Delirium tremens in head and neck surgery

Because of the high incidence of alcoholism in patients with cancer of the laryngopharynx and oral cavity, alcoholic withdrawal syndromes are a frequent postoperative complication in head and neck surgery. Delirium tremens, the most severe form of alcohol withdrawal, is characterized by a progressive symptom complex: anxiety, irritability, confusion, nausea, tremors, hallucinations, hyperpyrexia, convulsions, and delirium. It usually develops 48‐72 hours after the abrupt cessation of prolonged heavy alcoholic drinking but it may occur up to 10 days later. Delirium tremens usually persists for two or three days but there is considerable individual variation in the severity and the intensity of the reaction. Delirium tremens is caused by a rapidly falling blood alcohol level but the exact pathophysiological mechanism is unknown. Numerous theories have been proposed. Walder, et al., feel that one of the breakdown products of ethanol, possibly acetaldehyde, is the cause based on recent hemodialysis studies. Mays, et al., feel that an elevated serum free fatty acid level is causative. Albumin usually binds the fatty acids but when the albumin levels are low, the fatty acids circulate freely and are cytotoxic. In head and neck surgery, delirium tremens usually occurs in the postoperative period. An early diagnosis is difficult because the symptoms usually begin subtly on the second to fourth postsurgical day with agitation and confusion. Twenty‐four hours later when hallucinations, convulsions and delirium occur, the diagnosis is self‐evident. Except for hemodialysis therapy which is complex and not universally available, the treatment of delirium tremens is largely symptomatic and supportive but should begin promptly to minimize or prevent the later more severe symptoms. Paraldehyde and the psychotropic drugs such as chlordiazepoxide (librium) and diazepan (valium) are the most commonly used sedatives. The use of intravenous alcohol is contraindicated because of its short duration of action and narrow margin of safety. Maintaining proper fluid and electrolyte balance is most important. Since some alcoholic patients are dehydrated and some over‐hydrated, the usual parameters and indices for fluid and electrolyte replacement must be closely observed. Restraints, urinary catheters and close observation for lung, liver and gastrointestinal complications are necessary. The irrational, hallucinating, combative and delirious patient is difficult to manage in the postoperative period and is prone to many complications. Needles, feeding tubes, drainage tubes, tracheotomy tubes, wounds, dressings and skin flaps may be molested or removed. Optimum body positioning is impossible. Tracheal aspirations are increased and pneumonitis is likely. Sudden death from fatty emboli is possible. The mortality rate for delirium tremens is approximately 10 percent and when a complicating medical or surgical problem co‐exists, the mortality rate increases to 25 percent. Several case reports are presented to illustrate that delirium tremens in the postoperative period is not only a serious threat to the patient but a difficult challenge for the physician. In order to minimize the high postoperative morbidity and mortality of delirium tremens, the head and neck surgeon should be suspicious of the alcoholic patient, recognize the high risk patient, delay surgery when necessary and begin withdrawal therapy promptly.