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Postoperative Complications

Course #30764 - $90 -

#30764: Postoperative Complications

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Learning Tools - Case Studies

CASE STUDY 1

Patient A is a man 37 years of age who arrives in the PACU following surgical removal of his gallbladder. Surgical intervention using the laparoscopic approach is successful.

Patient A's airway and ability to maintain respiratory stability are evaluated immediately. His respiration is 16 breaths per minute, and his heart rate is 78 beats per minute. Oxygen is being administered at 2 liters via nasal cannula. A pulse oximeter is placed on his left forefinger, and his oxygen saturation is measured at 95%. The patient is arousable but easily drifts off to sleep.

A transfer of care report on the patient is received from the operating room staff. His operative course was unremarkable. Patient history obtained during the preoperative phase of care showed that he was a 2 pack per day smoker, and he denies taking any prescribed or over-the-counter medications. Patient A's weight is documented as 110 kg.

Further assessment of the patient demonstrates normal skin perfusion with good capillary refill in all extremities. He has a drain in his abdomen with a small amount of yellowish discharge. The wound site and sutures are clean and dry without bleeding or discharge. No Foley catheter is in place; when questioned, he denies the need to void. Completing a head-to-toe assessment shows no other alterations from Patient A's baseline.

Patient A wakes when the second set of vital signs is obtained. He reports that his pain is 6 on a 10-point scale. He states that he has pain in his shoulder and pressure in his abdomen. Morphine (5 mg) is ordered for the pain, and 4 mg is administered IV. His wife is in the waiting room, and she comes into the unit to visit and sits by his bed reading while the patient dozes off.

Repeat vital signs are obtained every 15 minutes for the first hour. At 45 minutes after admission, the patient's oxygen saturation is noted to be 90%. PACU staff suction secretions from the patient's throat, and he is instructed on how to use the incentive spirometer. His oxygen flow is increased to 4 liters/minute by nasal cannula. No change in the patient's oxygen saturation is noted over the next 15 minutes despite compliance with the respiratory exercises.

At one hour after admission, the patient's oxygen saturation remains at 89% to 90%, his respiratory rate is 16 breaths per minute, and he is more difficult to arouse. The nurse notifies the physician of the changes in Patient A's status. Oxygen delivery is changed again to a face mask at 4 liters/minute without improvement in the oxygen saturation level. All other parameters remain stable, demonstrating a readiness for discharge.

Despite the improvement in the patient's status, the oxygenation issue remains worrisome. The patient is admitted for an overnight hospital stay, and respiratory exercises are continued, eventually demonstrating an improvement in oxygen saturation to a high of 94%. The next morning, the patient is discharged home.

The assessment of Patient A was thorough and well-organized. The ABCs were evaluated upon admission to ensure the stability of the patient. The history was ascertained, and vital signs were obtained on the recommended basis. However, despite this excellent care, the patient did not demonstrate adequate improvement in his status to be discharged on the same day.

The patient's history of smoking may be the cause of the respiratory insufficiency. Whether the patient was honest in his assessment of his smoking habit could be debated; many patients do not fully and honestly report their cigarette and/or drug and alcohol use. In addition, the patient may not have reported the feelings of nasal congestion and signs of a developing "cold" to the anesthesiologist prior to surgery. Had this been shared, the surgery may have been postponed. The patient may have been instructed to cut back on cigarette use and wait until the cold symptoms subsided prior to having surgery. When patients underreport or are dishonest during the preoperative phase of care, the staff caring for the patient in the postoperative phase is put at a disadvantage.

CASE STUDY 2

Patient B, a woman 31 years of age, is admitted to phase I PACU after undergoing an abdominal hysterectomy. During the preoperative assessment, the patient noted that she is a nonsmoker, has a history of motion sickness, and is quite anxious concerning the surgery and her future prospects, as she will be "sterile" upon recovery. The report from the operating room is that the patient received inhalation anesthesia and a neuromuscular blocking agent during the procedure. Prior to discontinuing the anesthesia, the patient was administered 4 mg of ondansetron for PONV prophylaxis. Also noted was a period of hypotension caused by a significant amount of blood loss requiring the intraoperative infusion of two units of whole blood.

Upon awakening, Patient B is quite agitated. She is moving from side to side and is not yet oriented to place and time. When questioned, Patient B states that her pain is 7 on a scale of 10. The PACU nurse administers 2 mg hydromorphone IV per order. The narcotic appears to begin to take effect, and when questioned, Patient B's pain is now reported as a score of 4. However, she is now complaining of nausea and asking for an emesis basin as she is afraid she will vomit. The nurse asks her to take slow deep breaths through her mouth and encourages her to relax.

When Patient B's complaints of nausea do not recede, the nurse contacts the physician who orders another dose of ondansetron, which is administered. Thirty minutes after medication administration, the patient's complaints of nausea have not subsided and the nurse again requests an order for an antiemetic. At this point, the physician orders a scopolamine patch be placed on the patient. Subsequent to patch placement, Patient B notes that her nausea is resolving.

Case Study Discussion

Preoperative management of Patient B's nausea was handled well. The staff had ascertained the pertinent information; had a risk factor identification scale been utilized, the patient would have been ranked at a very severe level of risk for PONV. The anesthesiologist recognized this risk and treated Patient B with an appropriate dose of antiemetic prior to the termination of surgery.

There were omissions in care that could have reduced the risk of PONV development in this patient. Prior to the first dose of ondansetron in the operating room, a dose of dexamethasone could have been administered to enhance the effectiveness of the serotonin antagonist.

During the PACU phase of care, the nurse caring for Patient B instituted measures to manage both the patient's pain and nausea. However, there were extenuating circumstances that were not considered and could have reduced the development of this complication. It was noted in the operative report that the patient had an episode of hypotension and blood loss; this volume depletion most likely increased the risk of PONV. In addition, the patient may have remained volume-depleted into the PACU, and no note of this was made.

The physician ordered the second PACU dose of ondansetron, which was administered without benefit. The recommendation for rescue management of PONV is to change drug classes if one is not adequate; thus, another drug should have been ordered. The scopolamine patch seemed to have a beneficial response; upon further questioning of the patient, it was discovered that whenever she had previous bouts of motion sickness the patient used patches to help her manage her symptoms. Had this information been ascertained in the preoperative phase, the patch could have been applied preoperatively or in the operating room. It is critical to gather as much information as possible to reduce these types of delays in patient management.

CASE STUDY 3

Patient C is a high school senior. During the opening drive in the Friday night football game, Patient C is hit from behind. When he falls, he sustains open, comminuted fractures of his left tibia and fibula. Because he is unable to stand, an ambulance is brought onto the field to transport the young player to the hospital for evaluation.

Upon arrival at the emergency department, Patient C's leg is examined, x-rayed, and evaluated by the orthopedic surgeon on call. It is determined that prompt stabilization and cleansing of the wound would be optimal for the best possible outcome; thus, Patient C is prepared for surgery. His parents, who were at the game, arrive in the emergency department just moments after the ambulance and are available to give permission for the operative procedure. As Patient C has been medicated for pain, a history is obtained from the parents. There are no notable problems; Patient C is a healthy young man in excellent physical condition. He has not had previous operations and no previous exposure to anesthesia.

Patient C is transferred to the operating room. The anesthesiologist gives the patient a number of preoperative medications, including those to prevent PONV. The anesthesia of choice is enflurane (Ethrane), a volatile gas. The patient first receives succinylcholine prior to intubation, followed by the anesthetic gas. Within minutes, the anesthesiologist notes that Patient C's carbon dioxide levels are beginning to rise. Just as the surgeon is to begin, the patient sustains a cardiac arrest.

The anesthesiologist immediately stops the insufflation of the gas and begins to administer 100% oxygen. A code response is initiated by the remaining members of the operating team. The rescuer performing chest compressions notes that the patient's skin is warm. While resuscitative efforts continue, blood for laboratory evaluation is obtained. The arterial blood gas results demonstrate a pH of 6.9, partial pressure of oxygen (PaO 2 ) of 110 mm Hg, and a partial pressure of carbon dioxide (PaCO 2 ) of 55 mm Hg. At this point, the anesthesiologist's suspicions are confirmed; the patient is experiencing an episode of malignant hyperthermia.

As soon as the diagnosis is confirmed, the staff is ordered to administer dantrolene at a dose of 2 mg/kg. The operating room personnel contact the PACU to ask for assistance in drawing up and preparing the dantrolene. Only one nurse is available to leave the PACU, and she assists with mixing and administering the dantrolene as soon as it is prepared. Additionally, the patient requires repeat doses of sodium bicarbonate to combat the falling serum pH.

Within 15 minutes of administering the dantrolene, the patient begins to demonstrate a perfusing rhythm, although this is punctuated by frequent runs of premature ventricular contractions. Antiarrhythmics are administered to control cardiac complications.

