Altered Mental Status: A Tough - but Temporary - Hit

Steve had a rough two weeks. After a period of struggles with high arterial pressures on Home Dialysis, we suspected that his right upper arm fistula had become stenosed or narrowed. A fistulogram confirmed this, and Steve had an angioplasty to open the narrowed portions.

Access had become particularly critical, as we had learned that both internal jugular veins were narrowed and could not admit temporary central lines!

For this reason, Steve went on to have vein mapping - and the first of the two-part surgery to "install" a new fistula in the left upper arm. But a day or two later, his left hand was cool, numb, and pale - and his movement was impared.

The new fistula was "stealing" blood from the hand downstream, so Steve underwent a bypass graft to re-vascularize the hand - while still maintaining the new fistula.

All in all, there were three surgical procedures in eight days - with sedatives and narcotics for pain control. I had observed before that it seems to take a while for Steve to "clear" such necessary medications. For a day or two, he would be a bit "loopy" - not always tracking clearly, and sometimes frankly bizarre in his thought processes.

This time, the altered mental status persisted longer: for a period of about a week. When it didn't clear, I worried that we might be missing something - he had been mentally "off" when septic earlier in the year. Perhaps he was underdialyzed - repeating the uremic encephalopathy that had terrified me when he was first diagnosed with Acute Renal Failure in 2007. The ER labs confirmed that dialysis was on track, and a head CT confirmed that Steve had not had a stroke.

This afternoon, while discussing the intricacies of Philly Cheese Steaks with one of the nurses, it was clear that Steve was starting to surface. A little beat up, perhaps, but coming back.

Of all the variations we've witnessed in this journey, Altered Mental Status has been the most frightening. We are enormously relieved that this seems to have been temporary - probably the cummulative effect of medications over a relatively short time.

Tonight, I am relieved to have Steve back.
Take care. Linda Gromko, MD