I/NF Case #6 - Postoperative Delirium

[sozme]

I/NF CASE #6
Relevant to: Medicine, Surgery, Psychiatry
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Links to previous:
Case 1
Case 2
Case 3
Case 4
Case 5
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Trying to spice up this forum with more productive threads. This is the 6th case in this series. Will ask some of the highly valued SDN psychiatrists (@splik @GroverPsychMD @OldPsychDoc) to assist/critique some of the responses. Remember, these cases are meant for 3rd and 4th year medical students and interns. Upper level residents and attendings are encouraged to participate though.
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A 76-year-old woman 2 days S/P right hip replacement. She woke up from general anesthesia 12 hours after extubation. Since awakening, she has become increasingly agitated, yelling at the nurses. She has a history of Alzheimer's and chronic atrial fibrillation treated with warfarin. She has no other pertinent personal or family medical history. Current medications are donepezil, metoprolol tartrate, warfarin, and Lovenox.

On physical examination today, temperature is 37.2°C (99.0°F), blood pressure is 100/68 mm Hg, pulse rate is 100/min and irregular, respiration rate is 18/min, and BMI is 21. She can move all 4 extremities. She is inattentive and disoriented to time and place and exhibits combativeness alternating with hypersomnolence. The remainder of the neurologic examination is unremarkable, without evidence of focal findings or meningismus. She has not been eating for the past 2 meals, and exhibits paranoid delusions about the nurses trying to harm her.

Nurse calls you (the medicine/surgery/psych intern), asks to give her a doze of lorazepam and possibly order restraints. What do you do?
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UPDATE #1

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[cbrons]

Obviously you would fully examine in person (the obligatory first step for all of these night float cases).

This seems like straightforward delirium. No Ativan, and no restraints unless she is attacking people.

She is too paranoid to eat and that is the major problem here. AFAIK benzodiazepines are now considered inappropriate in treating psychosis in this patient population. Would start with 1mg IM Haldol. I think you can also use Seroquel for these purposes as well.

You can also order a sitter, which seems safer than restraints as long they are not attacking people.

 

[sliceofbread136]

I'll take a shot.

Would go see and examine patient for any obvious cause of post op delirium such as pneumonia/retention. Probably get some basic labs like cbc, bmp and glucose. Intracranial cause unlikely but I would keep in back of my head.

No Ativan or restraints. Would try redirection and giving sitter, hopefully there is a family member around who could help. If didn't work and severely agitated would try low dose haloperidol.

 

[neusu]

As others said.. Examine, labs (chemistry, cbc, ua). I'd also clarify with her and her family regarding home EtOH use, or other recreational meds she may be taking.

A 1:1 may help, or a posey near the nursing station. I generally prefer haldol to benzos for these sorts of things.

Given the h/o AF and reversal for surgery, it's not implausible she'd have an embolic infarct in the brain. She is non-focal, so it wouldn't be a large infarct. CT would likely be low yield, but the first study. MRI would be a better study.

Consult neurology for altered mental status, they love that!

 

[sliceofbread136]

As others said.. Examine, labs (chemistry, cbc, ua). I'd also clarify with her and her family regarding home EtOH use, or other recreational meds she may be taking.

A 1:1 may help, or a posey near the nursing station. I generally prefer haldol to benzos for these sorts of things.

Given the h/o AF and reversal for surgery, it's not implausible she'd have an embolic infarct in the brain. She is non-focal, so it wouldn't be a large infarct. CT would likely be low yield, but the first study. MRI would be a better study.

Consult neurology for altered mental status, they love that!

How feasible is a ct for someone who is altered?

 

[Redpancreas]

Trying to spice up this forum with more productive threads. This is the 6th case in this series. Will ask some of the highly valued SDN psychiatrists (@splik @GroverPsychMD @OldPsychDoc) to assist/critique some of the responses. Remember, these cases are meant for 3rd and 4th year medical students and interns. Upper level residents and attendings are encouraged to participate though.

Case 6
Relevant to: Medicine, Surgery, Psychiatry

Links to previous:
Case 1
Case 2
Case 3
Case 4
Case 5
======================================================================================
A 76-year-old woman 2 days S/P right hip replacement. She woke up from general anesthesia 12 hours after extubation. Since awakening, she has become increasingly agitated, yelling at the nurses. She has a history of Alzheimer's and chronic atrial fibrillation treated with warfarin. She has no other pertinent personal or family medical history. Current medications are donepezil, metoprolol tartrate, warfarin, and Lovenox.

