A 62-year-old woman on the postoperative floor is evaluated due to increasing confusion. The patient is unable to answer questions, keeps trying to get out of bed, and continues to pull on her intravenous lines. Six hours ago, she underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, staging, and debulking procedure for primary peritoneal cancer. After the procedure, the patient was placed on a continuous hydromorphone infusion for pain control. She was stable in the postanesthesia care unit and was moved to the postoperative floor 2 hours ago. Her medical conditions include type 2 diabetes mellitus, for which she takes insulin, and chronic hypertension. Temperature is 36.7 C (98.1 F), blood pressure is 90/50 mm Hg, pulse is 116/min, and respirations are 22/min. Cardiac examination shows sinus tachycardia with no rubs or murmurs. The lungs are clear to auscultation. The abdominal dressing is soaked with blood, and there is blood leaking between the staples at the incision site. Finger-stick blood glucose level is 150 mg/dL. Which of the following is the best next step in management of this patient?

Question

A 62-year-old woman on the postoperative floor is evaluated due to increasing confusion.  The patient is unable to answer questions, keeps trying to get out of bed, and continues to pull on her intravenous lines.  Six hours ago, she underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, staging, and debulking procedure for primary peritoneal cancer.  After the procedure, the patient was placed on a continuous hydromorphone infusion for pain control.  She was stable in the postanesthesia care unit and was moved to the postoperative floor 2 hours ago.  Her medical conditions include type 2 diabetes mellitus, for which she takes insulin, and chronic hypertension.  Temperature is 36.7 C (98.1 F), blood pressure is 90/50 mm Hg, pulse is 116/min, and respirations are 22/min.  Cardiac examination shows sinus tachycardia with no rubs or murmurs.  The lungs are clear to auscultation.  The abdominal dressing is soaked with blood, and there is blood leaking between the staples at the incision site.  Finger-stick blood glucose level is 150 mg/dL.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This postoperative patient has acute confusion (eg, inability to answer questions) and agitation (eg, pulling on lines) consistent with altered mental status (AMS) (eg, delirium). Older patients are at higher risk of postoperative delirium due to anesthesia sensitivity; however, the onset of postoperative delirium is typically immediately after a procedure. In contrast, this patient has developed acute decompensation after being previously stable and therefore requires evaluation for another precipitating cause of AMS. The most likely cause of AMS in this patient is hemorrhagic shock due to postoperative intraabdominal bleeding from her total abdominal hysterectomy with staging, which can be associated with large-volume blood loss and continued postoperative bleeding from friable malignant tissue. This can lead to dissection of the surgical planes by the accumulating blood and subsequent overflow through the incision site, as evidenced by the blood-soaked dressing and blood leaking between incisional staples. Large-volume blood loss eventually leads to hemorrhagic shock (eg, hypotension, tachycardia) and decreased end organ perfusion (eg, AMS), as in this patient. Patients with suspected significant intraabdominal bleeding require resuscitation and urgent laparotomy. (Choice A) Extreme glucose level abnormalities (eg, hypoglycemia, hyperosmolar hyperglycemic state) can cause altered mental status. In contrast, a blood glucose level of 150 mg/dL is unlikely to precipitate delirium; therefore, insulin would not improve this patient's status. (Choice B) Opiates (eg, hydromorphone infusion) may precipitate delirium, particularly in elderly postoperative patients. However, opiates typically cause bradycardia, decreased respiratory rate, and sedation, rather than tachycardia and agitation, as in this patient. In addition, decreasing this patient's hydromorphone infusion would not correct the precipitating cause of this patient's AMS, which is hemorrhagic shock due to intraabdominal bleeding. (Choice C) CT chest angiography can be used to diagnose a pulmonary embolus (PE), which may present with tachycardia and delirium due to hypoxemia. Although this patient is at increased risk for PE due to cancer and recent surgery, her hypotension and incisional bleeding are more consistent with intraabdominal bleeding. (Choice D) A CT scan of the head with and without contrast can be used to diagnose an acute stroke causing AMS. Although hypertension is a risk factor, acute stroke is less likely in this patient with hypotension and a concomitant blood-soaked dressing. Educational objective: Altered mental status (eg, confusion, agitation) can be a sign of hemorrhagic shock due to intraabdominal bleeding, particularly among elderly postoperative patients. Patients with suspected significant intraabdominal bleeding require urgent laparotomy. References: Hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/31194413) Complications of hysterectomy. (http://www.ncbi.nlm.nih.gov/pubmed/23635631)

A 62-Year-Old Woman on the Postoperative Floor Is Evaluated Due