Postoperative Delirium

Massachusetts General Hospital, Department of Psychiatry, Warren 615, 55 Fruit St., Boston, MA 02114, USA.
American Journal of Psychiatry (Impact Factor: 12.3). 08/2008; 165(7):803-12. DOI: 10.1176/appi.ajp.2008.08020181
Source: PubMed


Mr. A, a 50-year-old English-speaking Korean man, presented to the hospital with right scapular pain. CT of the chest showed two masses, and a CT-guided fine-needle aspiration biopsy study revealed poorly differentiated non-small-cell carcinoma of the lung. MRI of the brain, with and without gadolinium, showed neither a mass lesion nor abnormal enhancement suggestive of metastatic disease. Mr. A's medical history was significant for hepatitis C virus infection. He had a 40-pack-year history of cigarette smoking and a remote history of cocaine use. He acknowledged drinking three or four alcoholic beverages weekly but answered "no" to the four items of the CAGE questionnaire. Mr. A underwent two cycles of etoposide and cisplatin 50/50 chemotherapy, irradiation of the upper lobe of the right lung, and excision of this lobe and the overlying chest wall. Postoperatively, he was aware of his hospitalization and experienced pain at the excision site, which was controlled with fentanyl and bupivacaine epidural infusion. On the second postoperative day, Mr. A became less communicative and more agitated. Epidural infusions were stopped. No focal neurological deficits were found. That evening, he began to cry out unintelligibly and attempted to get out of bed. Soft restraints were applied. Because he was thought to be in alcohol withdrawal, lorazepam was administered intravenously in 1 mg doses every 2 hours (total 4 mg), with no reduction in agitation. Haloperidol (5 mg i.v.) was then administered with slight effect, and psychiatric consultation was requested. Mr. A's temperature was 100 F, pulse 135 bpm, and blood pressure 160/90 mm Hg. He was awake and moved all limbs vigorously, trying to wrest himself from the restraints. Although he attempted to respond when addressed in his native Korean, he produced no intelligible speech. He did not appear to be responding to internal stimuli. Rigidity, tremor, myoclonus, and asterixis were absent. ECG revealed sinus tachycardia with a corrected QT interval (QTc) of 413 msec. The patient's WBC count was 5300/mu l, hemoglobin concentration 6.6 g/dl, hematocrit 18.7%, and mean corpuscular volume (MCV) 94 fl. His transaminase and bilirubin levels were normal. His sodium concentration was 134 mmol/liter, potassium 3.8 mmol/liter, chloride 101 mmol/liter, bicarbonate 27.4 mmol/liter, BUN 27 mg/dl, creatinine 0.6 mg/dl, glucose 126 mg/dl, magnesium 1.4 meq/liter, and albumin 4.0 g/dl. Arterial blood analysis revealed a pH of 7.42, a Po(2) of 185 mm Hg, and a PCo(2) of 44 mm Hg on oxygen delivered at 4 liters/minute by nasal prong. The patient's blood alcohol level on admission was 0. Potassium and magnesium were administered intravenously. Haloperidol was administered intravenously in two 5-mg boluses, separated by 30 minutes, and the patient fell asleep. When roused, he was calm but disoriented and unable to answer questions accurately. His heart rate fell to 90 bpm and his systolic blood pressure decreased to 130 mm Hg. The patient was judged not to be in alcohol withdrawal, and lorazepam was tapered gradually over the next 48 hours. Chest X-ray and urinalysis were normal, and blood cultures were sterile. Over the next 24 hours, the patient received a total of 30 mg of haloperidol intravenously in 5-mg boluses, and his mental status markedly improved. He answered questions, followed instructions, and no longer attempted to climb out of bed or remove catheters and monitoring devices. In the subsequent days, he engaged in meaningful conversations. Sensorium, attention, memory, and thought process normalized by postoperative day 5. At discharge, his hematocrit was at 25%. He returned home on postoperative day 8 and has continued with cancer treatment.

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