New Onset Confusion

You are the General Surgery CT1 and are asked to see a 65 year old gentleman who is day 3 post splenectomy. The operation was challenging and took longer than expected. The patient initially recovered well, however is now becoming increasingly confused. The nurse also reports that the patient has been borderline pyrexial and is now requiring some oxygen via nasal cannulae as his saturations have dropped slightly.

Example answer introduction

In this scenario, this patient is acutely confused post-operatively and therefore I would attend urgently.   I would assess this patient using an A-E approach according to the CCRISP algorithm followed by a focused history and examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions and escalate to the general surgery registrar.

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications – VTE prophylaxis, analgesia, is the patient on antibiotics, sedative medication, any renal or hepatotoxic medication

  • Past medical history – history of liver or renal disease, diabetes, alcohol excess

  • Last meal

  • Events leading up to this point 

    • Indication for surgery

    • Review operation notes – any high risk of complication, was the operation difficult

    • Review drug chart

Abdominal examination

Examine to determine source of infection

  • Chest examination 

  • Abdominal Examination

  • Examine wounds and drains

  • Assess for possible DVT

  • Record GCS

Investigations

  • Blood tests– FBC, CRP, U&Es, Coagulation, bone profile

  • ABG – acid base status, PaC02, PaO2,, glucose, lactate

  • Urine dipstick

  • Cultures– blood, urine, sputum, and wound swab

  • Imaging– Chest X-ray, consider CT abdo - pelvis

Example questions to progress the station

Q1 What is your differential diagnosis?

Given the slight pyrexia and increased oxygen requirement, potential differential include

  • atelectasis

  • hospital acquired pneumonia

  • hypoventilation resulting in hypaemia and hypercarbia

 

Other potential causes

  • sepsis / infection

  • alcohol withdrawal

  • poorly controlled pain

  • over medication with sedative medication

  • electrolyte imbalance

  • liver/renal failure

  • stroke

Initial management

  • Empirical antibiotics as per local guidelines

  • IV fluids

  • Analgesia

  • Ensure DVT prophylaxis

  • Monitor fluid input/output

  • Catheter if septic 

  • Treat alcohol withdrawal if suspected

  • Discuss with general surgical registrar

 

Definitive management will depend on underlying cause. For example consider the below scenarios:

If CXR reveals basal atelectasis

  • treat as per atelectasis 

  • antibiotics as per micro guidelines – atelectasis increase risk of infection

  • chest physio

  • sit patient upright

  • optimise analgesia

If U+E demonstrates the following results:

  • Na 124 

  • K 3.9

  • Ur 7.2

  • Cr 88

  • EGFR >90

 

Evidence of hyponatraemia – this is a common cause in post operative period of confusion. 

  • Potential cause

    • Physiological  stress response to surgery resultsing in ADH secretion creating an SIADH resulting in hyponatramiea

    • Over administration of crystalloid fluid  with too much volume or too little sodium e.g. using dextrose

    • Drugs

    • Unusal losses of water/sodium e.g. post operative ileus

 

It is important to determine the cause and whether the hyponaetraemia is hypovolaemic, euvolaemic or hypervolaemic. Discussion with the medical registrar may be required

Escalation

Consider discussion with:

  • ​General Surgical registrar

  • Radiologist

  • Anaesthetics and theatres – if drainage/exploration required

  • Medical registrar

 

Note:

 

Post operative confusion is common complication especially in elderly patients.

There are many different reasons and therefore should always be investigated. 

The elderly and also immunocompromised patient are particularly challenging group as advancing age is a risk factor for development of delirium. Equally this group of patients are liekley to have co-morbidities and have poly-pharmacy.

 

Post operative confusion is associated with higher postoperative complication, increased mortality and increased length of hospital stay. 

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