Treating Respiratory Failure With Ativan/Lorazapam

[shellyscorner]

So, as a new member to this forum, please forgive me if as a student nurse, I have posted in an inappropriate place.

Okay, I saw something done the other day that made me really uncomfortable. And I'd just like to have some folks with some real experience give me their opinion! I'm going to apologize in advance guys, because I KNOW this is going to be a LONG ONE! But it seems like to me that you need to know as much of the story as I do in order to fully appreciate "my concern" and give me the most accurate answer as possible, AND so you can tell me to go stick my head back in the sand and mind my business, that I don't know enough yet to be calling a doctor an "ass" or to be questioning his treatment modalities! But, if I'm wrong, I'm wrong. AND I WANT TO KNOW IF I'M WRONG! I LOVE MY PATIENTS! And frankly, even though this woman was NOT MY patient, and I was ONLY an OBSERVER this night, IT BROKE MY HEART TO WATCH THIS WOMAN SUFFER NOT ONLY PHYSICALLY BUT EMOTIONALLY AND SPIRITUALLY AS WELL! As this doctor seemed to literally RELISH and TAKE DELIGHT in LITERALLY CRUSHING HER SPIRITS! There was NO RESPECT, NO DIGNITY, NO NOTHING EXCEPT WALKING ON HER, OVER HER, AND THROUGH HER!

So, I was in the ICU observing. There was a adult female pt with chronic lung disorder. She is on multiple inhalers at home and is dependent on supplemental O2 (6L @ rest and 8-10L on exertion) who was in admitted into hospital away from her home town after having a "breathing flair up" 5 min out from her doctors office. On presentation she appears to be having an asthma attack but her diagnosis has proven to be elusive at best over the years. She was rushed to the ED and was treated with IV solumedrol and repeated breathing treatments and within 2 hours was then admitted to the hospitals MICU in critical condition in respiratory failure of unknown etiology. According to her records, she was intubated inside 30 min. of her admission for the next 36 hours before being extubated. On Sun she was transferred to the regular floor where she had two more "flair-ups" before being discharged to home on Wed. After discharge, she had a return trip to the local ED on Sat. where she was treated with breathing treatments and sent home. The following weekend she again presented to the local ED on Fri evening where she was again treated with IV Solumedrol and breathing treatments and discharged home. Both of these ED visits occurred after having driving an hour one way to see her PCP for a post hospital check up. On July 2 after having again been to her primary doc office the previous day and having had to go run an errand the increased activity once again caused her to present to the local ED where she was immediately treated with IV solumedrol, multiple breathing treatments, IV mag sulfate, more breathing treatments. and upon rechecking her ABG's it was recognized that she was again going into respiratory failure and was admitted into the hospital ICU. While according to her history, she responds to an asthma protocol, her condition usually gets MUCH worse before it gets better, and unfortunately as a result, it's not uncommon for her to have to be intubated until she gets better. Her records indicate that she not only doesn't fit the "bell curve" in terms of how "timely" she responds to treatment in the "expected/normal time frame", but she apparently falls off the edge of the paper, in terms of how long it takes to get an obvious improvement. IF she has asthma, it appears to be VERY refractive to treatment. She had been responding to treatment, but because she "failed" the d-dimer, they took her for a CT scan to ensure that there was no PE. She did NOT handle the CT scan (laying flat) well at all!!! So they rushed her back to ICU anticipating having to intubate her as she was moving almost no air at all. I'd like to make note here that I was really quite impressed (yeah, I know, with ALL my experience, right?) with how well this woman dealt with her situation! She was CLEARLY EXTREMELY PHYSICALLY uncomfortable! She was in TREMENDOUS pain, both in her back, due to the muscles tightening up but also in her chest from what seemed to be both restriction AND obstruction. But what was so impressive, was that she has seemingly developed distraction techniques over the years to recognize and deal with the expected and/or anticipated anxieties that would rather go "with the territory" exceptionally well! She really did not seem to be anxious, at least only in the most minor degree, as she recognized the vicious cycle that she could/would get into if she allowed the anxiety to get out of control.

