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.
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Airway
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Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen
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Circulation
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Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic
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IV access - large bore and bloods including CRP
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Give fluid challenge of 250ml crystalloid solution if evidence of shock
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If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol
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Disability - GCS, pupillary response, blood sugar, temperature
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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.
Abdominal examination
Examine to determine source of infection
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Chest examination
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Abdominal Examination
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Examine wounds and drains
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Assess for possible DVT
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Record GCS
Investigations
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Blood tests– FBC, CRP, U&Es, Coagulation, bone profile
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ABG – acid base status, PaC02, PaO2,, glucose, lactate
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Urine dipstick
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Cultures– blood, urine, sputum, and wound swab
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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
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atelectasis
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hospital acquired pneumonia
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hypoventilation resulting in hypaemia and hypercarbia
Other potential causes
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sepsis / infection
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alcohol withdrawal
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poorly controlled pain
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over medication with sedative medication
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electrolyte imbalance
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liver/renal failure
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stroke
Escalation
Consider discussion with:
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General Surgical registrar
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Radiologist
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Anaesthetics and theatres – if drainage/exploration required
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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.