Sep 29, 2004

I have had friends who have had heart surgery and responded similarly.

One was like your Mom. Quick and kind of extreme--violent, even.

The other was more gradual. The paranoia developed over a couple of weeks and then hung over him for a couple of months, then went away.

Neither of them remembers it, although they have memories of events during the time they were experiencing this phenomenon.

My understanding is that there is something that can happen with heart surgery. ICU psychosis is an altered mental status related to being in the ICU--not enough stimuli to adjust one's sense of time (morning, afternoon, night), or day. Too much stimulus to actually rest (lights, noise, constantly being checked). And the whole thing is just plain stressful.

That's the best explanation I can offer. Glad to hear the experience was positive overall. Sorry your Mom was so ill.

Dinith88 · Sep 30, 2004

My understanding is that there is something that can happen with heart surgery.

The 'pump-head' phenomena is caused by being on cardio-pulmonary bypass pump. The main theory behind why this happens is that micro-emboli (probably d/t clamping the aorta while on pump) float up to your brain and cause 'micro-strokes'. It usually happens to people over 70 (who have some degree of arterioscerotic aorta, etc...and have less neuro reserve to begin with (ie 'age related atrophy, etc.')). This 'pump head' syndrome is usually evident fairly early in recovery and usually isnt very dramatic..and more of a mental 'slowdown'...but surely it can evolve into something more profound. This is why 'off-pump' cabg is the 'in vogue' surgery for these people. 'Pump head' isnt a factor and cabg related dementias are dramatically reduced. (studies are now suggesting that off-pump grafts may occlude sooner than traditional 'on-pump' grafts...so it's kinda like a trade-ff...but thats the stuff of a different thread)

'ICU syndrome' isnt unique to icu...it can happen in any hospital/nursing home setting. These people are again usually over 70, have age-related changes in their brain, and many times have a borderline/subtle or slowly emerging dementia. Stick them in a box for a few days and their problem is exacerbated.

Anesthesia on it's own can whack people out (especially older people)...and especially people with liver issues. And again there's the alcohol withdrawal issue...