Management of Post-nephrectomy Delirium in Patients with Traumatic Renal Rupture: A Case Report

Abstract


Introduction
Postoperative delirium (POD) is the most common surgical complication in older adults, occurring in 15 % to 25 % of patients following elective major surgery [1]. Besides, POD is a dramatic change in mental status that affects more than 7 million hospitalized patients in the U.S each year and also increases the probability that a patient will be hospitalized for 30 days after discharge [2]. There are few reports about postoperative delirium after nephrectomy for traumatic renal rupture. This case study discusses the case of traumatic renal rupture and reviews the literature. Therefore, after obtaining the patient's authorization and consent, we publish his clinical data to provide a reference for medical workers.

Case presentation Patient Chief Complaint and Past History
A 66-year-old male who fell from a boat 3 hours ago ruptured his kidney, with a history of diabetes, no history of hypertension, coronary heart disease, chronic obstructive pulmonary disease, asthma, and no history of drug and food allergies.

Physical Examination
The patient was conscious when he was admitted to the hospital. The skin on the left waist is local redness and swelling with tenderness.
Catheterization showed that red urine flowed from the urinary catheter, about 200 ml.

Abstract Background
Postoperative delirium is a typical impairment in cognition, especially for those older patients who suffered from surgery, characterized by an acute change in confusion and inattention. Due to the lack of reliable predictive markers of postoperative delirium, The onset time of postoperative delirium is unpredictable, and the treatment of postoperative delirium is brutal.

Case presentation
The case is of a 65-years-older man with kidney rupture, multiple fractures of the ninth rib, and diabetes suffered from nephrectomy and gastrointestinal decompression. Then he developed delirium 59 hours after surgery. By treating them with benzodiazepines (midazolam + diazepam) actively and so on, he recovered well and was discharged from the hospital.

Conclusion
A combination medication strategy of midazolam and diazepam effectively treated postoperative delirium after nephrectomy due to traumatic renal rupture. Besides medication, our case highlights the importance of care and psychological guidance in postoperative delirium.

Accessory Examination
An abdominal CT scan showed the left kidney rupture and the left ninth rib fracture.

Healing Process
The patient was admitted to the hospital for a left-sided nephrectomy and was given blood transfusions during the operation. The patient developed delirium 59 hours after the procedure and regained consciousness 127 hours after the operation. During the POD process, the patient returned to a conscious state after changing quiet wards, proper restraint, adjusting sleep time, and drug sedation.

Diagnostic Assessment
The laboratory test results when the patient was in the initial and final stage of POD are shown in Table 1.
The result of the MRI of the brain when the patient is in the state of POD is shown in Figure 1.

The Detection Method of POD
The confusion assessment method (CAM) was used to detect patients with POD [3].

Interventions and Follow-Up
The doctor told the patient that if he felt unwell after being discharged from the hospital, he should return to the hospital immediately for further treatment. At the 6-month follow-up, the patient recovered well.

Discussion
POD is a common medical problem treated as a complication due to unrecognized, misdiagnosed, and undertreated by doctors or nurses [4].
Therefore, it was essential to identify and assess risk factors early in the treatment of POD.
There were risk factors associated with POD, such as levels of Therefore, care should be the main agenda for POD in further research.
Most nurses and doctors in China considered delirium a severe problem, but their cognition of rage was lacking [11]. In Germany, although nurses believed POD and related problems were highly correlated, doctors seem to have limited knowledge of these conditions Finally, it has been controversial whether antipsychotic treatment is effective for delirium. There was rare evidence to support the use of antipsychotics for agitation, and anesthesia guidelines recommend avoiding benzodiazepines in older patients [17,18]. However, in our report, a patient with POD was successfully cured with midazolam, and there was no postoperative cognitive decline in the patient at the 6month follow-up. In the case of excluding individual differences, it is necessary to research the safety and reliability of midazolam in elderly patients with POD.

Conclusion
Our case reports are unique and informative. We need more evidence to support using any single biomarker as POD's sole risk or disease marker.
Besides, we need more evidence to support the evidence that POD is more likely to occur in patients with only one kidney due to the poor metabolism of anesthetics. Therefore, we should pay attention to the role of care in POD patients. The effectiveness of drug therapy for POD is a difficult question, and more studies are needed to confirm the reliability of the results.