Andrea Sikora Newsome, PharmD
“Don’t you put that damn thing on me again!” The patient hollers over the white noise of empty IV pump alerts and ventilator alarms. The nurse is trying to replace the patient’s condom catheter. At this point, other nurses are filing in, and the resident looks up and asks me what the dose is that I would recommend for quetiapine (Seroquel, an atypical antipsychotic, with some data supporting its use for ICU delirium, though this is an off-label use). The patient continues in a raised voice, “It hurts, and I’m plum sick of wetting all over myself.” His voice is angry, frustrated. This broad-shouldered, 6-foot man who works with his hands is now barefoot in an open-back gown in a room smaller than a prison cell, and the nurse wants to place a sticky plastic condom catheter on him. I shake my head at the resident, “Sounds like a pretty reasonable argument to me. He isn’t delirious. You think you’d want to wear one of those things?”
Delirium is a leading cause of agitation in the intensive care unit. Defined as a lack of attention, waxing and waning in nature, it makes people answer the question, “Does a stone float on water?” “Yes.” It is associated with increased length of hospital stays and mortality. But this wasn’t ICU delirium, this was a man giving a rational argument regarding his preferences. “I think the bigger question,” I continued, “is if we really need accurate ins and outs on him.” This sparked a conversation with the patient, and he ultimately agreed to measure his urine output for us.
“You know for being a pharmacist, you spend a lot of time telling us not to use drugs,” someone says. “Only the ones that won’t help,” I reply. The team laughs, but in some way, becoming an expert means not just knowing about our tools but knowing about their limitations, and knowing where there are gaps in our knowledge. Expertise is knowing enough to realize all that we do not know.
Delirium is deeply misunderstood by many practitioners. Many patients become disoriented, and we often don’t do the little things that make a difference - like turning the lights on in a patient’s room. Instead, we rely on pharmaceutical restraints. Vanderbilt’s ICU Delirium study group (icudelirium.org) has excellent resources on the topic and recommends that clinicians STOP and THINK. This approach recommends stopping offending agents and interventions that may be causing delirium and then thinking about and working up possible causes of delirium such as electrolyte imbalances or sepsis.
In this case, the patient just needed something stopped, not started.