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Post-Surgical Delirium Management — MRCPsych Paper B MCQ

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ModerateLiaison PsychiatryPost-Surgical Delirium ManagementMRCPsych Paper B

A 60-year-old man on a coronary care unit develops fluctuating inattention, confusion, visual hallucinations and agitation 48 hours after cardiac surgery. CAM-ICU assessment supports a diagnosis of delirium. He has no focal neurological signs and no history of head trauma. His medications include morphine by patient-controlled analgesia, furosemide and amiodarone. According to NICE CG103, what is the most appropriate initial management priority?

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Correct answer: C — Identify and treat precipitants, alongside reorientation and verbal de-escalation

The correct answer is C. NICE recommends that initial management of diagnosed delirium should identify and treat the underlying cause or combination of causes, while providing reorientation, reassurance and an appropriate environment. Relevant postoperative precipitants include opioid effects, hypoxia, infection, electrolyte or other metabolic disturbance, uncontrolled pain, constipation and urinary retention. Haloperidol is not routine first-line treatment: it is considered only when the person remains distressed or poses a risk despite verbal and non-verbal de-escalation. It is especially unsuitable here because concomitant amiodarone creates a contraindicated QT-prolonging combination. Lorazepam may exacerbate non-withdrawal delirium. CT brain imaging is not routinely required without focal neurology, head trauma or another indication of intracranial pathology. Liaison psychiatry may assist, but investigation and treatment should not be deferred.

Reference: National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care (CG103), sections 1.6 and 1.7. Updated 2023. https://www.nice.org.uk/guidance/cg103/chapter/Recommendations