So, after getting her back into the ICU, it was decided that even though the pt stated that BiPAP USED to work in these situations, it NO LONGER does, they opted to try more breathing treatment and BiPAP. as the doctors felt that the asthma protocol wasn't working. Even though it had been prior to her laying flat for the CT. They put the BiPAP on her and left her in the room alone for quite awhile. While everyone else attended to "other things' and other patients, I stood outside her room watching her struggle to breath. I noticed that it didn't seem as if her chest was rising/falling, but her belly SURE was! You could tell that she was becoming more confused and disoriented as she seemed to lose the coordination and continued to fight, in an attempt to get the mask off. When I was sure that was what she was in fact doing, I alerted her nurse who went in and tried to get her to stop, but instead she began to fight it even harder. They had to take the mask off to try to reseat it properly, She was FINALLY able to make them understand that while she WAS getting SOME air into her lungs, MOST of it was just going into her belly and she was getting very uncomfortable due to the distension! So they removed the BiPAP and resumed the breathing treatments and she was appearing to begin to VERY SLOWLY and VERY SLIGHTLY beginning to respond to the treatments. This is about when the PCCM came in. I'm sorry, but this guy was a COMPLETE ASS!!! He and this patient CLEARLY had some sort of history together and it WAS NOT a good one! Initially, she didn't realize he was there, as he stayed out of her room and was just reading her chart and talking to the nurses. Later, it seemed that the more he saw that he upset her, the more, for lack of better word, "enjoyment" he seemed to take in it. He made it VERY CLEAR that it is HIS opinion that this woman's problem is ALMOST ENTIRELY of psychiatric in origin. And what little of it that MIGHT NOT be psych in nature, was TOTALLY due to Vocal Cord Dysfunction.

She had had MULTIPLE PFT'S and has been r/o for almost EVERYTHING you can imagine! No COPD, SOME possible asthma, NO VCD after being scoped by multiple ENT's on multiple different occasions, r/o myasthenias gravis, no fungus', no allergies, AN AWFUL LOT of NO's BUT NO "YESES"!!! And apparently, according to her records, she has been extremely careful to keep her healthcare WELL centered to just two, occasionally 3 doctors (A PCP-Family Medicine, a psychiatrist, and an occasional Pulmonologist), to avoid even the appearance of doctor hoping and attention seeking behavior, AND on top of that, having seen the SAME PCP for 16 1/2 yrs., after a yr of treating her and realizing that he had to consider the possibility of a psychosomatic/psychogenic component to her disease. She began seeing a specific psychiatrist at her PCP's request and has seen the same psychiatrist for yrs, who has been practicing psychiatry for years. The goal was to r/o a psych component, monitor her for onset of new depression due to her chronic illness and lack of dx, and finally if all that was r/o, the goal was to establish a VERY LONG record of psychiatric stabiltiy. Which she states her psychiatrist has assured her is the case. Her records reflect this as well. This psychiatrist has ASSURED her that IN NO WAY does he see her disease process as ANYTHING BUT TOTALLY biologically based.

Now, this pulmonologist that was treating her on the night of July 2/morning of July 3rd decided he was going "prove" that this was anything "BUT lung" And this is where my concerns come from. Knowing that this patient was in respiratory failure, and knowing that the ICU nurse was concerned that her airway was compromised sufficiently that she felt she should have been intubated at this time. Instead, the PCCM gave the ICU nurse the order to give her a bolus IV push dose of 4mg Ativan. Now, I'm going to preface this next part with I don't feel competent to decide HOW SEVERE her respiratory failure was, when I looked up the contraindications of using Ativan/lorazepam this is what I found:

"Contraindications

Severe respiratory Failure - Benzodiazepines, including lorazepam, may depress central nervous system respiratory drive and are contraindicated in severe respiratory failure. An example would be the inappropriate use to relieve anxiety associated with acute severe asthma. The anxiolytic effects associated may also be detrimental to a patients willingness and ability to fight for breath. However if mechanical ventilation becomes necessary, lorazepam may be used to facilitate deep sedation." Lorazepam - Wikipedia, the free encyclopedia. . . I know I don't get to diagnose, but it really concerned me that the patient was given so much at one time. It ABSOLUTELY KNOCKED HER OUT! When she finally woke up, the doctor shocked me when he looked at her and stated, "Well . . . It worked! So, it CAN'T BE LUNG!!!" It was at that point the patient really became aware of the doctor being in the room and WHO he was. At this point she became VERY upset and demanded that he leave the room. I really thought she was going to become hysterical she was SO upset. The nurse came in and began to try and calm her down, as she was concerned that her breathing difficulties would again flair. She just cried out that, "NO! She didn't understand! That this doctor had almost allowed her to die several years back and she was terrified of him! She said she didn't think it was done intentionally, but she DIDN'T know if it was because he had made an error or if it would have happened anyway. But that she didn't want him anywhere near her! Were I in her shoes, I can't say that I would feel differently.

So, guys, am I making a mountain out of a mole hill here? I mean, I'm not looking to go and report anything or anything. It just really bothered me and I feel the need to TRULY understand what I observed that night. And I really look forward to hearing from you guys that have not only real nursing time under your belt, but also from ICU nurses that might have seen Ativan used in such a way before. Again, had she already been intubated/ventilated it wouldn't have bothered me so much, as I could have rationalized that she had the ventilator to breath for her. I just kept standing there holding my breath, afraid that she might actually STOP breathing!

However, if I'm am WRONG, be gentle . . . I am still learning! I just want to make sure that I'm asking the RIGHT questions!

Looking forward to hearing back! ~ Thanks for staying with me! I KNOW

[BuckyBadgerRN, ASN, RN]

Too long. Sorry. I'll wait for somebody to break it down.

