Can a patient with a history of chewing tobacco who is experiencing Intensive Care Unit (ICU) delirium benefit from a nicotine patch as part of their management plan?

Nicotine Patch for ICU Delirium in Chewing Tobacco Users

Yes, a nicotine patch can be beneficial for ICU patients with a history of chewing tobacco who develop delirium, as nicotine withdrawal is an under-recognized cause of ICU delirium and agitation, and nicotine replacement therapy has been shown to produce dramatic clinical improvement in brain-injured patients within hours of administration.

Rationale for Nicotine Replacement Therapy

Nicotine Withdrawal as a Delirium Trigger

• Active tobacco users (including chewing tobacco) who are forced into sudden abstinence upon ICU admission commonly develop nicotine withdrawal syndrome, which manifests as agitation and delirium. 1

• Nicotine withdrawal symptoms include anxiety, insomnia, depression, difficulty concentrating, irritability, anger, restlessness, and slowed heart rate—all of which overlap significantly with delirium presentations. 2

• In a prospective observational study of 144 mechanically ventilated ICU patients, active smokers had a 64% incidence of agitation compared to 32% in nonsmokers (P = 0.0005), with active smoking identified as an independent risk factor for agitation (OR 3.13,95% CI 1.45-6.74). 1

Evidence Supporting NRT in ICU Delirium

• Five case reports of brain-injured ICU patients with heavy tobacco use demonstrated dramatic and sustained clinical improvement within hours of transdermal nicotine replacement, suggesting nicotine withdrawal may be an under-recognized cause of delirium in acute brain injury. 3

• Nicotine withdrawal is associated with higher rates of self-removal of tubes and catheters, and increased need for supplemental sedatives, analgesics, neuroleptics, and physical restraints. 1

Practical Implementation

Dosing Strategy

• For chewing tobacco users, start with a 21 mg/24-hour nicotine patch if the patient was using ≥10 cigarettes-equivalent of nicotine daily; for lighter users, consider starting with a 14 mg patch. 4, 5

• Chewing tobacco users typically have significant nicotine dependence comparable to heavy smokers, so the 21 mg patch is usually appropriate. 2

Administration Protocol

• Apply the patch to clean, dry, hairless skin on the upper body or outer arm each morning. 5

• Rotate application sites daily to prevent skin irritation. 5

• If withdrawal symptoms persist despite patch therapy, immediately add a short-acting NRT form (nicotine gum, lozenge, nasal spray, or inhaler) rather than continuing patch alone, as combination NRT nearly doubles cessation success. 5

Treatment Duration in ICU Setting

• Continue NRT throughout the ICU stay and beyond until the patient is stable enough to participate in formal smoking cessation counseling. 2

• For long-term cessation after ICU discharge, maintain NRT for a minimum of 12 weeks. 4, 5

Safety Considerations

Cardiovascular Safety

• NRT is safe even in patients with cardiovascular disease, including those with coronary heart disease, as nicotine patches have been successfully tested without adverse effects in cardiac patients. 2

• Blood nicotine levels from NRT remain significantly lower than from smoking or chewing tobacco, making toxicity rare. 5

Common Side Effects

• Local skin reactions at the application site, nausea, sweating, mood alterations, and sleep disturbances are the most common adverse effects. 6

• Most nicotine-related adverse effects are dose-dependent and resolve within 12 hours if exposure is discontinued. 4, 6

Critical Caveats

Conflicting Evidence

• A 2016 systematic review found inconclusive evidence for NRT in ICU delirium management, with three studies reporting increased agitation/delirium with NRT use, one showing no benefit or harm, and two describing reduction of withdrawal symptoms. 7

• A randomized controlled trial of 40 ICU patients showed numerically decreased ICU stay (4.5 vs 7 days) and ventilator days (1.9 vs 3.5 days) with NRT, but these differences were not statistically significant. 8

When to Avoid NRT

• Do not use NRT in patients at significant risk for torsades de pointes (baseline QT prolongation, concurrent QT-prolonging medications, or history of this arrhythmia), though this applies more to antipsychotic medications than NRT. 2

• Recognize that many ICU medications (lidocaine, mexiletine, procainamide, atropine, cimetidine, meperidine) can independently cause delirium. 2

Alternative Considerations

Preferred Sedation Strategy

• If the patient requires ongoing sedation, use dexmedetomidine rather than benzodiazepines, as dexmedetomidine reduces delirium duration by approximately 20% compared to benzodiazepine infusions. 2

• Benzodiazepines are a risk factor for ICU delirium development and should be avoided except for alcohol or benzodiazepine withdrawal. 2

Antipsychotic Caution

• If antipsychotics are considered for severe agitation, quetiapine showed decreased hazard of in-hospital mortality (HR 0.58,95% CI 0.40-0.84) compared to haloperidol and olanzapine, which were associated with increased mortality and continued delirium. 9

Bottom Line Algorithm

1. Identify tobacco use history (including chewing tobacco) using the Fagerström Test of Nicotine Dependence at ICU admission. 1

2. For patients with moderate-to-heavy tobacco use who develop agitation or delirium, initiate a 21 mg nicotine patch immediately. 4, 3

3. Monitor for clinical improvement within hours to days; if inadequate response, add short-acting NRT. 5, 3

4. Simultaneously optimize sedation strategy by using dexmedetomidine over benzodiazepines. 2

5. Continue NRT throughout ICU stay and transition to formal cessation support post-discharge. 2