Post-operative confusion

Question 1

A 75 year old woman has an urgent operation for an incarcerated femoral hernia. 24 hours later she becomes anxious and confused. How would you assess and manage her?

Answer 1

Impression
This is most likely an instance of post-operative delirium in this 75 year old woman. There are a number of important medical and surgical complications which may be triggers for this delirium, including;

• electrolyte derangements
• pain
• medication interactions, anaesthetic agents
• infection: UTI, chest, etc
• VTE: DVT/PE
• REDS: ACS, stroke, etc

Goals

• Conduct targeted Hx/Ex/Ix, treat any underlying precipitants appropriately
• would manage acute delirium conservatively with bed rest, verbal de-escalation and creation of a safe, non-threatening and as familiar as possible environment, escalate to chemical sedation if persistent and unsafe levels of agitation.

Question 2

Post-operative confusion - History

Answer 2

History

• review patient notes including op report, assess for any complications which may explain existing symptoms.
• sx: pain, infection, (take collateral if patient unable to explain),
• Characterise PC: confusion, agitation, LOC, fluctuating course, hyper vs hypoactive, anxiety, other psych sx
• PMHx, PSHx, medications, allergies

Question 3

Post-operative confusion - Examination

Answer 3

Examination

• only as tolerated by patient, do not want to aggravate or escalate
• General appearance, vitals
• assess abdominal wounds, abdo exam for any overt tenderness suggestive of underlying pathology

Question 4

Post-operative confusion - Investigations

Answer 4

Investigations

• bedside: urinalysis, urine MCS,
• bloods: UEC, CMP, LFT, CRP/ESR, FBC
• Imaging: as indicated by findings on Hx/Ex

Question 5

Post-operative confusion - Management

Answer 5

Management

Acute delirium
Non-pharm
- keep in same room, encourage family visitation, patient and family education, approach front on, allow to roam and don’t try to apprehend or antagonise
Pharm
- escalate to chemical sedation with single dose of antipsychotic (haloperidol, olanzapine), one dose typically appropriate and only chart as once-only medication
- avoid benzodiazepines

Definitive
- investigate for underlying trigger beyond recent surgery (infective, vascular, etc) and manage accordingly.

Question 6

urgent considerations

Answer 6

Given incarcerated hernia repair;
start with A to E assessment

Consider specific and non-specific post-op complications
Non-specific:
- Pneumonia, atelectasis, UTI, DVT, delirium, line-sepsis, urosepsis secondary to catheterisation

Specific:

• ? bowel resection?
• ?perforation
• ?anastomotic leak