Confusion in the postoperative ward

Problem 4 Confusion in the postoperative ward



Toby T. Winton-Brown



You are the resident on call covering the night shift and finally about to get some sleep when a concerned nurse pages you requesting a phone order for sedation. A 67-year-old woman has become very agitated 3 days after a left total hip replacement. She has been yelling at the nurses, climbing out of bed and distressing the other patients.


Q.1


What do you tell the nurse over the phone?


This patient evidently has postoperative confusion and needs to be clinically assessed before any psychotropic medication can be given. Over the phone you establish the acuity of the situation – the patient’s vital signs are stable and she is not posing immediate danger to herself or others.


On approaching the ward it is obvious which patient is yours from the noise and commotion. She is half out of bed, clawing at her various drains and lines, and is muttering about the nurses stealing her dentures and poisoning her mashed potato.



Q.2


What might possibly have caused postoperative confusion in this patient? What factors put her at risk?


The patient’s blood pressure is 140/100 mmHG, pulse 100/min and regular, respiratory rate 30/min. Her temperature is 37.7°C. She is on IV fluids, has an indwelling urinary catheter and the fluids chart records a net deficit of 100 mL over the last 24 hours. The operative report records a routine procedure with no complications.


The nurses confirm an acute increase in her confusion over the last 24 hours, which has seemed to fluctuate and particularly worsened during the evening. There is no known history of prior cognitive or psychiatric problems.


When you attempt to examine the patient she becomes angry. She has trouble understanding your questions and is herself difficult to follow. You inspect the surgical wound, which appears clean and non-infected.



Q.3


How would you describe this woman’s clinical state?



Q.4


What investigations will you perform in order to confirm your diagnosis?


Aside from a raised MCV of 104 fL and a GGT of 116 U/L, the results of urinalysis, blood screen and ABGs are normal. The chest X-ray shows a small amount of bibasal atelectasis.



Q.5


What do you think is happening to this patient? What other history would be helpful?


You manage to get the patient’s son on the phone, although it is the middle of night. He is surprised to hear his mother is causing a disturbance – she is usually a quiet lady who keeps to herself since her husband died 5 years ago. He tells you his mother does not often use painkillers or sleeping tablets, but she does ‘drink quite a bit’. He estimates she drinks around a bottle of wine each evening.



Q.6


How does this information affect your assessment? What other information is useful? What is your management plan?


With appropriate management, and regular monitoring of her condition, the patient’s symptoms of delirium due to alcohol withdrawal settle over the next 48 hours.



Q.7


What should be done for this woman before discharge?


After a sensitive chat with you the patient admitted to a habit of drinking that had steadily worsened since her husband’s death some years ago. She has begun socializing less and less and now finds her days mostly oriented around her drinking and admitted she feels quite lonely. She accepts your suggestion of a referral for an assessment at the local alcohol outpatient service and she is discharged 10 days after her operation.



Answers


A.1 You need to establish the acuity of the situation, and the degree of risk to the patient and staff. Do you need to call security, or can you handle this yourself?


On attending the ward you will need to:


• Talk to the nurses to establish the time course, fluctuation and severity of the presenting problems, as well as the background level of cognitive functioning.

• Review the case notes to determine previous episodes, preoperative investigations and any co-morbid diagnoses.

• Review the operative record for any intraoperative difficulties.

• Review the observations chart, fluids chart, medication record and recent investigations.

• Seek a collateral history from relatives if available, particularly regarding pre-existing cognitive function and risk factors that may predispose to confusion.

• Talk to and examine the patient.

A.2 Postoperative confusion is common in the elderly and medically unfit, particularly following orthopaedic and cardiac surgery, occurring in up to 65% of cases. Surgical causes include atelectasis, postoperative wound infection or abscess, complications of anaesthesia and complications specific to the surgery. Postoperative confusion is an instance of delirium, and alongside these factors are the many predisposing and precipitating causes for acute confusion (Table 4.1). Most common are causes of cerebral hypoxia, drugs, infection, pain and iatrogenic factors.


Table 4.1 Predisposing and precipitating factors for delirium








Predisposing Factors Precipitating Factors

Demographic characteristics
• Age of 65 years or older

• Male sex

Cognitive status
• Dementia

• Cognitive impairment

• History of delirium

• Depression

Functional status
• Functional dependence

• Immobility

• Low level of activity

• History of falls

Sensory impairment
• Visual impairment

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Confusion in the postoperative ward

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