On physical examination today, temperature is 37.2°C (99.0°F), blood pressure is 100/68 mm Hg, pulse rate is 100/min and irregular, respiration rate is 18/min, and BMI is 21. She can move all 4 extremities. She is inattentive and disoriented to time and place and exhibits combativeness alternating with hypersomnolence. The remainder of the neurologic examination is unremarkable, without evidence of focal findings or meningismus. She has not been eating for the past 2 meals, and exhibits paranoid delusions about the nurses trying to harm her.

Nurse calls you (the medicine/surgery/psych intern), asks to give her a doze of lorazepam and possibly order restraints. What do you do?
======================================================================================

I really love these even though I dont contribute and hope you keep making more: most useful thing on SDN.


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[TooMuchResearch]

How feasible is a ct for someone who is altered?

Depends on if you can convince them to hold still for a minute. If yes, it's feasible. If no, you can get it to look for blood, but it will be a bad study.

 

[cbrons]

As others said.. Examine, labs (chemistry, cbc, ua). I'd also clarify with her and her family regarding home EtOH use, or other recreational meds she may be taking.

A 1:1 may help, or a posey near the nursing station. I generally prefer haldol to benzos for these sorts of things.

Given the h/o AF and reversal for surgery, it's not implausible she'd have an embolic infarct in the brain. She is non-focal, so it wouldn't be a large infarct. CT would likely be low yield, but the first study. MRI would be a better study.

Consult neurology for altered mental status, they love that!

I didnt think MRI would be indicated in a acute confusional state without focal symptoms. I bet most hospitalists in the community would pull that trigger though.

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[WildcatS11]

Obviously you would fully examine in person (the obligatory first step for all of these night float cases).

This seems like straightforward delirium. No Ativan, and no restraints unless she is attacking people.

She is too paranoid to eat and that is the major problem here. AFAIK benzodiazepines are now considered inappropriate in treating psychosis in this patient population. Would start with 1mg IM Haldol. I think you can also use Seroquel for these purposes as well.

You can also order a sitter, which seems safer than restraints as long they are not attacking people.

1 mg of haldol is a drop in the bucket. Especially IM. Go bigger, unless you want to be paged every 15 minutes through the rest of the night.

 

[neusu]

How feasible is a ct for someone who is altered?

CT is easy. MRI, not so much.

 

[Noisewater-TDX]

A nurse chiming in here.

Move her close to the nursing station, get a sitter (1:1 is unrealistic due to hospitals having poor staffing - lets be honest ), bed alarms on. Restraints would just piss her off, so that's a no. I would argue that a very low dose IV Haldol injection would be the way to go, I've seen IM attendings order 250-500 mcg before in a very similar situation. It did not sedate the patient, just significantly reduced the paranoia and agitation. (It also helps with possible EtOH withdrawal that someone mentioned above.)

Give the injection. make sure she has continuous pulse ox on. And then, if I had to guess, Labs, cultures, ABG or VBG, and CXR, maybe IV or PR Tylenol for low grade. Hold the CT for a reassessment.

 

[dadaddadaBATMAN]

A nurse chiming in here.

Move her close to the nursing station, get a sitter (1:1 is unrealistic due to hospitals having poor staffing - lets be honest ), bed alarms on. Restraints would just piss her off, so that's a no. I would argue that a very low dose IV Haldol injection would be the way to go, I've seen IM attendings order 250-500 mcg before in a very similar situation. It did not sedate the patient, just significantly reduced the paranoia and agitation. (It also helps with possible EtOH withdrawal that someone mentioned above.)

Give the injection. make sure she has continuous pulse ox on. And then, if I had to guess, Labs, cultures, ABG or VBG, and CXR, maybe IV or PR Tylenol for low grade. Hold the CT for a reassessment.

Great to hear from an outside perspective. Makes the case more realistic.

Just wanted to comment on haldol: although it may reduce the symptoms of etoh withdrawal, antipsychotics will lower the seizure threshold, which is probably a bad idea without bdz on board.

If you're strongly considering etoh, probably not a good choice without other agents available.

 

[Noisewater-TDX]

Great to hear from an outside perspective. Makes the case more realistic.

Just wanted to comment on haldol: although it may reduce the symptoms of etoh withdrawal, antipsychotics will lower the seizure threshold, which is probably a bad idea without bdz on board.

If you're strongly considering etoh, probably not a good choice without other agents available.

Forgot about that... I know most CIWA protocols incorporate haldol for severe withdrawls, but I guess that works on the premise that you have already tried Ativan.

