Care of the surgical patient II Flashcards
early warning scores (EWS)
help with ‘flagging up’ patients for urgent medical assessment and monitoring response to treatment.
which aprameters does NEWS look at
- respiration rate
- oxygen saturation
- systolic blood pressure
- pulse rate
- level of consciousness or new confusion (AVPU)
- temperature.
reaction to EWS
- low score – increased frequency of observations and nurse in charge notified;
- medium score –urgent call to patient’s primary medical team;
- high score – emergency call to medical emergency team/critical care outreach team.
define sepsis
life threatening organ dysfunction due to dysregulated host reponse to infection
septic shock
sepsis with hypotension, despite adequate fluid resuscitation or requiring the use of inotropic agents to maintain a normal systolic blood pressure.
lactate >2
Management usually involves aggressive fluid resuscitation and antibiotic therapy, with the likely involvement of the critical care team. Inotropes are often used to maintain organ perfusion.
screening tools for sepsis
SOFA and qSOFA
qSOFA parameters
RR >22
BP <100mmHg systolic
altered mental state
red flags for sepsis
sources of ifnection for sepsis
- Urine dip +/- culture
- Chest X-ray (CXR)
- Swabs (e.g. surgical wounds)
- Operative site assessment (via CT or US imaging)
- Cerebrospinal fluid sample (via LP)
- Stool culture
Sepsis on surgical wars
The common sources of pyrexia in a surgical patient can be remembered using the Seven C’s:
- Chest (infection)
- Cut (wound infection)
- Catheter (UTI)
- Collections (abdomen, pelvic etc.)
- Calves (DVT)
- Cannula (infection, if applicable)
- Central line (infection, if applicable)
manageemnt of sepsis
sepsis 6
BUFALO
B- blood culture
U- urine output
F- give fluids
A- antibiotics (IV)
L- measure lactate
O- oxygen
when to escalate management in a sepsis patient
- Evidence of septic shock
- Lactate > 4.0mmol
- Failure to improve from initial management
where to get ABG from
- Can use arterial lines
- Or take blood from the radial artery
types of respiratory failure
- Low PaO2 indicates hypoxia and respiratory failure
- Type 1- Normal pCO2 with low PaO2
- Type 2 -Raised pCO2 with low PaO2
reading ABG
- Look at PaO2- is the patient hypoxic
- Look at the pH (acid-base balance)
- Is the cause respiratory or metabolic?
Look at PaO2- is the patient hypoxic
- PaO2- amount of O2 dissolved in blood
- Check FiO2 (fraction of inhaled oxygen)
- Room air has a FiO2 of 21%
- Venturi masks used to control FiO2
Look at the pH (acid-base balance)
- Low- acidic
- High- alkalotic
causes of respiratory acidosis
Raised PaCO2- suggests patient is retaining CO2
- COPD (blue bloater)
- life threatening asthma attack (tired)
causes of respiratory alkalosis
- Low PaCO2- blowing off CO2 (hyperventilation- i.e anxiety)
causes of metabolic acidosis
Low pH due to low bicarbonate
- Raised lactate (tissue hypoxia e.g. sepsis)
- Raised ketones
- Raised H+
- Reduced bicarbonate
- diarrhoea, renal failure or type 2 renal tubular acidosis
methods of quantifying pain
two main sensory pathways (ascending)
dorsal column-medial leminscus system
spinothalamic system
outline the dorsal column-medial lemniscus system
e.g. detecting vibration in a lumbar dermatome
- Receptor in lumbar dermatome communicates with first order sensory neurone (cell body in dorsal root ganglion) and projects into the spinal cord
- First order neurone ascends up the SC to the medulla of the spinal cord, where it synapses onto a second order neurone
- Second order neurone decussates (cross the midline) and ascends all the way up to the thalamus and synapses onto third order neurone
- Medial lemniscus- pathway connecting the gracile and cuneate nuclei with the thalamus
- Third order neurone projects to the sensory cortex
- Lumbar region of the somatosensory cortex found medially
outline the spinothalamic system
e.g. detecting pain in the lumbar region
- Receptor in lumbar dermatome connects to first order neurone
- Synapses with second order neurone at approx. the level it enters (dorsal horn)
- Second order neurone decussates (crosses midline) and ascends up the cord (spinothalamic tract) into the brainstem and into the thalamus
- In the thalamus the second order neurone synapses with third order neurone which projects to the medial part of the primary sensory cortex (lower body)
e.g. detecting pain in the cervical region
- Receptor in cervical dermatome connects to first order neurone
- Synapses with second order neurone at approx. the level it enters (DH)
- Second order neurone decussates (crosses midline) and ascends up the cord (spinothalamic tract) into the brainstem and into the thalamus
- In the thalamus the second order neurone synapses with third order neurone which projects to the lateral part of the primary sensory cortex (upper body)
NSAIDS
action: analgesic and anti-inflammatory
MOA: COX- inhibitors, reducing prostaglandins, prostacyclins and thromboxane synthesis (which is good and bad)
