Acute confusion in a Postoperative Patient (Delirium Tremens)?

Post-surgery Delirium

Case 1: You are an orthopedic resident called by the ward NOD to see a 65-year-old man who had a left knee replacement
2 days ago. He had been quite okay until today where he seemed to be confused, restless and agitated. He had become
verbally aggressive and wants to pull out his drip and go home. His vital signs are BP 130/90, PR 102 regular, T 38.3, RR:
30. Cardiorespiratory examination is difficult because patient is not cooperative. Per abdomen examination reveals some
lower abdomen tenderness. CNS examination is normal as far as you can assess. You found the patient to be slightly
confused and disoriented to time, place and person. You could not do the whole MMSE because of lack of cooperation.
ECG is normal and you have asked the nurse to send the blood for troponin. Reviewing the medical record, you note that
the patient is drinking 6 cans of beer per day. His preoperative biochemistry was normal except for elevated GGT, Hgb 120,
MCV 110 with normal b12 and folate.

Task
a. Present and liaise with registrar who wants to know what is happening and what is the most likely diagnosis
b. How you suggest to manage the patient

- On reviewing the chart, patient drinks 6 cans of beers per day with mild anemia.
- The most likely diagnosis is delirium tremens due to alcohol withdrawal following surgery over the last 2-3 days.
- What else could cause delirium? Hypoxia, infection, electrolyte disturbance, metabolic causes, or narcotic
overdose due to pain relief.
- What further tests would you like to organize? FBE, Blood culture, CXR, ABG, ESR/CRP, Urine MSU, BSL, U&E,
LFTs. Review the drug chart and re-adjust pain relief and narcotics dosages. CT scan.
- How do you manage the patient? If the patient is getting violent, I would like to call security (to make environment
safe). Start high-flow OXYGEN!!!! Move patient to a quiet room with appropriate lighting and with one nurse
looking after the patient. Consider involving relatives and friends. Physical restrains as per hospital protocol. Be
prepared to sedate the patient (Diazepam PO or IM midazolam 2.5mg SD or olanzapine PO).
- Monitor the vital signs and IV access, fluid balance, oxygen and pulse oximetry. Consider IV thiamine.

Case 2: (Condition 149): You are an intern called to the ward to see a patient who became acutely confused after a left total
knee replacement. A few hours earlier, he started to behave in an irrational manner, became agitated and difficult to
manage. Until this stage he had been making an uneventful postoperative recovery. His confusion has now culminated in
the patient being disoriented, noisy, and difficult to restrain. The patients wife is with the patient and she has been unable to
help.

Task
a. Assess the situation
b. Formulate management plan
c. Counsel patients wife as to the cause of the current problem

Case: A 60-years-old man became restless and shouting in the postop ward. He had knee replacement this morning and
was uneventful. Morphine was given to relieve his pain. Investigations were done are results are pending. Patient has
hallucinations and delusions and MMSE shows that hes disoriented. He has history of drinking 4-6 cans of beer every night.

Task
a. Report to registrar about patients condition
b. Answer his questions

Assess situation
- Is my patient hemodynamically stable? I would like to start with DRABC and call for help and restrain patient as
per hospital protocol.
- Ensure and assess DANGER (physical restraints); DRABC
- Institute pulse oximetry and put in high-flow oxygen.
- Intravenous access: Insert IV cannula, collect blood samples for routine hematological and biochemical screens,
BSL, blood culture if febrile
- PMHx (DM or CVD), drug use (alcohol),
- Case notes and nursing observation: any recent change in VS, fluid balance, recent drug administration, details of
recent surgical procedure (complication, Blood loss), sleep pattern and behavior
- Comments in medical and nursing record and any abnormal laboratory investigations

Physical examination
 - Establish orientation
- Check vital signs and examine cardiorespiratory systems
- Look for evidence of sepsis (abdomen and wound)
- Look for evidence of VTE (legs, chest)
- Look for any neurological deficits
- Dipstick and BSL

Causes of Confusion
- Hypoxia (very common cause particularly in elderly) ABG, CXR, ECG
- Hypotension
- Sepsis
- Metabolic (electrolytes, blood sugar estimation, arterial pH)
- Cardiac disease (ECG)
- CVA (neurologic examination)
- Pain
- Opiate overdose or effect of other drugs
- Drug withdrawal (alcohol, benzodiazepines, narcotics)
- Exacerbation of pre-existing medical conditions (dementia, hypothyroidism)

Counsel
- Reassure: The situation is under control
- The investigations may yield a cause for confusion
- Alcohol withdrawal is a common cause of postoperative confusion and should be easily controlled and problem
self-limiting
- Regular reviews with monitoring of VS, I&O and any changes in behavior