Postoperative delirium and treatment with Physostigmine

Abstract

Postoperative delirium (POD) is a postsurgical complication that disproportionately affects older individuals and can be complex in its clinical presentation. The etiology of POD is often multifactorial, making diagnosis, consistent terminology usage, and treatment challenging. A 65-year-old man presented for a left carotid endarterectomy (CEA). His postoperative course was complicated by an episode of POD secondary to central anticholinergic syndrome (CAS), benzodiazepine use, underlying patient risk factors, or a combination of these potentially compounding variables. His medical history included an 80 to 90% occlusion of the left carotid artery, multiple transient ischemic attacks, hypertension, hyperlipidemia, depression, vertigo, anxiety, and 50 pack per year smoking history. After general anesthesia with desflurane, N2O, and endotracheal tube placement, the patient aroused combative, agitated, and delirious. He was treated with propofol 30 mg intravenously (IV), but his symptoms did not improve. He became increasingly agitated in the post-anesthesia care unit (PACU). He was treated with propofol 20 mg and midazolam 2 mg IV but remained combative and confused. Two doses of physostigmine 0.5 mg IV were administered, resulting in resolution of his symptoms. He was admitted to the intensive care unit for observation and was discharged the following morning without additional complications.