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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

Today’s tip is about when your loved one is in an ICU delirium or in an ICU psychosis and how to manage that. So let’s look at this, how patients do end up in with ICU psychosis or ICU delirium, and then let’s look at how that can be improved or even be resolved.

So currently we are working with a client who’s had their dad in ICU for about 47 days initially with a breathing tube  on a ventilator, in an induced coma because of COVID pneumonia.

And after about 20 days in ICU, their family member, their dad ended up with a tracheostomy because they were in an induced coma for too long, couldn’t wake up, couldn’t be weaned off the ventilator, ended up with the tracheostomy, but then the intensive care team continued with sedation, such as fentanyl and propofol. And one of the main reasons you want to do a tracheostomy is, so that you can stop sedation, wean it all off, wake people up, wake patients up, get them into a natural day and night rhythm, get them to some sort of “normality”, get them to interact with people, wake them up. Assess their neurology, assess their brain activity, their brain function, get them started on physical therapy, get them to mobilize and wean them off the ventilator. Because often you can only wean off the ventilator if patients are awake and out of the induced coma and compos mentis.

Now that is not the case in this situation where the ICU team continues with propofol and fentanyl and keeps sedating our client’s father. And that seems to be inappropriate with all the clinical information that we have. And now he seems to be in ICU delirium, ICU psychosis. He seems to be agitated, confused, depressed, and the list goes on because they keep sedating him for much longer than necessary. And didn’t mobilize him. Didn’t treat him like a human basically, because at the end of the day, you want to treat someone like a human, get them out of bed, breathing exercises and wean them off the ventilator.

So what’s the solution here. The solution is that as soon as the tracheostomy is done, that sedation should be stopped. Why? Because a breathing tube in the mouth or in the throat is very uncomfortable and it needs sedation for patients to be able to tolerate it. As soon as the breathing tube is out and the tracheostomy has been done, sedation can be stopped because most patients report, there is no pain with the tracheostomy. So why would you sedate those people in the first place? So now we’ve got this dilemma here that the patient is agitated. Every time they stop propofol and fentanyl the patient becomes agitated, delirious, aggressive, and the way forward is to stop this sedation also because fentanyl is addictive.

So that means when they stop fentanyl, it could also be an element of simply withdrawal from a fentanyl, because again, fentanyl is a very addictive, highly addictive substance, and it needs to be weaned off gradually. And in order to support that weaning of fentanyl, you can support it for example, with medications, such as clonidine, dexmedetomidine also known as precedex. Sometimes olanzapine sometimes Seroquel in rare cases or in some cases, haloperidol as well. But more importantly, get patients back into a day and night rhythm, get them out of bed, start physical therapy, start talking to them, explain to them what’s happened and what the next steps are to get them out of it.

That is my tip for today.

Now, if you have a loved one in intensive care, go to intensivecarehotline.com and call us on one of the numbers on the top of our website or simply send us an email to [email protected].

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This is Patrik Hutzel from intensivecarehotline.com and I’ll talk to you in a few days.