Post-op drowsiness

Question 1

What investigations would you like to organise for the patient?

Answer 1

Bedside:
Capillary blood glucose test

Hematological:
FBC, U&E, LFT, Clotting, G&S.
Arterial Blood gas.

Radiological:
- CXR assessing for consolidation suggestive of lower respiratory tract infection, or pulmonary oedema for fluid overload.
- CT Pulmonary Angiogram (if Wells score 4 or more).
- CT abdomen and pelvis to review for intra-abdominal collection/ anastomotic leak.

Question 2

What would you review in the patient’s drug chart?

Answer 2

• New medications which could result in drowsiness e.g. opioids, antihistamines etc
• Errors e.g. double prescriptions or over administration of medications such as opioids
• LMWH prescription e.g. precipitating PE
• Antibiotics prescribed or missed – precipitating the onset of infection

Question 3

On further assessment you note the pupils to be constricted. Given the most likely differential, what is the definitive treatment for this patient?

Answer 3

• Opioid toxicity/overdose
• IV naloxone, 400mcg stat, then 800mcg for up to 2 doses at 1-minute intervals, then 2mg for 1 dose, then 4mg
• assess following each administration
• chase results e.g. renal failure = accumulation of drug

Question 4

What is an intravenous PCA and how does it work?

Answer 4

• Patient Controlled Analgesia
• IV
• self-administer boluses of morphine from programable pump
• overdose avoided by limiting size and frequency of administration
• lockout time
• naloxone may be written PRN for opioid-based PCA