Simultaneously, the patient is cooled with external cold packs applied to the groin and axilla areas. The leg wound is dressed to prevent further contamination during the resuscitative efforts. Repeat blood is obtained for laboratory analysis. The patient's potassium is elevated, and the patient is started on a glucose-insulin drip.

After the patient's cardiac condition is stabilized, the operating room staff request transfer of the patient to the PACU for further management. The patient is moved, and the PACU staff becomes responsible for managing the patient. The antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued. During the first 30 minutes in the PACU, the patient's urine is noted to be a deep red color, indicative of developing rhabdomyolysis and potential renal failure. The patient is given 100 mg furosemide, and fluids are increased to 150 mL/hour. Within 20 minutes, the urine lightens in color, although it retains a reddish tinge.

Approximately three hours after the first cardiac arrest, the patient suffers a second arrest with the development of ventricular fibrillation. A second code response is called, and the patient is again resuscitated with dantrolene, antiarrhythmics, and sodium bicarbonate. Once again, the patient responds to treatment and regains a perfusing cardiac rhythm.

The patient is ordered to receive dantrolene every 4 hours for the following 48 hours to ensure that another episode of malignant hyperthermia does not develop. The patient is subsequently stabilized and transferred to the ICU, where he remains for 72 hours.

Patient C is a perfect candidate for the development of malignant hyperthermia. He is a young male with well-developed musculature. He has had no previous exposure to anesthesia, so his history was not negative for anesthesia complications; it was incomplete. The onset of cardiac arrest was quite rapid in this patient. This devastating complication can be quick in onset, as demonstrated here, or may be delayed and occur later during the operative procedure. The first indication of the development of malignant hyperthermia in this patient was the rising carbon dioxide level. The skin temperature remained normal during the early phase of development; the first person to note the rise in body temperature was the rescuer performing chest compressions.

The patient was managed appropriately. The staff was required to perform a number of actions to save this patient's life. Administering medications, preparing those medications, cooling the patient, and monitoring blood laboratory values is only part of the picture. The additional PACU nurse pulled to the operating room to help with the resuscitation was instrumental in providing the additional hands and expertise needed in this case.

Upon arrival in the PACU, the patient continued to require extensive stabilization measures. The repeat dantrolene had been ordered but had not yet been administered when the patient sustained the second cardiac arrest. It is imperative that the administration of repeat doses of dantrolene be continued to prevent this type of occurrence. Fortunately, the patient was young and healthy and responded to the treatment.

The long-term outcome for this patient was excellent. The resuscitative efforts were exceptional, and the patient did not sustain any long-term neurologic deficits. It is important to point out that the patient did not have his fracture stabilized at this time. Subsequent surgery was delayed to ensure the stability of the patient. Once stable, the patient had the orthopedic repair performed with epidural anesthesia. Although the risk of developing malignant hyperthermia again while undergoing epidural anesthesia is small, dantrolene was used prophylactically to ensure patient stability throughout the procedure.

CASE STUDY 4

Patient D is a male patient, 32 years of age, undergoing an uncomplicated bowel resection to repair damage and scarring of the bowel secondary to a traumatic automobile accident five years prior. The patient is a healthy, active male who states that he has smoked a pack of cigarettes a day off and on for the last 15 years. He had quit smoking after his auto accident but started again three years previously. His history is unremarkable for cardiovascular disease, and his anesthesia provider has reviewed his previous surgeries, performed at the time of the accident.

During surgery, the patient receives general inhalation anesthesia, intravenous narcotics, and neuromuscular blocking agents. The procedure runs approximately four hours in length. During the procedure, the patient has one short episode of hypotension that was managed with volume replacement.

Upon arrival in the PACU, the patient's vital signs are: blood pressure 118/62 mm Hg, pulse 78 beats per minute, respiratory rate 22 breaths per minute with shallow respirations, temperature 36.5°C, and oxygen saturation 91%. The patient had been extubated in the operating room just prior to transfer to the PACU. The nurse caring for the patient notes the signs and symptoms of respiratory distress, including the high respiratory rate, the shallow respirations, and the low oxygen saturation level. When the patient awakens complaining of pain, the nurse is hesitant to give too large of a dose of the narcotic that had been ordered.

After 30 minutes, the patient's respiratory rate is 18 breaths per minute, the oxygen saturation is 93%, and the patient is more alert. However, the patient continues to complain of ongoing pain, and the nurse leaves the patient's bedside to obtain the narcotics. Upon returning to the patient, the nurse finds the patient dozing. When the patient wakes, the nurse asks him to use the incentive spirometer; he had been instructed in its use in the preoperative phase of care. The patient complains of increasing abdominal pain and refuses to use the spirometer. At this point, the nurse chooses to administer 3 mg of hydromorphone as ordered for pain by the surgeon.

After receiving the hydromorphone, the patient again dozes off and appears to be comfortable. When obtaining the next set of vital signs, the nurse notices that the oxygen saturation has again dropped to 91%; however, as the patient's respiratory effort appears to be adequate, the nurse assumes this low saturation is a consequence of his smoking history. The patient has oxygen supplied by nasal prongs, and the nurse chooses not to intervene further. The patient is left sleeping while the nurse assists in the admission of another patient to the PACU.

Forty-five minutes after arrival in the PACU, Patient D experiences a respiratory arrest. The nurses immediately call a code and initiate resuscitative measures. The patient is administered naloxone, and positive pressure ventilation is initiated. However, bagging the patient is extremely difficult; the pop-off valve goes off with each ventilation, and the patient's chest is not rising as hoped.

Fortunately, the anesthesia provider responds and immediately asks for an endotracheal tube to reintubate the patient. When attempting to intubate the patient, the anesthesia provider finds it very difficult as a result of the patient developing laryngospasm. Succinylcholine is administered, and high positive-pressure oxygen is given via a jet vent. After another two attempts, the patient is successfully intubated. The patient is then placed on a mechanical ventilator with positive-end-expiratory pressure applied to help reduce the buildup of fluid in the lungs. He is started on a course of antibiotics and steroids and admitted to the ICU. After two days, the patient is extubated, moved to the surgical floor, and at day 6, is discharged from the hospital.

Patient D is a typical postoperative patient. He was healthy and had an uncomplicated surgical event. He should have progressed through the recovery period without a problem; however, he sustained a respiratory arrest and his recovery was prolonged. Fortunately, he survived without long-term sequelae.

The nurse caring for Patient D made assumptions about his condition based upon his preoperative history. The smoking history allowed her to be lulled into a sense of security knowing that smokers have altered oxygen saturations. His appearance of ease was comforting, and she became complacent in her vigilance.

When Patient D sustained the respiratory arrest, the initial cause was unknown. He had numerous risk factors; the arrest may have been caused by the dose of narcotics, in which case, naloxone would have been a treatment of choice. This was tried but without a successful response. He was hypoxemic upon arrival in the PACU, as evidenced by his low oxygen saturations. This hypoxemic state may have precipitated the respiratory arrest. In addition, he had received neuromuscular blocking agents in the operating room and the arrest may have been secondary to residual paralytic agent. However, upon intubation he was noted to have developed laryngospasm, which may indicate that he sustained an episode of NCPE. He was a candidate for NCPE due to his age, preoperative health status, and early extubation.

Whenever a patient sustains a life-threatening event such as a respiratory arrest, it is critical that care providers work to determine the cause. Identification of the cause can lead to the appropriate choice of a resuscitative effort. In this case, the nurse acted appropriately in administering the naloxone, although it was later determined that this was not the cause of the arrest. Despite the fact that NCPE was not considered until the patient was found to have a laryngospasm, the measures undertaken were appropriate. The only error was the complacency that the nurse exhibited towards the patient's status upon arrival in the PACU and the first 45 minutes of care. Early attention to the hypoxemic state may have prevented the development of the arrest, although this does not always make a difference in cases of NCPE.

Patient D should be educated prior to discharge regarding the development of this side effect. If further surgeries are needed, it is imperative that he be able to relate this information so that measures can be instituted to reduce the risk of respiratory compromise.

CASE STUDY 5

Patient E, a man 74 years of age, is undergoing surgery for a blockage in his left femoral artery. The patient has a history of significant vascular compromise of his left leg secondary to the blockage. A stent is placed during surgery, and the patient is subsequently transferred to the PACU. Upon arrival in the PACU, his vital signs are: blood pressure 162/86 mm Hg, pulse 80 beats per minute, respiratory rate 16 breaths per minute, core temperature 34.5°C, and oxygen saturation 90%. The patient was extubated prior to arrival in the PACU. After the patient is stabilized and an assessment is completed, he is warmed using a warm air convection device. To combat his low oxygen saturations, his oxygen flow is increased to 6 liters per nasal cannula.