 

[dadaddadaBATMAN]

Forgot about that... I know most CIWA protocols incorporate haldol for severe withdrawls, but I guess that works on the premise that you have already tried Ativan.

No worries, it happens, and it's usually easier to criticize a treatment plan than to make one.

I guess I can toss out my own ideas into the mix.

This looks like delerium, but that doesn't seem like a good end point for a ddx to me. It's a syndrome that has a cause.

This is a demented patient who has been moved from her home environment, is likely in pain s/p hip replacement, and may has a variety of different potential sources of infection (surgical wound, likely cath during surgery, new hardware in place).

I would be interested in an exam (especially mucous membranes and indications of fluid status, lung exam, abdominal exam, surgical site), a CBC and bmp trended to check for increasing leukocytosis/anemia or electrolyte disturbances given poor oral intake (we also need ins/outs on this person if possible, esp urine output), a ua to investigate potential infection, and to know what she was currently receiving for pain control. A cxr might also be reasonable based on the exam given the history of intubation during the procedure and current hospitalization. Her dementia would also make my threshold to chest x ray lower given risk of aspiration.

Although the patients tachycardia is likely secondary to agitation, it's worth noting that she currently has a relatively low blood pressure and is tachycardic despite b blockade. In a little old lady that would make me consider blood cultures if I found any good sources from the above testing, but I wouldn't get them yet.

No to bdz or restraints. I'd be ok with giving Haloperidol (clarify the etoh history with family), but although it will likely shut her up it won't solve whatever is the underlying cause. She should be near the nursing station (hopefully in a well lit room with natural light) and should have family present to re-orient as much as possible. If she isn't getting anything for pain, it would be nice to give her scheduled Tylenol (<3g daily given little old lady).

It also might be a good choice to look closely at whatever opiates she was receiving, as they may exacerbate the delerium if too high (snowed) or too low (**** pain control).

 

[TooMuchResearch]

People are on the right track with delirium. Just don't overlook the donezepil.

 

[Carouselambra]

Could the combination of her donezepil and recent anesthesia be causing urine retention and thus delirium? Bladder scan? There's also the possibility of infection/sepsis given the recent surgery and looking at her vitals unless that's her baseline. What was she before surgery?

 

[dadaddadaBATMAN]

Could the combination of her donezepil and recent anesthesia be causing urine retention and thus delirium? Bladder scan? There's also the possibility of infection/sepsis given the recent surgery and looking at her vitals unless that's her baseline. What was she before surgery?

My brain always wants to make donepezil an anticholinergic medication too, but the mechanism is as a central acetylcholinesterase inhibitor, which would mean cholinergic toxicity (urge incontinence, sludge, miosis, bradycardia bronchorrhea and bronchospasm) and not anti-cholinergic (urinary retention, hot as a hare, dry as a bone, etc) toxicity if anything.

I do love the thought of blaming the drugs, but I don't know that I'm smart enough to do it here without more info

 

[sozme]

Update 1

• Bladder scan is done by bedside RN. Results below:
  • PVR 65mL
• You ordered CMP, CBC, PO4, Mg2+. Significant values below:
• CMP
  • Na+ 133
  • Ca2+ 7.8
  • Phosphorus 2.0
• CBC:
  • Hgb 12.5
  • Hct. 38.5
  • Platelets 124,000/mm3
• You requested AP CXR. Unfortunately, unlike the phlebotomist and RNs, the patient was highly suspicious of the X-ray technicians, and began screaming incoherently at them. They attempted to get it twice, but patient was too combative.
• You ordered EKG, which was again done by bedside RN and is shown below.

It is now 0230, and the nurse is eyeing you with disdain, mumbling something about the uselessness of this year's intern class. She is strongly urging you to do something about patient's widely fluctuating mental status, and reports that patient has not eaten anything in 19 hours owing to suspicion that her food is poisoned. You make an off-handed remark about the low quality of hospital food to try to diffuse the situation, which the nurse responds with a terse smile that lets you know she is not in the mood. Your pager is now going off again, this time for another soft admit by the E.D. What are you going to do about this situation?

 

[cbrons]

Update 1

• Bladder scan is done by bedside RN. Results below:
  • PVR 65mL
• You ordered CMP, CBC, PO4, Mg2+. Significant values below:
• CMP
  • Na+ 133
  • Ca2+ 7.8
  • Phosphorus 2.0
• CBC:
  • Hgb 12.5
  • Hct. 38.5
  • Platelets 124,000/mm3
• You requested AP CXR. Unfortunately, unlike the phlebotomist and RNs, the patient was highly suspicious of the X-ray technicians, and began screaming incoherently at them. They attempted to get it twice, but patient was too combative.
• You ordered EKG, which was again done by bedside RN and is shown below.

