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May 11, 2007

Pain and Delirium in the ICU Setting

Bekaserdans72x723 Beka - Yesterday I got hit by a patient. The week before a patient tried to break my wrist during a bout of delirium. The week prior to that event 5 of my colleagues had to wrestle with a patient who was in DT’s from alcohol withdrawal. That’s 3 weeks’ worth of punches, hits, curses, spitting, and screaming from patients who all were experiencing delirium to certain degrees. And one of them was mechanically ventilated until he extubated himself.

I came home each day tired and fatigued after long nights of non-stop rages from these patients. Each was given mega-doses of "Vitamin H"  (our name for Haldol,) which I was somewhat biased against, as it was a neuroleptic that could induce abnormal involuntary movements. However, the doses sedated each patient quickly.

I also came home dissatisfied with the way each patient had been handled. Haldol and wrist restraints had been initiated for sedative purposes and maintenance of patient safety. I began an online search about delirium in the ICU setting and came across this Medscape article, Pain, Delirium, and Sedation in the Mechanically Ventilated Patient, from the Highlights of the Society of Critical Care Medicine 36th Critical Care Congress.

The article reported that more than 80% of ICU patients experience delirium, which adds to their mortality and morbidity rates. I certainly can attest to that fact.  As I read the article there was no mention of the use of restraints or the use of intravenous Precedex, which was the primary sedative used in our CTICU along with “Vitamin H.”

Were we doing the right things for these patients? Were we recognizing that delirium could be caused by pain?

Sifting back through these 3 patients' records a few days later, I noted that none of them had received any pain medicine following open heart surgery. Now, I would imagine that the placement of chest tubes could be compared to “a few knives stuck in you” and a sternum that had been broken would be also painful. I was beginning to wonder if during all our “busy-ness,” pain level assessments and management were being relatively ignored, compared to hemodynamic assessments, which seemed to always be addressed first during grand rounds?

Any thoughts on this? How do you deal with patients and delirium in a critical care setting?

May 11, 2007 in Beka | Permalink

Comments

I recently was hospitalized with double pneumonia and went into respiratory arrest. I was kept in and out of a medically induced coma and was intubated. I spent a month in the hospital followed by a week in a nusing facility for rehab.
The worst thing about the whole experience was the paranoia I suffered while comatose and upon waking for long periods of time. TERRIFYING dreams while comatose, and continued paranoid thinking when awakened, intermittantly with lucid thinking. I attacked a nurse; I told family members I was being held against my will. The mental suffering was extraordinary, and, as a retired mental health therapist, I only wish that if I had tohave this experience I had had it when I was still working with paranoid schizophrenics as it would have helped me better understand the tenacity with which patients hold onto their delusions! I was taking Haldol, and Artane during this time. There MUST BE better alternatives for sedation while one is intubated...

Posted by: n.k.long | Jun 16, 2008 5:47:41 PM

What is long QT?

Posted by: shella | Jan 8, 2008 7:14:59 PM

Prisons treat, don't treat prisoners too well

Posted by: buy bonnisan | Jun 27, 2007 1:57:29 PM

I am baffled by the continuing abuse the doctors allow us to face when they KNOW someone is going to go into DT's!! If they know it, they need to be preemptive and order appropriate meds(we use ativan and librium) One hospital I worked at had a scale that determined what med to be given basec on patient's symptoms. This worked out very well with our high population of ETOH abusers.

Currently I work in a 10 bed MICU and we have quite a few patients on vents. We use propofol (Milk of Amnesia) or atavan, versed along with fentanyl. I love the propofol as it keeps 'em nice and chilled out but metabolizes quickly and allows you to wake them up quickly.

SHAME on those people who don't think enough of their patients to medicate their patients pain appropriately! What if it was their family member???

Posted by: susan | Jun 8, 2007 1:02:29 PM

Hi,
I enjoy your postings, but I had to comment on the patients you described as being delirious or in DT's.
How about Valium for withdrawal from alcohol? These patients are obviously in withdrawal which progressed to DT's - totally unnecessary. We start with a loading dose of Valium 10 mg and then gradually decrease the dose until the patient is detoxed. This works great - I have never had a patient go into DT's after this protocol was initiated. Haldol is not the drug of choice in this instance. If the patient uses alcohol and other drugs, you could use a Phenbarb detox just as well.

Posted by: abby | May 22, 2007 4:04:12 PM

I work in a general ICU and am just completing my ICU critical care pathway course (ex ENB 100);i am just compiling information to support an assignment based on ICU psychosis and my main considerations were 1; pain, 2; ICU layout, windows, space etc, 3; noise and intervention and 4; sedation. I would be pleased and very grateful to hear of other ICU nurses' experiences and philosophies, whartever they may be.

Posted by: Ruthie Matthews | May 17, 2007 10:18:36 AM

I work in a CVICU and I am baffled by this.
I have NEVER not given pain meds to a confused patient.
We have a pain protocal created by our Acute pain service team that includes tylenol and gabapenten, we have prn morphine or fentanyl until chest tube removal.
Once all lines and tubes are pulled usually 18 hours post op we switch to long acting oxycontin with oxycodone for break thru.
We add antipsychotics if needed.If a patient becomes over sedated and is at risk for pneumonia we readjust the meds until they wake up.
We treat pain with narcotics for up to two weeks post..we need them up walking, talking and coughing and pain keeps them bed bound.
We also get our demented patients out of the bed
, being confused is not a free pass out of the protocal.
Treat their pain and get them out of the bed..they get better faster.

Chemical restraint is sometimes needed but most of the time nurses get all bent out of shape over nothing.
If your patient reacts violently to being turned or repositioned stop doing it. Leave them alone when they are agitated. Yes, the bed will be a mess, they may have to skip a bath and a shave,so what? Better they look a little rough then sedated off their ass because the nurse just couldn't get her work done while they fidgeted. Restrain their hands for safety and leave them be. Treat their pain and leave them be.
Another tip is treat them as if they were fully competent. Yes, I know that seems nuts but it isn't. Keep your tone normal and treat them the same as any other patient who reacts negatively to your care. Just because they are confused doesn't mean you get to run your agenda over their resistance. If they say no respect it and walk away. Even confused patients clue in to the people who allow them dignity.
Ever notice some nurses seem to have no problem while some are struggling?
it is in their approach.
It took me alot of years to stop being frustrated by my confused patients.
Once I gave up the fight I stopped getting hit .
I woke up and realized I have no personal investments here. Their behaviour is not a reflection of my care so I can chill out and let them be mad squirmers that refuse their meds. I just keep their lines safe and find IV substitutions.
Also it is part of your competency standard to be assessing pain every hour in the ICU. How are you withholding pain meds if you aren't assessing pain?

By the way "you" is the royal you not you personally.
We also try not to use Haldol , it can cause long QT and can lead to real issues in our population.

Posted by: mo | May 17, 2007 12:58:04 AM

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