Fifteen minutes after arrival, the patient complains of severe pain in his left leg. His peripheral pulses are good, and his color is pink. However, as this was the surgical site, the nurse immediately contacts the surgeon. The surgeon speculates that the pain is secondary to new perfusion in this leg and the removal of sequestered by-products of circulation. He orders the patient to receive 3 mg hydromorphone for pain, which helps resolve the patient's complaints.

One hour after admission, the patient's vital signs return to preoperative values; his body temperature is now 36°C. At this point, he complains of pain in both lower extremities. Upon assessment, it is found that his peripheral pulses are weak in the right leg and the color of this extremity is dusky and cool to touch. His left leg remains warm, pink, and with good peripheral pulses. The patient's legs are elevated on a pillow to improve blood return to the heart, and he is again administered hydromorphone. After the second dose of hydromorphone, the patient drifts off to sleep. When he wakes, he continues to complain of pain in both extremities. The right leg remains cool, dusky, and with poor peripheral perfusion. The nurse again contacts the surgeon, who determines that the patient is possibly developing a DVT in the right calf. The patient has graduated compression stockings applied to the right leg to reduce the risk of further clot formation. As the patient had been heparinized in the operating room, no further anticoagulants are ordered.

The patient is discharged from the PACU to the surgical ward. At day 3, when he is ambulating in the hall, Patient E suffers a cardiac arrest and is not able to be resuscitated. He most likely sustained a pulmonary embolus secondary to the DVT in the right leg. The ambulation may have caused the clot to be knocked loose, allowing it to travel to the pulmonary vasculature.

This patient was at high risk for DVT formation both due to the type and extent of surgery as well as his history of peripheral vascular disease. As he was anticoagulated in the operating room, no further interventions were instituted. However, the guidelines for management and prophylaxis of this type of patient recommend the institution of graduated compression stockings or intermittent pneumatic compression devices in addition to anticoagulation [50] . It can be speculated that this may have reduced his incidence of DVT formation; however, due to his extensive vascular history, he was at high risk prior to, during, and after surgery. It would be speculation to determine if this event may have been preventable.

The nurse caring for the patient performed her job according to policy. The only change that may have been recommended is the placement of the graduated compression stockings on the right leg prior to surgery or after the patient was stabilized in the PACU.

CASE STUDY 6

Patient F, a woman 47 years of age, has sustained a comminuted fracture of her left tibia and fibula after falling on wet grass. Patient F is transferred to the emergency department, where the determination is made to take her to the operating room for internal fixation and subsequent casting.

Following surgery, Patient F is admitted to the PACU with a cast on her left leg. The leg is elevated on top of pillows to ensure adequate drainage. Upon awakening, the patient complains of pain of 9 on a 10-point scale. She is medicated with hydromorphone and falls back to sleep. Forty-five minutes later, she again complains of continued pain. At this point, she receives 3 mg of intravenous morphine. While reviewing the patient's chart and medication orders, the PACU nurse discovers that the patient has a history of frequent narcotic use and is labeled a "complainer" who is frequently seen in the emergency department or physician's office with vague complaints of pain and requests for refills of her narcotics.

After two hours in the PACU, the patient is transferred to the orthopedic floor for continued recovery. Other than her complaints of pain, her PACU stay is uneventful. When giving report to the nurses on the floor, the PACU nurse relays her findings regarding the patient's complaints of pain and repeat requests for pain medications.

During the remainder of the day and into the evening shift, the patient is monitored every four hours. She is medicated as ordered, but within one to two hours after receiving her medications she calls the nurse for additional analgesia. She continues to complain of pain, stating that she feels a burning sensation in her left leg. Her cast is checked and appears to be intact, without peripheral swelling of her leg, and peripheral pulses are present but weak.

At midnight, the patient calls the nurse with continued complaints of pain. The nurse notes that the cast is tight; the patient is no longer keeping it elevated as instructed. The orthopedist on call is contacted, and the decision is made over the telephone to bivalve the patient's cast to ensure adequate circulation. This is accomplished, and the patient appears more comfortable, although her reported pain score remains at 6.

The following morning the patient is seen by the orthopedic surgeon, who notes the bivalved cast and continued complaints of pain. The surgeon orders the cast to be replaced, which is accomplished. That evening the patient again complains of pain, this time giving a score report of 10. The physician is again contacted by telephone, and additional pain medications are ordered. Throughout the night, the patient continues to complain of pain despite frequent doses of narcotics.

The patient is scheduled for discharge in the morning. When seen by the surgeon prior to discharge, it is noted that the patient's foot is cool to touch and peripheral pulses remain weak. She has continued complaints of pain and does not want to be discharged at this time. At this point, the surgeon considers the possibility that the patient may be developing a case of compartment syndrome. The cast is removed, and the extremity is tense and cool, with poor color. The patient is immediately taken to the operating room, where a fasciotomy was performed. Upon opening the compartment, it is noted that there is extensive necrotic tissue that requires debridement. The remaining amount of muscle is minimal. The patient eventually recovers but with severe disability in her ambulatory capabilities.

This patient sustained a long-term disability secondary to rapidly developing compartment syndrome. As discussed, rapid assessment and intervention is required to prevent this type of sequelae. The classic sign of compartment syndrome is pain that is out of proportion to the injury. This patient had continued complaints of pain; however, due to her history as someone who was always complaining of pain, her complaints were not taken seriously. All patient complaints should be addressed and believed; the lack of attention to these complaints led to a long-term disability in this patient.

Compartment syndrome is a common complication following fracture, and the possibility of this complication should have been recognized earlier. In fact, the first evening, when the first cast was bivalved, compartment syndrome should have been considered. It was more than 36 hours before the diagnosis of compartment syndrome was made, enough time for severe tissue necrosis to develop. Had the patient undergone a fasciotomy rather than bivalving the cast, the outcome may have been different.

This case demonstrates the need for prompt recognition of patient's complaints and consideration of all potential complications, regardless of the patient's previous history. The nurses and physicians in this case neglected the patient's pain complaints because of her prior history. The patient should have been given the benefit of the doubt, which may have allowed for earlier intervention.

This case subsequently went to litigation. The physicians involved in her care admitted to malpractice in neglecting to recognize and diagnose the development of the compartment syndrome earlier in her care when the potential for complications may have been decreased. The nurses admitted to malpractice as they chose to disregard the patient's complaints when further investigation should have been undertaken. It is a sad outcome, especially as it was a preventable complication.

CASE STUDY 7

Patient G is a man, 83 years of age, who is undergoing colon resection for removal of cancerous nodes. The operative procedure proceeds without complication, and the patient is transferred to the PACU without incident.

During the first postoperative hour, the patient is noted to be hypotensive, with a systolic blood pressure of 80 mm Hg. A review of the patient's history indicates that his normal systolic pressure on admission was 160 mm Hg. The patient is noted to take furosemide, hydrochloride thiazide, metoprolol, and lisinopril for blood pressure control. With this information in mind, it is obvious that the patient's systolic pressure is significantly lower than anticipated.

Upon awakening, the patient is confused and disoriented. He needs continual reminders to help orient to person, place, and time. He is not compliant with postoperative instructions and tries to remove the dressing from his abdomen. He complains of pain when asked but is not able to rate the pain on a scale of 1 to 10. He requires wrist restraints to prevent him from disrupting the surgical site.

The patient is also noted to have a history of congestive heart failure following a myocardial infarction many years ago. While fluid resuscitation would be the first step in supporting the patient's blood pressure, the risk of developing further cardiac failure should be considered. Prior to instituting further management, the patient's history and medication use is reviewed.

The patient stated upon admission that he had been NPO after midnight, as instructed. He was told to take his medications in the morning with a small sip of water prior to arriving at the hospital, to which he complied. His wife told the nurses that he did not eat the food recommended on his bowel prep program the evening before surgery; he was anxious and wanted to ensure that his colon had been cleaned out sufficiently. His wife also noted that he had complied with the bowel prep cleansing as instructed.

The patient is administered additional intravenous fluids at a rate of 75 mL/hour. He is finally discharged from the PACU five hours after surgery and transferred to the surgical ward. On the surgical ward, his blood pressure remains low, with an average systolic pressure of 90–100 mm Hg. The patient is discharged on day 3 with a blood pressure of 102/86 mm Hg.

This case presents the typical complication of under-resuscitation and subsequent volume depletion. The patient's response to this complication was the development of a prolonged hypotensive episode, complicated by confusion and disorientation upon awakening.

Further history should have been ascertained from the patient and the patient's wife prior to surgery. The staff was unaware that the patient had been NPO for such a length of time. When asked if he complied with the bowel cleansing as ordered, the patient replied yes; no further questions were asked to ensure how he complied, when he last ate, etc. This assumption increased the risk of compromise.

In addition, the patient took his normal blood pressure control medications prior to surgery. While holding of these medications is often done on the day of surgery, the nurses needed to recognize the potential risk this offered. Ensuring adequate resuscitation and volume status in the preoperative and operative phases of care should have been instituted.

