What to do for a patient with a history of chronic pain, who has self-removed their Spinal Cord Stimulator (SCS) while delirious?

Management of Self-Removed Suprapubic Catheter (SPC) in Delirious Patient

Immediately assess and stabilize the patient's airway, breathing, and circulation, then address the underlying delirium through identification and treatment of reversible causes while simultaneously managing the urological complication from the removed catheter. 1

Immediate Stabilization and Assessment

• Check vital signs including oxygen saturation and provide supplemental oxygen only if the patient is hypoxic, as hypoxemia can worsen confusion 1
• Assess blood glucose immediately to rule out hypoglycemia as a reversible cause of delirium 1
• Monitor for fever as elevated temperature can worsen outcomes and may indicate infection 1
• Perform targeted neurological examination to identify focal deficits that might suggest stroke or other structural lesions 1

Address the Delirium First

Identify and Treat Reversible Causes

• Systematically review all medications, particularly benzodiazepines (the most strongly evidenced modifiable risk factor for delirium), anticholinergics, opioids, and sedative-hypnotics, and discontinue or reduce deliriogenic medications 2, 3
• Assess for and treat infection including urinary tract, respiratory, and CNS sources, as sepsis is a common precipitant of delirium 1, 3
• Correct metabolic disturbances including electrolyte abnormalities (particularly hyponatremia), dehydration, hypoxia, and elevated blood urea nitrogen 2, 3
• Ensure adequate hydration by encouraging oral intake or considering subcutaneous/intravenous fluids if necessary, taking into account comorbid conditions 2
• Assess for constipation as a complication of dehydration and treat appropriately 2
• Evaluate for alcohol or benzodiazepine withdrawal in at-risk patients, as these manifest as hyperactive delirium and require benzodiazepines as first-line treatment 2, 3

Non-Pharmacological Interventions (Implement Immediately)

• Provide environmental modifications including appropriate lighting, visible clocks and calendars (consider 24-hour clock), clear signage, and minimize sensory overload 2, 1
• Ensure continuity of care by avoiding unnecessary room changes and maintaining consistent caregivers familiar with the patient 2
• Facilitate regular family visits to help with reorientation and provide familiar presence 2, 1
• Implement cognitive stimulation through reorienting communication, explaining location and roles, and reminiscence activities 2

Pharmacological Management of Delirium (Only if Necessary)

• Reserve pharmacological interventions for patients with severe agitation posing safety risks, distressing perceptual disturbances (hallucinations), or when preventing essential medical care 2, 1
• Do NOT use haloperidol or risperidone for mild-to-moderate delirium as they have no demonstrable benefit and may worsen symptoms 1
• For severe hyperactive delirium with significant distress, use low-dose antipsychotics: haloperidol (0.5-2 mg IV initially), olanzapine, quetiapine, or risperidone, and discontinue immediately once distressful symptoms resolve 2, 4
• Avoid benzodiazepines as first-line agents except in alcohol or sedative withdrawal 2, 1
• Consider adding benzodiazepines (such as lorazepam) only for agitation refractory to high doses of neuroleptics, ensuring therapeutic levels of neuroleptics are present first 2

Manage the Urological Complication

Assess Catheter Tract Status

• Examine the suprapubic site for signs of infection, bleeding, or tract closure
• Determine how long the catheter has been out, as tracts can close rapidly (within hours in some cases)
• Assess bladder distension through physical examination and consider bladder ultrasound if available

Urological Management Options

• If the tract is still patent (typically within 4-6 hours of removal), attempt gentle reinsertion of a similar or smaller-sized catheter with appropriate lubrication
• If reinsertion is unsuccessful or the tract has closed, place a transurethral catheter immediately to ensure bladder drainage and prevent urinary retention
• Consult urology urgently if there is difficulty with catheter placement, signs of bladder injury, significant bleeding, or if the patient requires long-term suprapubic catheterization
• Monitor for complications including urinary retention, bladder perforation, peritonitis, or urosepsis

Optimize Pain Management

• Assess and optimize pain control as undertreated pain is independently associated with delirium, but preferentially use non-opioid analgesics (acetaminophen, gabapentin, NSAIDs if not contraindicated) to minimize opioid-related delirium risk 2
• If opioids are necessary, use the lowest effective dose and monitor closely for sedation and respiratory depression 2

Prevent Recurrence

• Implement fall and safety precautions to prevent further self-harm during confused states 1
• Consider physical presence of family member or sitter rather than physical restraints, which can worsen agitation 1
• Secure the replacement catheter with appropriate fixation devices to prevent repeat removal
• Continue multicomponent delirium prevention strategies including reorientation, mobilization when appropriate, and addressing all modifiable risk factors 2

Critical Pitfalls to Avoid

• Do not overlook medication side effects as potential causes of the delirium 1
• Do not use physical restraints as first-line management, as they worsen agitation and confusion 1
• Do not administer sedatives without addressing underlying causes of the delirium 1
• Do not delay urological assessment while managing delirium, as urinary retention can cause significant morbidity
• Do not assume bacteriuria requires treatment in delirious patients without fever or systemic signs of infection, as treating asymptomatic bacteriuria in delirium provides no benefit and increases harm from antibiotics 2