Agitation and prescribing pressure on a medical ward
A 68-year-old man is day 3 post-hemicolectomy. He has a history of alcohol dependence (about 80 g/day for 20 years, last drink 5 days ago) and bipolar I disorder on lithium 900 mg nocte. Overnight he is restless, tremulous, diaphoretic, pulse 118, BP 168/94, temperature 37.9 C, and pulls at his IV and nasogastric tube. He is oriented to person only and says he sees 'rats on the ceiling'. The surgical registrar wants 'a sedative, quick, so he doesn't pull his lines out'. Serum lithium is 0.62 mmol/L, creatinine 130 micromol/L (baseline 95), sodium 133, ALT mildly elevated, CK 600. The ward has a 1:4 nursing ratio and no high-dependency bed is available tonight.
1. What is the differential diagnosis and what would you do in the next two hours?
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This is a delirium until proven otherwise, on a background of alcohol withdrawal and lithium therapy. The differential is (1) alcohol withdrawal delirium/DTs, supported by the 5-day abstinence, tremor, diaphoresis, autonomic activation and visual hallucinations; (2) delirium from postoperative causes - sepsis, hypovolaemia, opioid or anticholinergic load, hypoxia, urinary retention, faecal impaction; (3) lithium toxicity, though the level is only 0.62 mmol/L and rising creatinine suggests volume depletion and reduced clearance rather than gross toxicity; (4) hypoactive/other encephalopathy including hepatic or Wernicke's.
Next two hours: ABC, oxygen saturation, capillary glucose, repeat observations with a sedation score, bladder scan, ECG, septic screen (blood cultures, urine, wound, chest), VBG, and correction of volume depletion with careful saline. Give parenteral thiamine before any glucose. Hold lithium until renal function and volume status are re-assessed, and stop any deliriogenic drugs (opioids, anticholinergics, antihistamines). Use a validated withdrawal scale (CIWA-Ar) to guide symptom-triggered benzodiazepines - in a postoperative elderly patient with hepatic impairment, small doses of a short-acting agent such as lorazepam, with monitoring, are safer than large loading doses. Non-pharmacological measures (reorientation, glasses, hearing aids, family presence, one-to-one nursing, avoiding restraints) are first-line and must be documented. Antipsychotics are not first-line for withdrawal and risk QT prolongation and further confusion; if agitation endangers lines despite the above, use the lowest dose of a short-acting agent with ECG monitoring and clear review times. Escalate for higher-level nursing or medical review rather than accepting a 1:4 ratio for a delirious patient.
2. How would you respond to the registrar's request for a 'quick sedative'?
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Acknowledge the clinical pressure - a pulling patient is a genuine safety risk - then reframe the request. Sedation treats the symptom and masks the cause; it also increases aspiration, falls, and prolongs delirium. Explain that the priority is to identify and treat the precipitant, and that the safest pharmacological route here is symptom-triggered benzodiazepine for withdrawal, with thiamine and volume repletion, plus environmental measures. Offer a concrete plan the team can enact tonight: a written observation and escalation protocol, a named nurse, a review time, and clear criteria for calling psychiatry or ICU. Document the discussion and the rationale for not simply sedating. If the team remains concerned, escalate to the consultant surgeon and the after-hours hospital coordinator to secure adequate nursing; this is an organisational as well as clinical problem. Avoid colluding with a request that would be defensible only if less restrictive measures had failed and been documented.