List the potential aetiology of a severely altered mental status in a 65-year-old man, 48 hours after major hepatic resection for hepatocellular carcinoma. Outline your management of this patient.
Mental state could be severely depressed or patient may be agitated or confused.
In general the potential aetiologies are the same, though some more likely in each type of state. Consider: decreased oxygen delivery to braiin (hypoxaemia, low cardiac output, low blood pressure), effects of drugs (those administered or those withdrawing from), intracerebral pathology (thromboembolism, rarely bleed eg. into undetected secondaries), electrolyte disorders (especially glucose, Na and Calcium), infections (unlikely; eg. systemic/meningitis/encephalitis), postoperative confusional state (uncertain but probably multifactorial aetiology), post-ictal or psychiatric disorder.
Management involves exclusion of reversible and specific treatable causes considered likely/possible (eg. SpO2, vital signs, glucose, electrolytes, review drugs and history). Appropriate treatment of any specific abnormalities detected. Protection of patient and staff with cautious use of restraint (chemical or physical) if absolutely necessary or specifically indicated.
Potential aetiology for a severely altered mental status post hepatic resection:
Specific management of hepatic encephalopathy
Management of the precipitating cause
Supportive management of the encephalopathic patient
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