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Dr. Andrew Rynne

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Suggest treatment for delirium and pain from an underlying etiology

Answered by
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Dr. Panagiotis Zografakis

Internal Medicine Specialist

Practicing since :1999

Answered : 3597 Questions

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Posted on Sat, 31 Oct 2015 in Medicines and Side Effects
Question: If an elderly hospital patient is suffering from delirium and is in pain from an underlying aetiology (possibly, but not confirmed, sepsis) and has been administered Lasix (frusemide), O2, normal saline, and antibiotics (cephalothin and metronidazole) but has now become terminal then could the continuation of the "treatment" without the objective of saving the patient's life cause an alleviation of the symptoms of either the pain or delirium if neither analgesia nor antipsychotics are additionally administered to the patient?
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Answered by Dr. Panagiotis Zografakis 14 minutes later
Brief Answer:
a cause has to be established

Detailed Answer:
Hello,

I haven't quite understood the reason this patient has been considered as 'terminal', since there is no diagnosis yet! Delirium can be caused by various conditions in an old individual, including infections, electrolyte disorders, tumors, etc. The underlying cause should be sought and treated.

I can't say whether the symptoms of pain and delirium would be alleviated without knowing their cause! And I can't understand the reason that antipsychotics and painkillers have not been administered.

Can you please further explain the situation? Perhaps you can provide some test reports/results or any kind of relevant clinical information.

Kind Regards!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Panagiotis Zografakis 14 hours later
Thank you Dr. Zografakis. A few days ago the patient became delirius and reported being in pain. He strongly satisfied the conditions for suspected severe sepsis. Blood cultures were taken but the results are not back as yet. A chest Xray indicates that he may also have hypostatic pneumonia. He also has CCF and has had low BP for a few day. A doctor who examined him at the time that I sent my email simply said that on the basis of his examination and the continued deterioration over the last 2 days that the patient is now terminal. His sodium level is now 157 mmol/L, WCC is 13.9X10^9/L, CRP is 162.0 mg/L. His pulse rate is 90 and his O2 saturation is 96-98% on 02 (he has been diagnosed with hypoxia). The result of a rectal examination and bladder scan are fine, and a CT scan of his brain 2 days go indicated nothing was amiss. His 02 input has now been increased. He was given PRN haloperidol for delirium yesterday but exceeded the prescribed amount. Perhaps the doctor does not want to administer any more of it for that reason. But this does not make sense to me because the doctor says the patient is terminal. He was on PRN hydromorphone for pain yesterday but did not exceed the prescribed amount. So I am at a loss as to why he cannot have more hydromorphoine for pain. I simply cannot understand how the current "treatment" could alleviate the symptoms of pain and delirium.
doctor
Answered by Dr. Panagiotis Zografakis 14 minutes later
Brief Answer:
treatment is indicated

Detailed Answer:
You're welcome!

So the patient has a severe infection, hypernatremia (which means dehydration), a good oxygen saturation (despite having to use supplemental oxygen) and being treated for pain of unknown (?) origin.

I do not have all the clinical data obviously but for a patient like that I would have done the following:
- administer antibiotics for the infection and seek the pathogen with cultures. There are empirical treatments for pneumonia depending on whether it has initiated in the community or in the hospital.
- treat dehydration with a combination of intravenous fluid administration and diuresis. Urine production and fluid administration have to be careful balanced.
- if fluid administration is not enough to restore his blood pressure (and renal function) to near normal then vasopressors might have to be employed (perhaps in the ICU).
- Treat the symptoms: where does this pain originate from? What causes it? Aggression and confusion can be treated with haloperidol or similar drugs and the pain can be treated with paracetamol (or more potent drugs if needed, like opioids for example). Perhaps improving the hydration status of the patient, will improve his mental status.

I still can't understand why this patient has been considered as terminal. I know he's old and he's having a severe condition but I've seen many patients like him recover with proper treatment. Of course his doctors have the complete picture of his condition. I'm only talking about the data I have right now...

I hope you find my comments helpful!
You can contact me again, if you'd like any clarification or further information.

Kind Regards!
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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