View attachment 210181

It is now 0230, and the nurse is eyeing you with disdain, mumbling something about the uselessness of this year's intern class. She is strongly urging you to do something about patient's widely fluctuating mental status, and reports that patient has not eaten anything in 19 hours owing to suspicion that her food is poisoned. You make an off-handed remark about the low quality of hospital food to try to diffuse the situation, which the nurse responds with a terse smile that lets you know she is not in the mood. Your pager is now going off again, this time for another soft admit by the E.D. What are you going to do about this situation?

Those labs and EKG don't scare me.

Haloperidol 1mg IV

Tell nurse to take chill pill.

?

 

[dadaddadaBATMAN]

Update 1

• Bladder scan is done by bedside RN. Results below:
  • PVR 65mL
• You ordered CMP, CBC, PO4, Mg2+. Significant values below:
• CMP
  • Na+ 133
  • Ca2+ 7.8
  • Phosphorus 2.0
• CBC:
  • Hgb 12.5
  • Hct. 38.5
  • Platelets 124,000/mm3
• You requested AP CXR. Unfortunately, unlike the phlebotomist and RNs, the patient was highly suspicious of the X-ray technicians, and began screaming incoherently at them. They attempted to get it twice, but patient was too combative.
• You ordered EKG, which was again done by bedside RN and is shown below.

View attachment 210181

It is now 0230, and the nurse is eyeing you with disdain, mumbling something about the uselessness of this year's intern class. She is strongly urging you to do something about patient's widely fluctuating mental status, and reports that patient has not eaten anything in 19 hours owing to suspicion that her food is poisoned. You make an off-handed remark about the low quality of hospital food to try to diffuse the situation, which the nurse responds with a terse smile that lets you know she is not in the mood. Your pager is now going off again, this time for another soft admit by the E.D. What are you going to do about this situation?

1. Silently pray that the nurse steps within biting distance of delirious patient.
2. Pray that the patient is in fact a biter, and that a 19hr fast brings out the canibalistic side of her
3. Grouse silently to myself about the lab not giving me a white count even if it was normal
4. Grumble less silently about not getting AVF on the ekg, especially when there are t wave inversions in lead III
5. Look at the ST elevations in Lead 1 and AVL. Experience existential crisis while you wonder whether that's explained by lvh via voltage criteria
6. Find an old EKG.

Edit: look it up, discover that the st elevations in lvh are usually in v1-v3. Most likely does not explain it, although looking again I may be wrong about lead 1.

I'd consider this worth a call to my senior at this point

 

[Stagg737]

Update 1

• Bladder scan is done by bedside RN. Results below:
  • PVR 65mL
• You ordered CMP, CBC, PO4, Mg2+. Significant values below:
• CMP
  • Na+ 133
  • Ca2+ 7.8
  • Phosphorus 2.0
• CBC:
  • Hgb 12.5
  • Hct. 38.5
  • Platelets 124,000/mm3
• You requested AP CXR. Unfortunately, unlike the phlebotomist and RNs, the patient was highly suspicious of the X-ray technicians, and began screaming incoherently at them. They attempted to get it twice, but patient was too combative.
• You ordered EKG, which was again done by bedside RN and is shown below.

View attachment 210181

It is now 0230, and the nurse is eyeing you with disdain, mumbling something about the uselessness of this year's intern class. She is strongly urging you to do something about patient's widely fluctuating mental status, and reports that patient has not eaten anything in 19 hours owing to suspicion that her food is poisoned. You make an off-handed remark about the low quality of hospital food to try to diffuse the situation, which the nurse responds with a terse smile that lets you know she is not in the mood. Your pager is now going off again, this time for another soft admit by the E.D. What are you going to do about this situation?

A few things are concerning me with her labs. Irregular tachy with low BP and T-wave inversions doesn't really make me happy, especially when we throw the hypocalcemia and thrombocytopenia in there.

DDx: Drug interaction --> drug-induced delirium/cardiac issues (would like to know dose and compliance of Donezepil), EtOH withdrawal/interaction, delirium d/t Alzheimer's/dementia

As mentioned earlier, I'd want to make check off all my boxes when it comes to hx of EtOH use. Last thing that's needed is for the pt to go into DTs because someone took a crappy history. Given the patient's current cardiac concerns and her high probability of having some level of dementia from the Alzheimer's I'd probably avoid the haldol in favor of an atypical, though I'm not sure if that is warranted at this point. Either way, get her a sitter and order new labs first thing in the morning.

