Venous access must be established immediately. The older and
larger patient with aggressive delirium is a particular risk to
care providers, and restraint and sedation may be necessary to protect
staff. A central venous catheter is useful for assessment of central
venous pressure and maintenance of volume status and euglycemia
(targeting serum glucose levels between 110 and 130 mg/dL).
Serial surveillance of electrolyte concentrations, body weight,
and strictly maintained records of intake and urinary output are
needed to evaluate fluid status and guide fluid requirements, which
may be in the range of 85% to 100% of maintenance
fluids. Close attention to the onset of renal dysfunction is warranted,
as overzealous use of diuretics, (used to treat edema or ascites),
or the use of nephrotoxic antibodies may be potential precipitants
of dehydration, acute tubular necrosis, or functional renal failure (hepatorenal
syndrome). Hypotension should be treated promptly. The use of “renal
doses” of dopamine may help to maintain renal perfusion. When
urine output decreases to less than 1.0 mL/kg/hour,
it may become impossible to maintain fluid balance, and consideration
should be given to begin renal supportive therapy, such as continuous
venovenous hemofiltration.
A nasogastric tube may be passed electively in the patient with
altered mental status and a poor gag reflex, and used for regular
gentle saline lavage to detect upper gastrointestinal hemorrhage.
Placement to gravity is helpful to avoid the gastric mucosal lesions
associated with intermittent suction. Gastric pH is maintained above 4.0
with intravenous proton pump inhibitor agents (eg, pantoprazole 1
to 1.5 mg/kg/day IV daily) or an H2 receptor
antagonist to prevent gastrointestinal bleeding.