Anesthetic agents are vasodilators. This combined with the administration of blood pressure reducing agents caused a significant drop in the patient's systolic pressure. The patient's systolic pressure remained low even at the time of discharge; it is critical to alert this patient to this development and ensure that the patient follow up with either the surgeon or the cardiologist. As the drugs cleared from the patient's body, the normal systolic pressure should have been achieved.

The confusion and disorientation that developed in the PACU was most likely a consequence of low perfusion pressure within the cranial cavity of this patient. There are several reasons for postoperative confusion in the elderly; those reasons should be identified and treated. In this case, had the patient received fluid resuscitation earlier in the course of care, this neurologic development may have been avoided.

Managing an elderly patient with a history of multiple disease processes, medication use, and anesthetic administration is challenging. Further in-depth evaluation and history taking is critical to ensure safe care delivery throughout the operative period.

CASE STUDY 8

Patient H, a man 34 years of age, is admitted to the PACU following abdominal surgery for colitis. In the operating room, the patient's disease was found to be extensive, and he now has an ileostomy for stool drainage. He had a large mid-line incision reaching from the pubis to the distal sternum.

Upon admission, his vital signs are: blood pressure 102/60 mm Hg, pulse 72 beats per minute, respiratory rate 16 breaths per minute, oxygen saturation 94%, and core temperature 35°C. He is somnolent but opens his eyes upon repeated commands. The formation of the stoma was discussed with the patient prior to surgery as a last choice option; however, he was unaware at that point in his care of the extent of his disease and the need for the ileostomy.

After 15 minutes, the repeat vital signs are unchanged except for the blood pressure, which is 90/58 mm Hg. His body temperature remains at 35°C. Measures to rewarm the patient are undertaken. He continues to sleep, although he is arousable. After 30 minutes, the patient's blood pressure drops to 84/48 mm Hg. It is also noted that urine output is only 5–10 mL of dark yellow urine in the Foley catheter tubing. The physician is notified, and she orders a fluid challenge of 100 mL.

After the fluid challenge, the patient's blood pressure rises to 92/60 mm Hg. Although this is below baseline, it does show improvement. However, urine output remains the same; there is no recognizable response to this fluid challenge. The ostomy drainage does increase and is measured at 100 mL of very light yellow liquid.

Two hours after admission, the patient remains in the PACU. His core body temperature remains low, and his blood pressure is below baseline. Little urine output has been noted, but ostomy output is at 250 mL since surgery. Bowel tones are heard as high-pitched squeaks. Additionally, the patient remains significantly sleepy and slow to respond to commands.

After three hours, the patient is transferred to the surgical inpatient unit. His blood pressure is 98/60 mm Hg, pulse 70 beats per minute, respiratory rate 16 breaths per minute, core body temperature 35°C, and oxygen saturation 96%. Urine output totals 30 mL since the end of surgery; ostomy drainage totals 350 mL. The patient is arousable but sleeping when not stimulated.

That same evening, approximately seven hours after surgery, the patient is awake and complaining of severe abdominal pain. His abdomen is distended; ostomy drainage now measures an additional 300 mL, and urine output is 150 mL. The surgeon is notified, and the patient is evaluated. At this point, the surgeon speculates that there may be leakage at the stoma site. The patient is prepped for the operating room for further evaluation.

While waiting for the surgical team to arrive, the patient begins passing a significant amount of gas into the ostomy bag. The amount of drainage remains high, but with the passing of the gas the distension begins to resolve and the patient notes that his pain has diminished. It is determined that the surgery will be delayed pending resolution of the abdominal distension.

The patient remains in the hospital for another four days. He receives instructions on how to manage his stoma and ostomy. His stoma drainage remains high for the first two days. He tries solid foods on day 3 but develops severe abdominal cramping and distension yet again. His diet is changed to soft foods, and over the course of the next week, he is eventually able to tolerate a normal diet.

This patient was admitted following an extensive abdominal procedure. Upon arrival in the PACU, his core body temperature was low; however, this is common in patients undergoing an open abdominal procedure of extended length. The only error in care was the delay in beginning to warm the patient. Rewarming measures, using forced air warming, should be the standard of practice for this type of patient.

The patient developed hypovolemia, as evidenced by his low blood pressure. This period of decreased circulating volume could have potentiated the risk of subsequent ileus formation. The fluid challenge of 100 mL was ordered without awareness of the ostomy output. This output should be included in the volume assessment of the patient prior to reporting his vital signs. Most likely, a large fluid challenge would have benefited the patient and could have helped to prevent the ileus formation.

When the patient complained of severe pain while in the nursing unit, it was appropriate to consider the risk of failure of the stoma sutures. This is not an uncommon complication in this type of surgery, especially with the distended abdomen. However, the patient required a more detailed evaluation prior to being prepped for surgery. Ileus formation was not considered because the patient had audible bowel tones. While most patients with postoperative ileus do not exhibit bowel tones, these tones are not uncommon for patients with a stoma and significant changes in their GI tract. One procedure that may be beneficial for these patients is the insertion of a tube into the stoma. However, with the concern of disruption of the sutures, this was not an appropriate course of action for Patient H and was not performed.

While the patient did exhibit postoperative complications, the development was not unexpected. The assessment of the patient could have been better; assessing the intake and output beginning before surgery may have alerted the staff to the hypovolemic state. If this had been recognized and treated earlier, the ileus formation may have been averted. However, it is not uncommon for this patient type to develop an ileus, so it is difficult to determine whether it was a controllable complication. The patient's ultimate outcome was not affected by these complications, but his recovery period could have been more comfortable and without risk had certain assessment parameters been monitored more closely.

CASE STUDY 9

Patient I is a girl, 5 years of age, undergoing a surgical intervention to correct a congenital cleft lip and palate. She is small for her age and has had multiple difficulties with food intake. During the first year of life, it was nearly impossible for her to suck either at the nipple or on a bottle due to the shape and size of the defect. Despite multiple attempts and alternative methods of feeding, her growth has been slowed due to malnourishment. As she became able to ingest solid foods, she had difficulty with swallowing and had multiple bouts of sinus infections due to food particles being forced into the open sinuses.

In the preoperative phase of care, Patient I is noted to be quite anxious, crying in her mother's arms and shying away from the caregivers. She does not want an IV line started and throws a tantrum when this is attempted. Despite her young age, she is well aware of the multitude of interventions that occur in a hospital setting and she is determined to maintain some control over these developments. Her mother comforts her and does not appear to have much control over Patient I's behavior.

The corrective repair progresses without complication, although the surgery is long, more than six hours in length. When Patient I is transferred to the PACU, she is intubated and asleep. The surgeons do not want her to awaken abruptly and risk dislodgement of the endotracheal tube and/or damage to the surgical site. Her vital signs are stable compared to those obtained during the preoperative phase of care. She has an IV line in her right forearm, a Foley catheter, and cardiac monitoring electrodes on her chest, along with the endotracheal tube.

After Patient I is stabilized in the PACU, her mother is allowed in to see her and sit at the bedside. The mother is instructed to watch the patient and notify the nurses if she starts to awaken and reach for the tubes. The mother is overwhelmed by the change in her daughter's appearance, something she has dreamed about for the last five years.

After 30 minutes in the PACU, Patient I begins to move in bed. Her eyes remain closed but she appears to be awakening and somewhat agitated. The orders are to administer narcotics to the patient for pain; however, the patient is unable to use any type of pain scale due to the decrease in cognition. The mother is holding the child's hand when the child pulls her hand away and starts to reach for her mouth. The nurse sees this happening and is able to grasp the child's wrist and prevent her from reaching the tube and surgical site. Wrist restraints are applied to ensure that the patient is not able to repeat this potentially life-threatening action.

At 60 minutes, the patient begins to open her eyes and starts to move from side to side. She is pulling against the restraints and trying to sit up so she can reach the endotracheal tube to remove it. The nurse instructs the patient that she must lie still and that the tube must remain in place. The nurse attempts to use an illustrated pain scale, but the patient refuses to cooperate, continuing to pull at the restraints.

During this combative period, the patient's blood pressure and pulse rate continue to rise and blood is noted on the dressing around her mouth. It is imperative that something be done to reduce the risk of damage; the nurse decides to medicate the patient with the narcotic ordered to help control the agitation and allow the child to relax and perhaps fall asleep. This objective is achieved, and the patient falls asleep and appears relaxed. Her vital signs again return to preoperative values.

Ninety minutes after surgery, the surgeon enters the PACU to examine the patient. While touching the patient's dressing, the patient's eyes open; she grasps the hand of the surgeon and tries to grasp the endotracheal tube. She is shaking her head violently from side to side, and the dressing on her face begins to loosen. The physician yells for assistance, and the nurse holds the head of the child still so the tube and dressing can be re-stabilized and secured. The look in the eyes of the child is one of pure terror. By now the only way the patient is able to lash out is to kick her legs, and she is thrashing about in the bed. Her mother is trying to calm her, but the child does not appear to recognize her mother or at least does not respond to the mother's efforts.

