Critically unwell surgical patient Flashcards
What does 2 or more of these symptoms indicate?
- Temp >38°C (100.4°F) or < 36°C (96.8°F)
- Heart Rate > 90
- Respiratory Rate > 20 or PaCO2 < 32 mm Hg
- WBC > 12,000/mm3, < 4,000/mm3
SIRS
systemic inflammatory response syndrome
(a cause of shock e.g. acute circulatory failure with inadequate tissue perfusion causing cellular hypoxia)
What is sepsis?
SIRS (systemic inflammatory response syndrome) + source of infection
What does this describe?
- organ dysfunction, hypotension, or hypoperfusion.
- Lactic Acidosis,
- SBP <90 or SBP Drop ≥ 40 mm Hg of normal
Severe sepsis
What is septic shock?
Septic shock = severe sepsis with hypotension, despite adequate fluid resuscitation
rememebring sepsis = SIRS (systemic inflammaotry response syndrome) + source of infection
What is multiple organ dysfunction syndrome?
evidence of >2 organs failing
What is the sepsis 6?
Rx for sepsis?
Take: Abg (lactate), cultures, UO
Give: oxygen, fluid challenge, abx
best guess abx –> @sgul = co-amoxiclav & gentamicin
- Change therapy based on cultures
- Physiotherapy
- ITU
- Surgery
- Interventional radiology
What is the equation for BP?
BP = CO x TPR [HR x SV (CO) x TPR}
What causes of hypotension are there?
- Hypovolaemia
- cardiogenic
- obstructive
- vasodilatory state
What cause of hypotension are these?
- PE
- Tamponade
- Tension pneumothorax
Obstructive hypotension
What causes of hypotension are these?
- Blood loss
- Plasma loss
- Saline loss
- Dehydration
Hypovolaemia
CO x TPR [HR x SV x TPR]
What causes of hypotension are these?
- MyocardiaI infarction
- Cardiac failure
- Myocardial contusion
- Arrhythmia
Cardiogenic
BP =CO x TPR [HR x SV x TPR] e.g. cardiogenic = decreased CO
What causes of hypotension are these?
- Sepsis
- Neurogenic
- Trauma & transection of spinal cord
- Epidural
- Anaphylaxis
- Adrenal insufficiency (LT steroids)
Vasodilatory state
e.g. BP: CO x TPR [HR x SV x TPR]
What can happens if you have hypotension in the body?
HYPOTENSION + HYPOXAEMIA = ARREST
:(
What should be given in these circumstances?
- Poor UO - 10ml/kg
- Low BP - 20ml/kg
- HF & poor UO - 5ml/kg
= Fluid challenge!
- Poor UO - 10ml/kg
- Low BP - 20ml/kg
- HF & poor UO - 5ml/kg
What happens to the bodys fluid in surgery?
Surgical insult and metabolic stress –> RAAS activated –> Na retention
BUT surgery also involved many losses of fluid –> NG aspirates, ileostomy & fistula outputs, diarrhoea, ileus, sweat
What should be done with fluid balance pre-, intra- and post- op?
Pre-op =
encourage oral fluids until 2hrs before,
6 hrs for foods
IV fluids if required e.g. mechanical bowel prep as this dehydrates
Intra-op =
monitored closely
post-op =
oral fluids, IV fluids should be Na poor (as RAAS system retaining Na is activated by surgical insult)
What should you replace lost blood with in massive haemorrhage?
simply replace with blood if bleeding (want the clotting factors and oxygenation capacity or RBC)
crystallois = saline w/K+ or hartmanns
rarely colloid (though in GI bleed can use colloid? according to grey book emergencies)
What can these conditions all cause?
- Cardiac – arrhythmias, MI, pericarditis, contusion
- Circulatory – shock, PE
- Inflammation / infection
- Metabolic – acidosis
- Haematological – anaemia
- Endocrine – Thyrotoxicosis
- Drugs – Aminophylline, digitalis toxicity, beta agonists
- Anxiety and pain
Tachycardia!
What can these conditions all cause?
- Hypovolaemia
- Sepsis
- Nephrotoxic drugs
Poor urine output!
What can these conditions all cause?
- Surgery
- Wind: Atelectasis, pneumonia
- Wound: infection
- Water: urine infection
- Walking: DVT/PE (3-4days post-op)
- Wonder drugs: blood transfusion reaction, malignant hyperpyrexia (reaction to anaesthetic
Fever!
What can these conditions all cause?
- Usually AB or C
- Exclude hypoglycaemia, narcotic OD & sepsis
- Alcohol? (day 3-4 post-op - get collateral history)
Confusion!
What conditions can cause tachycardia?
- Cardiac – arrhythmias, MI, pericarditis, contusion
- Circulatory – shock, PE
- Inflammation / infection
- Metabolic – acidosis
- Haematological – anaemia
- Endocrine – Thyrotoxicosis
- Drugs – Aminophylline, digitalis toxicity, beta agonists
- Anxiety and pain
What conditions can cause poor urine output?
- Hypovolaemia
- Sepsis
- Nephrotoxic drugs
What conditions can cause fever?
- Surgery (aka surgery ITSELF can cause fever)
- Wind: Atelectasis, pneumonia
- Wound: infection
- Water: urine infection
- Walking: DVT/PE (3-4days post-op)
- Wonder drugs: blood transfusion reaction, malignant hyperpyrexia (reaction to anaesthetic