[emtb2rn, BSN, RN, EMT-B]

I'm in resp distress from simply trying to wade through that post. I'm getting pretty anxious, distress getting worse. Sure wish there was a med that would calm me down so i could breathe easier...

[Sun0408, ASN, RN]

How did the pt respond?? You wrote so much but wrote nothing about how the pt responded.

Not saying this lady was not experiencing a true issue, but I've seen some crazy things people do to get attention, drugs or admitted to the ICU.

I have also given pts Ativan for resp issues, it does calm them down enough to help ease their breathing efforts. I have also given morphine for the same reason. Sometimes it works, sometimes it doesn't. If she needed to be intubated, she was in the right place.

Was the doc right, I have no clue, was he an ass, maybe. The ICU is a tough place to be and you will see lots of suffering if you stay.

[pigginsrn]

IME when MDs can't figure something out, they often go to a psych origin. Truth is, many physicians refuse to admit sometimes they just don't know.

[KatieMI, BSN, MSN, RN]

The patient in question had increased work of breathing. It is a common finding which may or may not have anything at all to do with hypoxia. After a while of breathing as a fish taken out of water, one gets tired and eventually breathing can become too hard and too painful just to go on. In addition to that, feeling of "not enough air" is frightening, which makes patient breathing harder and moving the pathologic circle 'round and 'round till it ends with tube down the throat and deep sedation.

It doesn't matter what started the circle in the first place. It may be psych case or asthma attack or something else. The key is, patient just gets physically tired of breathing.

One of the best things that can be done in such situation is minimal sedation, not enough to stop respiratory drive altogether but enough to make patient comfortable, not panicking and not gasping for air. Ativan is commonly used for this purpose.

Now, dear OP, is your turn:

1). What are TWO questions you MUST know answers before giving the patient 4 mg of Ativan IV? (there are more than two of them, actually, but you're just a student :)

2) Which one specific med MUST be immediately available in the unit for a nurse safely administer Ativan?

3). Same as 2) if order says "6 mg of morphine IVP"

4). What monitors the patient must be on for safely administering this order?

5). You wrote that the patient had hypoxia. What test you'd like to see to determine if it is "hypoxia" or "hypoxemia"?

[Julius Seizure]

If she is panicky and perhaps tachypneic, and fighting against the bipap, she is using her oxygen reserves more quickly, right? That's not good for her.

So maybe a little Ativan to help chill her out will allow her to tolerate the respiratory support that she needs. I would have a hard time tolerating a bipap mask as well - it's not comfortable, neither the mask not how it's forcing air in.

What I mean to say is that the Ativan was not given for a psych reason, it was given to allow her to tolerate her treatment better. We often keep patients on low dose precedex infusions for similar reasons.

I work in peds, so 4mg seems like a large dose to me if she was naive to the drug. But I'm not a great judge of that in the adult population. As always, drug dosing requires taking many factors into consideration.

As another poster said, she's in the right place if it makes her need intubation. But chilling the patient out may have helped allow the treatment to actually help her more.

[psu_213, BSN, RN]

I can't possibly address every issue, and there are several. I will just tell you what one doctor (whom I respect very much) told me..."if they aren't trying to rip the BiPAP off, then things are going badly." While many people tolerate BiPAP without an issues, the fact that she is trying to remove it may not be all that much of an issue.

I very much appreciate your your feelings and your instinct to advocate for a patient; however, you have seem to know an awful lot about the situation, the alleged hx. between the doc and the pt., etc, while you were just "observing."

[shellyscorner]

Sorry! Wasn't sure what you guys did and didn't need to know to help me understand what I was seeing!

[meanmaryjean, DNP, RN]

I'm guessing you're a family member (hence the use of Wikipedia for medical advice) and are trying to get up to give you advice about your loved one. That violates TOS.

[shellyscorner]

Not that I'm the one to make the judgement here, I REALLY recognize that, but it wasn't that the drug in and of it's self worried me, it was the amount that concerned me. It just seemed like so much. Although, when I looked it up, the max suggested dose was 8mg., but I'm not familiar with the circumstances with when that dose would be appropriate. I never dreamed you could give someone 8mg of Ativan! Four surprised me, can't imagine using 8mg, unless the patient used it on a regular basis and at higher does that what I'm familiar with (like .5 to 2mg doses). But again, I recognize I DON'T have the experience to make that call, which is why I ask about it. And again, it's not my place to DO anything about it, I was just curious. And if I understand your comment properly, no, she did/does not, to my knowledge take Ativan at all as an outpatient. As to the BiPAP mask, yeah, I don't know how well I'd handle that either! Thanks for your thoughts!

[shellyscorner]

I'm guessing you're a family member (hence the use of Wikipedia for medical advice) and are trying to get up to give you advice about your loved one. That violates TOS.

I'm sorry you feel that way. But no,that's not correct. And yes, your right! That would violate the TOS! Frankly, I didn't have a PDR at home.