The surgeon orders a dose of midazolam in an effort to calm the child and ensure the safety of the tube and surgical site. After administration, the child does calm down and is no longer struggling; however, she does not appear to fall asleep. She continues to have a very scared look in her eyes, and she does not appear to be fully aware of what is going on around her. Within 20 minutes, the child is dozing quietly and appears to be much more comfortable.

Two hours after surgery, the patient again awakens and is calm and cooperative. She is responding to her mother and is receiving comfort from her mother's presence. She is again instructed as to the need for the restraints and is not pulling against them. She tries to talk and begins coughing against the endotracheal tube. The surgeon has ordered that the patient remain intubated for at least the first 48 hours post-surgery to ensure adequate time for the wound healing to begin. This is going to be a challenge with this patient as she is trying continually to either remove or talk around the tube.

The patient is stable at three hours and is transferred to the ICU, as she remains intubated. Report is given to the staff. While the patient is being moved to the ICU bed and her hands are free, she grabs the endotracheal tube and pulls. Fortunately, she is prevented from removing the tube, although the tube is checked to ensure proper placement. At 48 hours, she is extubated and transferred to the pediatric floor. Within four days she is discharged home without further complication.

This child presents a number of challenges to the PACU staff. Airway management is always the first step in stabilizing a patient who has arrived from the operating suite, and this patient did have a secure airway at the time of transfer. The concern developed when the patient began to awaken and tried to remove the tube. Had she been successful at pulling the tube, this could have been a life-threatening complication. Attempting to mask ventilate the child would be challenging with the surgical repair site preventing the achievement of a good seal with the mask. Re-intubation would have to be performed with extreme caution to prevent damage to the surgical repair.

The child was initially stable, and the recovery appeared to be without incident. However, after the child started to awaken she demonstrated many of the signs of emergence delirium, which is more common in children than adults. She was thrashing about, pulling on her restraints, and uncooperative with instructions. Her mother did not appear to be able to calm her, indicating the possibility that she was disoriented and confused.

While the nurse was aware of the need to protect the child, she chose to administer the narcotics as ordered rather than receive an order for a different medication. It may have been that the narcotic was the right choice; the patient could have been in pain, although this was not assessed due to her behavior. On the other hand, the narcotic could have caused the second bout of combativeness noted upon the surgeon's arrival. When the patient was able to grasp the endotracheal tube, it was determined that the mother had released the restraint while holding her daughter's hand. This could have been another life-threatening complication; the nurse needed to not only ensure that the mother understood the need for the restraints but also check for proper placement of the restraints when her vital signs were obtained.

Midazolam was the drug that was able to allow the child to fall asleep and awaken in a more controlled state. Although midazolam may be a cause of emergence delirium and confusion in children, it is also one of the first drugs considered in its management. For this patient, it was the right drug, although the right time may have been during the first episode of combativeness. Not all children must be medicated; however, with the risks of tube dislodgement and surgical site disruption being quite high in this child, the administration of midazolam in the earlier phase of care may have been a better choice.

This case demonstrates the multitude of issues in dealing with pediatric patients. Although patients are educated prior to the surgical intervention, this education is not fully understood and the child may not follow instructions as directed. The mother was an excellent source of comfort to her child but also put her child at huge risk by untying the restraints. Parents should have continual reminders of their place in the care of their child.

The risk of postextubation croup was not addressed but could have presented a significant challenge to this patient either in the ICU or once on the pediatric unit. The risk of this form of croup increases when the patient has remained intubated for a length of time and/or when the child fights against the tube, both risk factors in this case. Fortunately, this did not occur and the patient was eventually discharged without further incident.

Children present challenges regularly in the PACU. Their risk of compromise is greater, and the complications are different. Astute care will allow for safe recovery during this period.

CASE STUDY 10

Patient J is a man, 87 years of age, undergoing surgical repair of a fractured hip. He was living at home independently when he slipped and fell in the bathroom, fracturing his right femoral neck. He was on the floor for an indeterminate amount of time prior to being found by a neighbor who checked on him when he had not been seen for a number of hours. Emergency service personnel were called. They found the patient on the bathroom floor in a confused state. He was unable to accurately note the date or time, and he had no recollection of how he ended up on the floor. During the head-to-toe assessment, it was noted that Patient J had sustained a small scalp laceration over his right temporal region, which was clotted by the time the ambulance personnel arrived. His leg was in a displaced position, and a fractured hip was suspected. He was also noted to have a healed scar on his sternum, indicative of a previous open-heart procedure.

Upon arrival in the emergency department, the patient is evaluated by orthopedic, cardiology, and neurology specialists. His history is reviewed and reveals a previous open-heart procedure eight years prior to admission, a long history of smoking prior to the cardiac procedure, and a history of lifelong obesity. The patient's skin condition is poor; he has multiple bruises in varying stages of healing. He has multiple folds of fatty skin, and between these folds, the skin is quite dirty and foul smelling, indicating a poor hygienic state. He has a list of medications in his wallet, which identifies the following drugs: digoxin, simvastatin, furosemide, potassium chloride, amlodipine, and lisinopril. Due to his current state of confusion, the accuracy of this list and the last time the patient took his prescribed medications are unable to be determined.

Patient J's greatest immediate need is stabilization of the fractured femur. The neurologist deems that it is appropriate to perform the surgery under general anesthesia and that postoperative neurologic assessment should be initiated. The cardiologist agrees that the patient is stable from a cardiac standpoint and that he will most likely be able to tolerate the effects of anesthesia. The orthopedic surgeon performs the fractured hip repair.

Upon transfer to the PACU, the patient is still asleep; he was extubated in the operating room, has a cardiac monitor on and a Foley catheter in place, and his hip is positioned for optimum healing. His vital signs are: blood pressure 162/100 mm Hg, pulse 80 beats per minute, respiratory rate 22 breaths per minute, oxygen saturation 89% on 4 liters nasal prongs, and core temperature 34.5°C. No urine is noted in the Foley catheter. The greatest initial concern is the lower oxygen saturation; the nasal prongs are replaced by a face mask at a flow rate of 6 liters per minute. Within 15 minutes of switching the oxygen delivery device, the oxygen saturation increases to 91%.

Thirty minutes after arrival in the PACU, the patient remains asleep. His vital signs are stable; however, his body temperature remains at 35°C despite forced air warming. He is not moving nor does he appear to be in any discomfort. His skin condition does not appear to have improved. His lower extremities are cool to touch, and peripheral perfusion is poor.

At approximately 40 minutes after arrival in the PACU, the patient sustains a cardiac arrest. Resuscitation efforts continue for approximately 20 minutes without success, and the physician in charge pronounces the patient dead.

This patient is representative of the typical postoperative geriatric patient. He has multiple health issues and takes many medications. His physical status is compromised by his nutritional status, in this case, obesity. He was living independently prior to this event; he did not have family close by, and his history was only ascertained by the information that his neighbor and the first care responders were able to locate. Even with that, the accuracy of this information was questioned. Prior to the fall, the patient had been happily living his life, which was subsequently lost after the surgery.

After the patient was pronounced dead, it was speculated that he had developed a clot that occluded his pulmonary vasculature. If this was indeed the case, the outcome would not have changed despite the resuscitation efforts. However, due to his advanced age and condition, a postmortem exam was not performed and the cause of death was never confirmed.

The patient's condition was compromised by numerous factors. He had a positive cardiac and smoking history and may have sustained a neurologic event at the time of the fall, or a neurologic event may have precipitated the fall. His obesity presented a number of issues. His skin condition was quite poor, and his apparent lack of hygiene would increase his risk of postoperative infection. While he was considered to be independent, his current health state was definitely not optimal.

Had this patient survived, in all likelihood, he would not have been able to return to an independent living environment. He would have required care in a rehabilitation facility to learn to ambulate post-surgery. Whether he would be strong enough to recover to a fully independent state was questionable.

This case demonstrates the many issues and challenges in managing the elderly patient. The lack of concrete information in the preoperative stage can impact the decisions that are made in the operating suite. Patient J's poor health status put him at increased risk for complication development. Even if the patient had survived, his long-term outcome would have been significantly different than the lifestyle he had prior to the injury. Preparing the patient and family for these less-than-optimum outcomes should be considered part of the preoperative care measures.

CASE STUDY 11

Patient K is a woman, 42 years of age, who weighs 432 pounds. She has a BMI of 62 and is scheduled to undergo a restrictive bariatric procedure. Her history is positive for hypertension, diabetes controlled with two to three insulin injections daily, gastroesophageal reflux disease, and obstructive sleep apnea. She is nervous prior to surgery, yet anxiously awaiting the new life that she sees in her future.

