What are the next steps for a patient with delirium, potential Deep Vein Thrombosis (DVT), and psychiatric issues, who has been restarted on psychiatric medications and is not keeping their leg straight after a transient venous pacemaker (TVPm)?

Immediate Management of Delirium with Leg Immobilization Issues Post-TVPM

For a delirious patient who cannot keep their leg straight after transvenous pacemaker placement, immediately implement multicomponent nonpharmacologic interventions while evaluating for reversible causes, and consider short-term low-dose antipsychotics only if the patient's agitation poses imminent risk of harm to themselves (such as dislodging the pacemaker) after behavioral measures fail. 1, 2

Immediate Nonpharmacologic Interventions (First Priority)

Start these interventions NOW before considering any medications: 1, 2

• Reorientation strategies: Have staff or family members stay with the patient to provide calm, repeated explanations about where they are, why they need to keep their leg straight, and that they are safe 3

• Environmental modifications: Create a quiet environment, reduce unnecessary noise and stimulation, ensure adequate lighting during day and darkness at night to regulate sleep-wake cycles 3, 1

• Physical positioning aids: Use pillows or soft positioning devices (NOT restraints) to gently support the leg in proper position 4

• Family presence: Having a family member stay with the patient is one of the most effective interventions to promote orientation, sense of security, and safety 3, 1

• Cognitive stimulation: Engage the patient in conversation, use familiar objects from home, play familiar music 3

• Sensory optimization: Ensure glasses and hearing aids are in place if the patient uses them 1, 2

Evaluate and Treat Reversible Causes NOW

While implementing nonpharmacologic measures, simultaneously assess for: 1, 2

• Infection: Check for urinary tract infection, pneumonia, or line infections 3, 1

• Metabolic derangements: Review electrolytes, glucose, calcium, magnesium 2

• Hypoxia: Ensure adequate oxygenation 3, 1

• Pain: Assess and treat pain adequately but avoid excessive opioids 3, 1

• Medications: Review all medications and discontinue any with anticholinergic properties, benzodiazepines (unless for alcohol withdrawal), or other delirium-inducing drugs 1, 2

• Dehydration: Ensure adequate hydration 3, 1

• Urinary retention or constipation: Check for bladder distension or fecal impaction 3

Pharmacologic Management (Only If Necessary)

The psychiatric medications restarted this morning may actually be worsening the delirium depending on what they are. 3, 1

When to Consider Antipsychotics:

Use antipsychotics ONLY if: 3, 1

• The patient is severely agitated and threatening substantial harm to themselves (e.g., actively trying to pull out the pacemaker despite all nonpharmacologic interventions)
• The patient has distressing hallucinations or delusions causing significant distress
• Behavioral interventions have failed or are not possible

Specific Medication Recommendations:

If antipsychotics are necessary: 3, 2

• Haloperidol 0.5-1 mg IV/IM/PO is the most commonly used, though evidence for efficacy is limited 3, 5
• Quetiapine 12.5-25 mg PO may be considered as an alternative 2, 6
• Use the lowest effective dose for the shortest possible duration 3, 1
• Discontinue immediately once the distressing symptoms resolve 3, 2

Critical Warnings About Medications:

DO NOT use benzodiazepines unless this patient has alcohol or sedative withdrawal 3, 1, 5 - benzodiazepines will worsen delirium in most cases 7

Antipsychotics do NOT treat the underlying delirium - they only manage severe agitation temporarily 3, 2 - the delirium will persist until you address the underlying causes 1, 2

Review what psychiatric medications were restarted - if they include anticholinergics, benzodiazepines, or sedating medications, these may be contributing to the delirium and should be discontinued 3, 1

Specific Strategy for Leg Immobilization

The "T-A-DA" method (Tolerate, Anticipate, Don't Agitate): 4

• Tolerate: Accept that the patient may move somewhat; focus on preventing harmful movements rather than perfect immobilization 4

• Anticipate: Predict when the patient is likely to become more restless (during care activities, at night) and have staff present during these times 4

• Don't Agitate: Avoid confrontational approaches or repeated commands to "keep your leg straight" which may increase agitation 4

Monitoring and Reassessment

Reassess the patient frequently: 1, 2

• Use the Confusion Assessment Method (CAM) to monitor delirium severity 1
• Evaluate daily whether antipsychotics (if used) can be discontinued 3
• Continue searching for and treating reversible causes 1, 2

Common Pitfalls to Avoid

Do not assume this is a purely psychiatric problem - delirium is a medical emergency with an underlying medical cause that must be identified 1, 5

Do not use physical restraints - these worsen delirium, increase agitation, and are associated with worse outcomes 4, 5

Do not continue antipsychotics beyond the acute crisis - 47% of patients inappropriately continue receiving antipsychotics after discharge without clear indication 3