 

[TooMuchResearch]

My brain always wants to make donepezil an anticholinergic medication too, but the mechanism is as a central acetylcholinesterase inhibitor, which would mean cholinergic toxicity (urge incontinence, sludge, miosis, bradycardia bronchorrhea and bronchospasm) and not anti-cholinergic (urinary retention, hot as a hare, dry as a bone, etc) toxicity if anything.

I do love the thought of blaming the drugs, but I don't know that I'm smart enough to do it here without more info

It's cholinergic. There are reports of a withdrawal syndrome when it is stopped. I haven't read much about it, but it wouldn't shock me if the withdrawal syndrome looked a touch anti-cholinergic.

 

[TooMuchResearch]

A few things are concerning me with her labs. Irregular tachy with low BP and T-wave inversions doesn't really make me happy, especially when we throw the hypocalcemia and thrombocytopenia in there.

DDx: Drug interaction --> drug-induced delirium/cardiac issues (would like to know dose and compliance of Donezepil), EtOH withdrawal/interaction, delirium d/t Alzheimer's/dementia

As mentioned earlier, I'd want to make check off all my boxes when it comes to hx of EtOH use. Last thing that's needed is for the pt to go into DTs because someone took a crappy history. Given the patient's current cardiac concerns and her high probability of having some level of dementia from the Alzheimer's I'd probably avoid the haldol in favor of an atypical, though I'm not sure if that is warranted at this point. Either way, get her a sitter and order new labs first thing in the morning.

Zyprexa is preferred to Haldol if she'll take pills, you're willing to give her IM, or your hospital allows it given IV.

Haldol will still get the job done, but not at 1 mg.

 

[Noisewater-TDX]

1. Silently pray that the nurse steps within biting distance of delirious patient.
2. Pray that the patient is in fact a biter, and that a 19hr fast brings out the canibalistic side of her

I actually got bitten by a confused patient in the ER one time... ya know what, she got a ride on the van, the Ativan. (I wish i could find that meme)

Zyprexa is preferred to Haldol if she'll take pills, you're willing to give her IM, or your hospital allows it given IV.

Haldol will still get the job done, but not at 1 mg.

Yeah, that's why I suggested in the mcg range IV. Works really well for the acute issues while the docs figure out what the hell is going on... I like it, from a nursing perspective anyways.

 

[Instatewaiter]

My main concern is that is not her EKG. Not only is she in sinus on the EKG (ie not irregular or in her "chronic" AF) but she is not tachycardic. This is concerning!

 

[sliceofbread136]

My main concern is that is not her EKG. Not only is she in sinus on the EKG (ie not irregular or in her "chronic" AF) but she is not tachycardic. This is concerning!

Guess the nurse messed up

 

[evilbooyaa]

Guess the nurse messed up

Nurse accidentally did EKG on herself, probs

 

[sozme]

1. Silently pray that the nurse steps within biting distance of delirious patient.
2. Pray that the patient is in fact a biter, and that a 19hr fast brings out the canibalistic side of her
3. Grouse silently to myself about the lab not giving me a white count even if it was normal
4. Grumble less silently about not getting AVF on the ekg, especially when there are t wave inversions in lead III
5. Look at the ST elevations in Lead 1 and AVL. Experience existential crisis while you wonder whether that's explained by lvh via voltage criteria
6. Find an old EKG.

Edit: look it up, discover that the st elevations in lvh are usually in v1-v3. Most likely does not explain it, although looking again I may be wrong about lead 1.

I'd consider this worth a call to my senior at this point

My main concern is that is not her EKG. Not only is she in sinus on the EKG (ie not irregular or in her "chronic" AF) but she is not tachycardic. This is concerning!

Guess the nurse messed up

Nurse accidentally did EKG on herself, probs

She now brings you the correct EKG, apologizing for giving you the wrong one, but as she explains, it is actually your fault she gave you the wrong one because your bad sense of humor was making her angry and forcing her to rush her work.

 

[Psai]

2 days postop from a hip?

PE vs infection vs bleed imo

Snow her, nchct, pe chest, ua, blood cultures, treat for infection empirically

I know shes on warfarin and lovenox so I'm thinking maybe a fat embolus

 

[cbrons]

Bumping non cancerous thread

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