The operative course of care is unremarkable. The patient has a gastric band placed, creating a small pouch. She is transferred to the PACU having been extubated. Her vital signs upon admission are: blood pressure 182/112 mm Hg, pulse 82 beats per minute, respiratory rate 24 breaths per minute, core temperature 35°C, and oxygen saturation 91%. She remains very somnolent but opens her eyes with loud verbal stimulus.

Upon admission, the concern for this patient is the low oxygen saturation. She maintained a saturation of 94% during the procedure but the postoperative saturation remains 90% to 91%. Oxygen is being delivered by nasal cannula at 4 liters/minute. The nurse caring for the patient is unsuccessful at awakening her for more than a few seconds. The oxygen delivery system is changed to a face mask with a liter flow of 6 liters/minute. Little improvement in the patient's status is seen with this change.

It would be optimal to awaken the patient to have her participate in respiratory exercises; however, she remains quite sleepy while in the unit. Elevating the head of the bed may help her oxygenation but does little to increase her oxygen saturation values. Arterial blood gas analysis is obtained; the results are pH of 7.34, PaO 2 of 74, and PaCO 2 of 47. With these results it is obvious that the patient is hypoventilating, most likely secondary to pressure on the diaphragm limiting her respiratory excursion effort.

The patient remains somnolent for the next four hours. Her oxygen saturation values remain around 91% despite the efforts of the staff. After four hours in the PACU, she is transferred to the inpatient unit for an overnight stay. She remains hypoxic until the following afternoon.

The patient in this case study demonstrated one of the more common complications following bariatric surgery: hypoventilation. The upward displacement of Patient K's diaphragm prevented full expansion of her lungs, causing carbon dioxide levels to rise while oxygenation values remained low. Although the levels were low, they were not to the point of being life-threatening.

One measure that may be used to improve oxygenation in patients following surgery is respiratory exercises to help expand the lungs and encourage the patient to expel secretions. To accomplish this goal, the patient should be cooperative and have an appropriate cognitive level to follow the commands. As this patient remained somnolent for a lengthy period, efforts at obtaining her cooperation were unsuccessful. It is not uncommon for obese patients to experience a delay in awakening following anesthesia. The drugs are absorbed into the fatty tissue, and release occurs over an extended period. One measure that may have been successful in arousing the patient more quickly is a fluid challenge. This extra fluid can often help circulate the remaining anesthetic and speed the metabolism of the medication, allowing the patient to awaken more quickly. While this may not always be the answer to delayed awakening, it is often successful in obese patients.

Fortunately, this patient did not experience any of the other postoperative complications that are common following bariatric surgery. After her respiratory status improved, she was able to meet the criteria for discharge and was sent home the next day.

In follow-up with this patient, she lost more than 100 pounds in the first year following surgery. She started an exercise regimen and is determined to continue with her weight loss. While 100 pounds is quite a bit of weight to lose, her weight is now 330 pounds; therefore, she remains at risk for the complications of obesity. Her diabetes has not resolved, yet she remains hopeful that with continued weight loss, she will one day be free of insulin injections. Morbidly obese patients have a long and often arduous path ahead of them and should not expect miracles to happen overnight.

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Basic science: neuropathogenesis of delirium, approach to postoperative delirium in the elderly: the view of the geriatrician and current concepts, knowledge gap, case scenario: postoperative delirium in elderly surgical patients.

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Jean Mantz , Hugh C. Hemmings , Jacques Boddaert; Case Scenario: Postoperative Delirium in Elderly Surgical Patients. Anesthesiology 2010; 112:189–195 doi: https://doi.org/10.1097/ALN.0b013e3181c2d661

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  • Ris (Zotero)
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DELIRIUM is increasingly recognized as a major adverse event occurring postoperatively in elderly surgical patients. Once the diagnosis has been established, the main goal of delirium therapy is to identify important, potentially life-threatening, treatable, organic causes responsible for this syndrome. The purpose of this clinical pathologic conference is to highlight key points essential for the diagnosis and treatment of delirium occurring after anesthesia and surgery.

An 81-yr-old woman presented with delirium 4 days after undergoing laparoscopic colon surgery under general anesthesia. She had a history of major tobacco consumption (2 cigarette packs/day for 45 yr) and still smokes. She also had moderate hypertension and peripheral vascular disease for which she had been treated with bare metal stents in both iliac arteries and the left femoral artery 3 yr ago. Chronic medications consisted of clopidogrel (75 mg/day), simvastatin (20 mg/day), bromazepam (6 mg/day), valsartan (160 mg/day), and bisoprolol (10 mg/day). She was admitted for laparoscopic surgical treatment of sigmoid diverticulitis complicated by sigmoido-vaginal fistula. Several episodes of polymicrobial urinary tract infections had been treated with antibiotics before admission. Preoperative examination revealed satisfactory cardiopulmonary status. Blood electrolytes were normal, troponin Ic was less than 0.04 ng/ml, hemoglobin was 12.9 g/dl, and platelet count was 260 g/l. Electrocardiogram showed regular sinus rhythm, blood pressure was 168/78 mmHg, and stress-echocardiography was negative for ischemia but showed left ventricular diastolic dysfunction with left ventricular hypertrophy. Doppler ultrasound examination of the carotid arteries was normal.

Clopidogrel, simvastatin, bromazepam, and bisoprolol were continued until the day of surgery, whereas valsartan was discontinued 2 days before surgery. Anesthesia was induced with propofol, sufentanil, and atracurium, and it was maintained with desflurane in O 2 /N 2 O 50:50. After an uneventful 3-h operation that consisted of sigmoidectomy, colorectal anastomosis, and ileostomy, residual neuromuscular blockade was reversed with neostigmine and atropine, the trachea was extubated, and the patient was transferred to the postanesthesia care unit (PACU) and then to the surgical ward. Postoperative analgesia consisted of intravenous propacetamol (500 mg 4 doses per day), nefopam (20 mg 3 doses per day), and morphine titration in the PACU. Patient-controlled analgesia with morphine hydrochloride (bolus = 1 mg, refractory interval = 7 min) was used during the first 48 postoperative hours. Epidural analgesia was not used in this case.

On postoperative day 4, the patient experienced several episodes of confusion, logorrhea, and disorientation. Glasgow Coma Scale score was 15. Temperature was 37.2°C but had a transient peak to 38.4°C the day before. Physical examination revealed slight abdominal tenderness, diarrheic stool in the ileosotomy, and normal cardiac and pulmonary auscultation. Blood leukocytes were 10,000/ml, hemoglobin was 12.9 g/dl, blood electrolytes were normal, and computed tomographic scan revealed a 3-cm diameter fluid collection at the colorectal anastomosis ( fig. 1 ).

Fig. 1. Abdominal computed tomography scan performed on the fourth postoperative day revealing a 3-cm diameter fluid collection at the colorectal anastomosis (arrow ).

Fig. 1. Abdominal computed tomography scan performed on the fourth postoperative day revealing a 3-cm diameter fluid collection at the colorectal anastomosis ( arrow  ).

Important issues to consider in this case include the following.

1. How Is Delirium Diagnosed in the Postoperative Period?

Delirium, defined as an acute decline in attention and cognition, represents a serious complication in patients after anesthesia and surgery and is predictive of mortality at 6 months in intensive care unit (ICU) patients. 1 There is increasing evidence that delirium precedes development of postoperative cognitive dysfunction after ICU admission. 1 Delirium exhibits both hyperactive and hypoactive forms, the latter being more common in the elderly and more often unrecognized. 2 The main clinical features of delirium are summarized in table 1 . Diagnosis in the postsurgical setting is based on validated clinical scales. However, to date, most postoperative patients admitted to the PACU or the ICU have not been formally assessed for delirium or cognitive dysfunction with appropriate preoperative tests, which makes the time of onset of symptoms uncertain. The Confusion Assessment Method for Intensive Care Unit Patients Scale has been validated in medical and coronary ICU patients as a reliable tool to detect delirium. 3 Diagnostic criteria include abrupt onset and fluctuating course, inattention, and either disorganized thinking or coma. However, the capacity of Confusion Assessment Method for Intensive Care Unit Patients Scale for detecting delirium in the PACU is inferior to recently reported scales. 4 The Nursing Delirium Screening Scale includes five items scored 0–2: disorientation, inappropriate behavior, inappropriate communication, illusions/hallucinations, and psychomotor retardation. Delirium is indicated by a score ≥ 2. The Delirium Detection Score has been adapted to the PACU and includes five items scored 0–7: orientation, hallucination, agitation, anxiety, and paroxysmal sweating. Diagnosis of delirium is based on a Delirium Detection Score ≥ 7. The Nursing Delirium Screening Scale and Delirium Detection Score might be useful as additional tools to pain scores for ensuring patient comfort and restoration of postoperative brain function in the PACU. In this case, delirium was indicated by each of these scales (Confusion Assessment Method for Intensive Care Unit Patients Score = 3/4, Nursing Delirium Screening Scale Score = 6, Delirium Detection Score = 12).

