A 68-year-old man is evaluated in the cardiac care unit for confusion and agitation 3 days after coronary artery bypass grafting. Other than blood transfusion for perioperative bleeding, the surgery was uncomplicated. After initial difficulty weaning, the patient was successfully extubated on postoperative day 2. His pain has been well controlled with IV morphine, and he was calm throughout the day. This evening, the patient suddenly became anxious and started to pull his IV catheter. Medical history is significant for type 2 diabetes mellitus, dyslipidemia, and peripheral artery disease. He does not drink alcohol. Temperature is 37.1 C (98.8 F), blood pressure is 138/86 mm Hg, pulse is regular at 96/min, and respirations are 18/min. Pulse oximetry is 96% on room air. The patient is oriented to person but not place or time. During examination, he tries to grab the bed rails and sit up but calms down easily with reorientation. The patient states that he is frightened by small animals hopping around his bed. He has no apparent focal weakness. Laboratory studies are normal. What is the best initial intervention to help prevent self-harm in this patient?

Question

A 68-year-old man is evaluated in the cardiac care unit for confusion and agitation 3 days after coronary artery bypass grafting.  Other than blood transfusion for perioperative bleeding, the surgery was uncomplicated.  After initial difficulty weaning, the patient was successfully extubated on postoperative day 2.  His pain has been well controlled with IV morphine, and he was calm throughout the day.  This evening, the patient suddenly became anxious and started to pull his IV catheter.  Medical history is significant for type 2 diabetes mellitus, dyslipidemia, and peripheral artery disease.  He does not drink alcohol.  Temperature is 37.1 C (98.8 F), blood pressure is 138/86 mm Hg, pulse is regular at 96/min, and respirations are 18/min.  Pulse oximetry is 96% on room air.  The patient is oriented to person but not place or time.  During examination, he tries to grab the bed rails and sit up but calms down easily with reorientation.  The patient states that he is frightened by small animals hopping around his bed.  He has no apparent focal weakness.  Laboratory studies are normal.  What is the best initial intervention to help prevent self-harm in this patient?

Quizplus · Accepted Answer

11ec25c8_d828_76de_bc81_dbff2e637962_MD0003_00 This postsurgical patient has acute mental status changes (eg, confusion, disorientation) associated with agitation and hallucinations, consistent with delirium. Postoperative delirium is a common surgical complication, and incidence increases with patient risk factors (eg, advanced age, dementia) and surgical complexity. Delirium is particularly prevalent after cardiac surgery, possibly due to cognitive dysfunction induced by cerebral microemboli related to cardiopulmonary bypass. Management of delirium requires simultaneous control of behavioral symptoms and treatment of underlying causes. Nonpharmacologic measures (eg, sleep facilitation, mobilization) are the mainstays of delirium symptom management. Personal interaction (eg, reassurance, physical touch) can alleviate agitation and reduce the risk of self-harm. Familiar people (eg, relatives, friends) are the best resource; however, professional sitters can provide these interactions when no family members are available. In addition, sitters can provide constant observation, which decreases the need for physical restraints. When agitation fails to respond to supportive care and patient danger persists, antipsychotic medications (eg, haloperidol, quetiapine) are often used. This indication is off-label and requires careful assessment of risks/benefits, as well as close monitoring for adverse effects (eg, hypotension, QT prolongation). Physical restraints are a last resort and should be used only when all other measures fail with ongoing dangerous behavior (Choice A). Restraints prolong delirium, increase agitation, and promote complications (eg, pressure ulcers, aspiration). (Choice B) Opioids (eg, morphine) frequently cause delirium; however, uncontrolled pain often contributes to delirium, as well. Although nonopioid medications are preferred, opioids frequently are necessary in postoperative patients. Therefore, discontinuing all analgesics could aggravate pain-driven delirium and increase self-harm risk. (Choice D) Restricting daytime interaction encourages sleep out of phase with natural light-dark cycles. This promotes sleep-wake reversal, which commonly precipitates or worsens delirium. Daytime nonpharmacologic measures (eg, personal interaction, mobilization) help maintain normal circadian rhythm. (Choice E) Benzodiazepines should be avoided in delirium because they frequently prolong (rather than treat) it. Benzodiazepines (eg, lorazepam) are indicated only for the treatment of delirium due to withdrawal syndromes (eg, alcohol, sedative-hypnotic) or when antipsychotics fail to control dangerous behaviors. Educational objective: Nonpharmacologic management of delirium symptoms is preferred whenever possible. Personal interaction and constant observation reduce the need for physical restraints and can be provided by family members or professional sitters. References: Delirium in elderly people. (http://www.ncbi.nlm.nih.gov/pubmed/23992774)

A 68-Year-Old Man Is Evaluated in the Cardiac Care Unit