An 82-year-old man is found to be agitated and confused on day 2 following surgery for a right hip fracture. The surgery was uncomplicated and was not accompanied by hemodynamic instability. The patient has a history of mild cognitive impairment and lives at home with his daughter. He also has hypertension, gout, and benign prostatic hyperplasia. Temperature is 37.2 C (99 F), blood pressure is 134/90 mm Hg, and pulse is 100/min. The patient has 2 peripheral intravenous lines that appear clean. He does not have a Foley catheter. Lungs are clear on auscultation. Heart rhythm is regular with a faint mid-systolic murmur heard over the left sternal border. The lower abdomen is tender and palpation exacerbates the agitation. The surgical site appears clean with minimal discharge. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

An 82-year-old man is found to be agitated and confused on day 2 following surgery for a right hip fracture.  The surgery was uncomplicated and was not accompanied by hemodynamic instability.  The patient has a history of mild cognitive impairment and lives at home with his daughter.  He also has hypertension, gout, and benign prostatic hyperplasia.  Temperature is 37.2 C (99 F), blood pressure is 134/90 mm Hg, and pulse is 100/min.  The patient has 2 peripheral intravenous lines that appear clean.  He does not have a Foley catheter.  Lungs are clear on auscultation.  Heart rhythm is regular with a faint mid-systolic murmur heard over the left sternal border.  The lower abdomen is tender and palpation exacerbates the agitation.  The surgical site appears clean with minimal discharge.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This elderly male patient with agitation, tachycardia, and lower abdominal (suprapubic) tenderness 2 days following surgical repair of a hip fracture likely has acute urinary retention (AUR). The major risk factors for development of AUR include: Male sex (AUR rarely occurs in women) Advanced age (~33% of men age >80 will develop AUR) History of benign prostatic hyperplasia History of neurologic disease (eg, mild cognitive impairment) Surgery (especially abdominal surgery, pelvic surgery, and joint arthroplasty) It is likely that this patient has also recently taken medications (eg, anesthetics, opioids, anticholinergics) that are common precipitants of AUR. In a patient with suspected AUR who is unable to void, the diagnosis is confirmed by bladder ultrasound demonstrating ≥300 mL of urine. Treatment is with insertion of a Foley catheter, and urinalysis should be collected to rule out urinary tract infection (a potential cause of AUR). Obesity, abdominal ascites, or tissue edema may render bladder ultrasound inaccurate; in such cases, Foley catheter insertion can be both diagnostic and therapeutic. (Choices A and B) CT scan and x-rays of the abdomen are often helpful in diagnosing causes of acute abdominal pain (eg, colitis, nephrolithiasis, appendicitis). However, AUR should be suspected first in this patient with numerous risk factors. (Choice D) Blood cultures followed by intravenous vancomycin would be appropriate for treatment of suspected gram-positive bacteremia, which may present with confusion and tachycardia. This patient's clean surgical site, lower abdominal tenderness, and absence of fever and leukocytosis make AUR more likely. (Choice E) A quiet environment may help improve delirium, which is a common cause of agitation and confusion in hospitalized elderly patients. However, AUR commonly causes confusion and agitation and should be suspected first in this patient with numerous risk factors. If possible, the use of haloperidol and other typical antipsychotics should be avoided in elderly patients. Educational objective: Acute urinary retention (AUR) is common in elderly men, especially in the setting of underlying benign prostatic hyperplasia. The risk of AUR is further increased during the postoperative period. Diagnosis is made using bladder ultrasound. References: Risk factors for postoperative urinary retention in men undergoing total hip arthroplasty. (http://www.ncbi.nlm.nih.gov/pubmed/26091224)

An 82-Year-Old Man Is Found to Be Agitated and Confused