2. What Is the Pathophysiology of Postoperative Delirium in the Elderly?

The pathophysiology of delirium after anesthesia and surgery remains obscure and is multifactorial. Hypothetical mechanisms for postoperative delirium include disordered neurotransmission, inflammation, and stress. Evidence supports the role of reduced cholinergic transmission or excessive dopaminergic tone in delirium. Proinflammatory cytokines such as tumor necrosis factor-α or interleukin-1, which have also been implicated, can alter neurotransmission, enhance neurotoxicity, and increase blood-brain barrier permeability. 5 Genetic factors have also been identified as risk factors for developing postoperative delirium in the elderly. 6 The aging brain exhibits both quantitative and qualitative changes in neuronal circuitry 7,8 that could account for the greater sensitivity of elder patients to delirium.

3. What Are the Causes of Postoperative Delirium?

On diagnosis of delirium, efforts turn to identification of the cause. Factors contributing to delirium in the postoperative period are listed in table 1 . Factors related to the patients include pain, hypoxemia, hypotension, metabolic disorders, sepsis, and drug or alcohol withdrawal. Intense postoperative pain is a cause of hyperactive delirium with agitation. 9 Pain-induced delirium caused by undiagnosed urinary retention is common because residual bladder volume is elevated after anesthesia and surgery in the PACU 10 Hypoxemia and hypotension can cause delirium. Electrolyte disorders can also cause delirium, as with hyponatremia, because of absorption of water during endourologic or endogynecologic surgery. Hypernatremia and hypoglycemia in diabetic patients can also cause postoperative delirium. Hypoactive delirium can occur in patients with Parkinson disease because levodopa is given only orally. Patients addicted to nicotine, ethanol, opioids, or benzodiazepines are at high risk of developing delirium in the postoperative period. The incidence of postoperative confusion is increased in older persons taking chronic benzodiazepines. 11 Delirium tremens must also be considered and prevented in the case of alcoholic patients.

Factors not related to the patient include use of physical restraints, cardiac surgery, drugs (including anesthetics), and sleep deprivation. Perioperative acute ischemic stroke is an important cause of morbidity and mortality associated with both cardiac and noncardiac surgery, particularly in elderly patients. 12 Delirium without any sensory or motor deficit can be the only clinical manifestation of stroke in this context. Residual effects of muscle relaxants can contribute to delirium/agitation because of depression of pharygolaryngeal muscle activity and hypoxemia. Residual paralysis is frequently observed in the patients in PACU because of the underuse of neuromuscular function monitoring and incomplete antagonism of the effects of neuromuscular blockers, which increases postoperative respiratory complications, particularly hypoxemic episodes. 13 Drug-induced delirium is an obvious concern after anesthesia, because many drugs used in the perioperative period can contribute to delirium in older persons. 14 The use of anticholinergic agents is associated with delirium, particularly in older patients. 15 Delirium induced by ketamine has also been reported in this context. 16 Propofol has been associated with an increased incidence of emergence delirium in children. 17 In long-duration laparoscopic surgery performed in elderly patients under an anesthetic regimen with propofol-based anesthesia, an increase in the severity, but not incidence, of delirium on postoperative days 2 and 3 has been reported in comparison with a sevoflurane-based anesthetic regimen. 18 Although the use of nitrous oxide in elderly patients has been challenged recently, no data support an increase in the incidence of postoperative delirium in high-risk surgical patients undergoing anesthesia and surgery. 19 On the other hand, statins have been reported to attenuate delirium in patients undergoing cardiac surgery. 20  

4. What Was the Probable Cause of Delirium in This Case?

The most likely explanation of acute postoperative delirium in this case was postoperative peritonitis, which can precipitate delirium. 21 The fever the day before surgery supports this diagnosis, a nonspecific but frequent physical sign present in peritonitis. Fever as a sign of infection can be blunted or absent in older patients with infection. 22 Although the pathophysiology of sepsis-induced delirium remains poorly understood, several lines of evidence suggest that sepsis can alter the blood-brain barrier through the production of proinflammatory cytokines, such as interleukin 1-β, promoting leukocyte endothelial adhesion, and endothelial damage. 5 Interestingly, patients with sustained septic shock exhibit abnormal magnetic resonance imaging findings with various degrees of encephalopathy and damage to white matter tracts. 23 Altered synaptic transmission and excitability of hippocampal pyramidal neurons have been reported in an animal model of sepsis. 24 Sepsis-induced delirium might also be explained in part by an increase in oxygen requirements or hypoxia.

Table 1. Clinical Features and Factors Contributing to Postoperative Delirium in Elderly Surgical Patients

Table 1. Clinical Features and Factors Contributing to Postoperative Delirium in Elderly Surgical Patients

Subsequent Course

The patient received broad spectrum antibiotics and returned to surgery for exploratory laparotomy. Peritonitis caused by leakage of the colorectal anastomosis was confirmed by peritoneal fluid cultures positive for Escherichia coli  . The postoperative course was complicated by respiratory, circulatory, and renal failure requiring mechanical ventilation with continuous intravenous sedation (midazolam and fentanyl) and inotropic support. The patient's condition slowly improved and she was extubated 8 days later. The day after extubation, a second episode of delirium ensued with disorganized thinking, inattention, and olfactory hallucinations. Her physical status remained stable, with no fever, normal electrolytes and no recurrence of circulatory, respiratory, or renal failure. Abdominal computed tomography scan was normal. Current medications, including antibiotics, could not account for the delirium.

5. What Was the Cause and Treatment of the Second Delirium Episode?  

Because organic causes and persistent intraabdominal sepsis were unlikely, withdrawal syndrome was considered the most likely cause of this delirium episode. Benzodiazepine withdrawal syndrome could also have contributed to the first episode of delirium as a predisposing factor in addition to sepsis. The patient had been taking bromazepam chronically but had not received it since the second operation. She had also received 8 days of continuous intravenous sedation with midazolam while being mechanically ventilated. She was therefore at high risk of developing benzodiazepine withdrawal syndrome. 25 Opioid withdrawal could not be excluded, because fentanyl was administered intravenously for 8 days. 25 Nicotine withdrawal has also been reported in ICU patients, 26 but a nicotine patch failed to reverse the delirium in this case. Bromazepam was then administered orally and the delirium resolved within 2 h. The patient was discharged from the hospital 8 days later and remains well 1 yr later.

6. How Can Postoperative Delirium Be Treated or Prevented in Elderly Patients?  

Only dangerous agitation associated with delirium requires emergent pharmacologic intervention, whereas alternative strategies, including searching for an organic cause, must be considered first. Because of increased sensitivity of elderly persons to drugs, starting with small dosages and titration to effect is advised. 14 Neuroleptics such as haloperidol, a well-tolerated, easily titratable, nonrespiratory depressant butyrophenone antipsychotic, can be used for sedation. 27 In a randomized placebo-controlled trial, haloperidol prophylaxis decreased the severity and duration, but not the incidence, of postoperative delirium in high-risk elderly patients undergoing hip replacement. 28 Implementation of a delirium assessment tool in the ICU can reduce haloperidol use by allowing considerable reduction in the dosage and duration of treatment. 29 Reduced incidence of delirium in hospitalized elderly patients can be achieved by management of cognitive dysfunction, sleep deprivation, immobility, visual and hearing impairment, and dehydration. 30 Preventive strategies, such as preservation of sleep and multimodal physiotherapy, should be considered as well. Recently, a strategy for rehabilitation consisting of interruption of sedation and physical and occupational therapy during the early days of critical illness resulted in a reduction in the duration of delirium in ICU patients. 31 Sleep deprivation is also a common cause of delirium in ICU patients, who exhibit both qualitative and quantitative alterations of sleep. 32 Sleep disorders predispose to development of cognitive dysfunction in ICU patients, 2 such that improving sleep quality is an important goal. The α2-adrenoceptor agonist dexmedetomidine increases the number of delirium-free days in mechanically ventilated ICU patients and could become the preferred strategy for sedation in the ICU. 33  

The etiology of delirium, particularly in the postoperative period, is most often multifactorial and difficult to diagnose. 34 Interactions between patient risk factors, medical illness, and therapy can produce such a complex neuropsychiatric syndrome. Drugs are one of the most common causes and one of the most treatable. The risk of drug-induced delirium is high in hospitalized elders in whom polypharmacy, altered pharmacokinetics and pharmacokinetics, and underlying pathology all interact to cause delirium. 14 Many drugs have been implicated, but central nervous system active drugs, all commonly used in the perioperative period, are most often implicated.

