Delirium on the surgical ICU: one nurse to four patients and a demand for 10 mg haloperidol
Mr P, 58, is day three after emergency laparotomy for a perforated duodenal ulcer. He is septic on meropenem, has a nasogastric tube, a urinary catheter, two abdominal drains and a morphine patient-controlled analgesia pump; his sodium is 128 mmol/L and CRP 210 mg/L. Since last evening he has been agitated, is pulling at his drains, attempts to climb over the side rails and has not slept. He is oriented to person only, with fluctuating attention and misperceives the infusion pump as an animal. The ICU tonight is staffed at one nurse to four patients against a usual one to two, and no one-to-one nurse is available. The surgical registrar tells you by telephone to prescribe haloperidol 10 mg intramuscularly and physical restraints so that he stops interfering with the drains, adding that delirium is a psychiatric problem and asking you to sort it out so that the ward round is not delayed. The patient's wife is at the bedside and is distressed.
1. How would you handle the exchange with the surgical registrar and run the bedside discussion so that the patient gets a safe plan?
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Do not negotiate this on the telephone; go to the bedside. Invite the registrar, the nurse in charge and the wife to a short huddle.
Open with the shared goal: everyone wants him to leave ICU without pulling out a drain, falling or developing pressure damage. Reframe the behaviour as a symptom, not a psychiatric nuisance: hyperactive delirium in a septic postoperative patient is a marker of worse outcome and higher mortality, and its treatment is primarily medical.
Give a working formulation out loud: multifactorial delirium from sepsis, opioid, sodium 128, sleep deprivation, catheter and drains, sensory deprivation. Then state the specific objection: 10 mg intramuscular haloperidol in a septic, mildly hyponatraemic man risks QT prolongation, hypotension, extrapyramidal effects and paradoxically worse delirium. Offer an alternative the registrar can accept: haloperidol 0.5 to 1 mg orally or intramuscularly, or quetiapine 12.5 to 25 mg, with an ECG and electrolytes, reserved for distress or danger rather than staff convenience.
End with something concrete in return, a written delirium order set and review in two hours, so the registrar leaves with a plan rather than a rebuke. Never correct a colleague in front of the family; agree the message before speaking to her.
2. Set out your non-pharmacological and pharmacological plan with the details you would actually write in the notes.
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Non-pharmacological (the treatment, not an adjunct): daylight exposure and orientation with a clock and calendar; the wife present during the day and a familiar voice at night; glasses and hearing aids in place; clustered observations to allow an uninterrupted sleep period, eye mask and earplugs; remove tethers where safe (catheter out if not required, drains secured, PCA reviewed); low bed, sensor mat rather than side rails; early mobilisation once sepsis allows; treat constipation and pain with multimodal analgesia.
Correct the causes: repeat sodium, check glucose and calcium, review all anticholinergic and sedative drugs, assess for urinary retention and chest infection, review antibiotic dosing in a septic patient.
Pharmacological: reserve antipsychotics for severe distress or imminent danger. Write haloperidol 0.5 to 1 mg orally or intramuscularly, maximum twice in 24 hours, after ECG with QTc under 450 ms and normal potassium and magnesium; or quetiapine 12.5 to 25 mg. Avoid benzodiazepines unless this is alcohol withdrawal. Review sedation score, QTc and extra-pyramidal signs after each dose. A note that says haloperidol 10 mg and restraint, with no cause list, monitoring or review time, is indefensible.
3. The nurse in charge says there is no one to observe him and restraints will be used. How do you respond and what do you document?
Read the worked answer
Name the real problem out loud, pleasantly: restraint is being proposed because of staffing, not because restraint is the safest clinical option. A confused man tied to a bed, pulling harder against ties, with a nasogastric tube and drains, is at higher risk of aspiration, injury and worsening delirium, and restraint requires continuous observation anyway, so it does not solve the staffing gap.
Practical alternatives to negotiate: move him to the bed opposite the nurses' station, ask the wife to stay tonight if she is willing, page the duty manager for redeployment or an agency shift, and agree a 30-minute behavioural plan with the nurse in charge. If restraint is nevertheless used, it must follow a documented protocol: who authorised it, the least restrictive alternative tried, duration, position, circulation and sedation checks, hydration, and review intervals.
Document your advice, the residual risk and to whom you escalated, and send an incident report if a safe plan cannot be provided. Also inform the surgical consultant in writing, not to complain but because the risk persists after you leave. Your position is that you are not refusing to help, you are refusing to prescribe a dangerous dose without an indication.