Although the mechanisms of drug-induced delirium are not well defined, imbalances in major cortical and subcortical neurotransmitter systems are probably important. Disturbances in multiple neurotransmitters have been implicated in delirium, but the neurochemical basis of delirium is most often explained by a deficit in cholinergic transmission (“cholinergic hypothesis”). 35 Acetylcholine plays important roles in attention, consciousness, and memory, and it is critically affected in dementia. Alterations in cholinergic system function are supported by the observations that anticholinergic intoxication produces a delirium that can be reversed by cholinesterase inhibitors and by the propensity of antimuscarinic drugs to induce delirium. Indeed, a number of drugs associated with delirium have marked antimuscarinic side effects. Serum anticholinergic activity can be used to indicate a patient's net anticholinergic load from drugs and endogenous sources and has been positively correlated with delirium symptoms. 36 Anticholinergic effects have also been implicated in postoperative cognitive impairment. 37 But the pathophysiology is clearly more complicated because cholinesterase inhibitors do not typically treat or prevent postoperative delirium. Nonpharmacologic factors, such as ischemia or inflammation, can also contribute to postoperative delirium ( fig. 2 ).

Fig. 2. Hypotheses for neuropathogenesis of delirium in elderly surgical patients. Activation (ascending arrows ) or inhibition (descending arrows ) of neurotransmitters, cytokines, and hormones by various factors (medications, withdrawal syndrome, sleep disorders, organ failure, inflammation, sepsis, and so on) can contribute to postoperative delirium in elder patients undergoing anesthesia and surgery. GABA =γ-aminobutyric acid.

Fig. 2. Hypotheses for neuropathogenesis of delirium in elderly surgical patients. Activation ( ascending arrows  ) or inhibition ( descending arrows  ) of neurotransmitters, cytokines, and hormones by various factors (medications, withdrawal syndrome, sleep disorders, organ failure, inflammation, sepsis, and so on) can contribute to postoperative delirium in elder patients undergoing anesthesia and surgery. GABA =γ-aminobutyric acid.

Alterations in neurotransmission involving the γ-aminobutyric acid, glutamate, and the monoamines (serotonin, norepinephrine, and dopamine) have also been linked to the pathogenesis of delirium, which is not that surprising, given the multiple interactions between these systems. A number of sedative/hypnotics including inhaled anesthetics, propofol, and benzodiazepines potentiate γ-aminobutyric acid-mediated transmission through γ-aminobutyric acid type A receptors in the central nervous system. The monoamine transmitters have prominent neuromodulatory roles in regulating cognitive function, arousal, sleep, and mood, and they are modulated by cholinergic pathways. An excess of dopaminergic transmission has been implicated in hyperactive delirium, which can respond to antipsychotic dopamine receptor antagonists such as haloperidol. There seems to be an inverse relationship between acetylcholine and dopamine system activity in delirium, and the terminal fields of these transmitters overlap extensively in the brain. Antiparkinsonian drugs such as levodopa can induce delirium, and dopamine antagonists can treat its symptoms. Both increases and decreases in serotonin signaling have been associated with delirium, which can be induced by selective serotonin reuptake inhibitors. Excessive norepinephrine has also been associated with hyperactive delirium.

For elderly patients, a surgical procedure is an acute event with potential life- and autonomy-threatening adverse outcomes. Prevention of cardiovascular events and stroke, postoperative delirium, poor nutrition, and loss of autonomy represent associated challenges for frail elderly patients in the perioperative period.

Delirium occurs more frequently with advancing age, but the underlying mechanisms are not clearly understood. Patients with increased postoperative delirium risk require specific attention. Numerous conditions are associated with postoperative delirium, which require specific attention as well. 34 A validated model of delirium prediction has been reported based on four criteria evaluated using specific scales, including illness severity (Acute Physiology and Chronic Health Evaluation Score), 38 visual impairment (Snellen test), 39 cognitive impairment (Mini Mental State Evaluation Score), 40 and serum urea/creatinine ratio. 41 For hip fracture surgery, postoperative delirium was reported in 37% of patients in the high-risk group compared with 3.8% in the low-risk group. 42  

In addition to these factors, cognitive impairment is the strongest factor associated with postoperative delirium; dementia and delirium are closely related. First, their symptoms strongly overlap, and time is required to get a valuable neuropsychological evaluation far from the acute episode. Second, patients with dementia are highly prone to delirium. 43 Third, half the patients undergoing delirium will develop dementia. 44 Finally, dementia can sometimes be difficult to diagnose, because elderly patients with a starting dementia can erroneously be considered normal because of compensatory mechanisms. Delirium was reported as a sign of undetected dementia with a 55% incidence 2 yr later in a small study 44 and might accelerate the trajectory of cognitive decline in patients with Alzheimer disease. 45  

Preoperative depression increases the risk for postoperative delirium. 46 In vascular surgery, patients with postoperative delirium had higher preoperative scores of depressive symptoms, using the Hamilton Depression Scale. 47 In younger patients, delirium was associated with depression using the preoperative Geriatric Depression Scale—Short Form Score 48 or the Beck Depression Inventory. 49 Recently, patients with an overlap syndrome of delirium and depressive symptoms had a particularly poor outcome prognosis including nursing home placement, 1 yr death, and 1 month functional decline. 50 Simple questions about memory complaints, activities of daily living, depressive symptoms, excessive familial or professional help, as well as previous postoperative delirium or drug-induced delirium provide crucial information for anesthesiologists. Some scales give clear information about global cognitive function (Mini Mental State Evaluation), 40 depression (Geriatric Depression Scale-short form), 51 and autonomy (Activity of Daily Living and Instrumental Activity of Daily Living Scales). 52,53 They are the cornerstones of most geriatric assessments, but physicians must be trained in their use.

A focus about assessment of autonomy in elderly patients is crucial for global and cognitive evaluation. First, a loss of physical or cognitive autonomy is always a disease-associated condition. Ageing people without any disease do not need help for reading (look for the glasses and search for cataract or macular degeneration), hearing (look for hearing aids and search for ear wax), feeding (search for depression or underlying disease or treatment), or thinking (search for dementia and depression) for example. Second, dementia criteria require loss of autonomy, and attention of physician to dementia is frequently drawn by loss of autonomy. Finally, use of validated scales (Activity of Daily Living or Instrumental Activity of Daily Living) highlights points frequently considered as nonsignificant by family or caregivers. However, evaluation of autonomy depends on the sociocultural level and requires specific questions depending on individual past activities or hobbies. Most importantly, a loss of autonomy is never an age-related normality but always a disease-associated symptom. For example, in this case, a cognitive assessment could have been discussed in the presence of difficulties for financial or medication management, looking for possible cognitive dysfunction related to vascular disease or age-related neurodegenerative disease. Whether a diagnosis of dementia should be made before surgery remains unclear because there is no evidence that preoperative treatment of dementia prevents postoperative delirium. This issue is a challenge for future research.

Medication use is another important concern. The role of anesthetics has been discussed previously. Preoperative benzodiazepines are associated with postoperative delirium. 11 Such prescriptions should always be questioned during preoperative assessment, because they are associated with falls or memory complaints. If preoperative medication is chosen, hydroxyzine or small doses of mianserine may be considered. Sudden withdrawal of benzodiazepines is a classic cause of delirium and must be avoided.

Numerous perioperative complications can trigger postoperative delirium. A randomized study reported a reduction of postoperative delirium in patients with hip fracture using a geriatric assessment and care plan (relative risk 0.64, 95% confidence interval 0.37–0.98). 54 This assessment included all parameters considered essential in the perioperative period: central nervous system oxygen delivery, fluid and electrolyte balance, treatment of severe pain, elimination of unnecessary medications, regulation of bowel and bladder function, nutritional intake, early mobilization and rehabilitation, management of postoperative complications, and appropriate environmental stimuli. A recent study in a large cohort confirmed and extended these findings. 55 Those patients could require cognitive assessment at regular intervals after surgery by geriatricians or neurologists.

Although the pathophysiological mechanisms underlying delirium are poorly understood and clearly multifactorial, drugs acting on the cholinergic, γ-aminobutyric acid-mediated, and monaminergic neurotransmitter pathways are frequently involved. Future efforts to clarify these mechanisms and their relationship to other patient factors such as dementia should enhance diagnosis, treatment, and prevention. Collaborative approaches, including anesthesiologists, surgeons, and geriatricians, are essential for optimal management. The link between the perioperative period, postoperative delirium, and long-term postoperative cognitive dysfunction in elderly surgical patients represents an important research area. Finally, data suggest that assessment and early intervention can predict and avoid postoperative delirium in elderly patients. Future directions for preventing postoperative delirium in elderly patients should encourage combined anesthetic/geriatric approaches. The impact of such strategies as the use of pharmacologic agents, the evaluation of preoperative memory and executive functions, or the control of environmental factors on postoperative delirium in elderly surgical patients represent important challenges for future investigations.

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