Foundation Flashcards
what maintenance fluids would you presecribe for a NPO patient?
a typical 3L combination includes 1L Hartmanns or normal saline + 2L 5% dextrose + KCl acc to patient bloods
choose Hartmanns if hypoNa, NS if hyperNa
if K+ normal levels = 20 mmol divided across the 3L
how to measure a patient’s hydration status
clinical signs of dehydration (least sensitive)
dry mucous membranes
reduced skin turgor
increased capillary refill time
vitals
HR – increased HR
BP – reduced BP
urinary output (most sensitive)
>30ml/hr or >0.5ml/kg/hr = adequate
10-30ml/hr = oliguria
<10ml/hr = anuria
what are the 5 Rs of prescribing fluids
resuscitation
routine maintenance
replacement
redistribution
reassessment
classification of hypovolaemic shock
acc to American College of Surgeons
class I = loss up to 750ml blood
HR >100
BP normal
class II = 750-1500ml
BP still normal
pulse P narrowed
cap refill time 2-3s
RR increased 20-30
urine output reduced 20-30ml/hr
class III shock = 1500-2000 ml
HR >120
BP reduced
class IV shock = >2000ml
HR >140
BP sig reduced <100
cap refill >5s
RR >40
urine output negligible
what are the normal daily fluid and electrolyte requirements?
H2O: 30ml/kg/day or 1500ml + 20ml/kg
Na & Cl: 1-2 mmol/kg/day
K: 0.5-1.0 mmol/kg/day
how to choose fluid for fluid replacement
acc to type of fluid loss
Extracellular fluid loss —- eg. diarrhoea, vomiting, burns, stomas = give smthg similar to plasma (ie Hartmanns)
classic dehydration = normal maintenance fluids (ie Dextrose-saline)
blood loss = blood
how do you measure nutritional status?
recent weight loss
clinical exam — mid upper arm circumference, triceps skin fold thickness, grip strength
CT scan — level of L4, muscle mass + fat free mass + fat mass
serum albumin
MUST Malnutrition Universal Screening Tool score
acc to BMI, weight 3 months ago + acute disease effect
what are the types of nutritional support
enteral nutrition — given via NG/NJ tube, or if unsafe swallow = gastrostomy or jejustomy
parenteral nutrition — if oral NG or NJ not possible eg. bowel resection
via CVC central venous catheter (more common)
or peripheral — via large diameter venous catheter
complications + monitoring for TPN
complications
hyperglycaemia
serum electrolyte abnormalities
line sepsis
liver disease — eventually will get fatty liver & liver failure
refeeding syndrome
monitoring
daily glucose + U&E until established
twice wkly LFTs (monitor for liver failure)
wkly Cu + Mg + PO4 + Manganese
nutritional needs of a person
caloric needs for catabolic patient = 25-30 kcal/kg/day
protein = 1g/kg/day
post-op fever DDx + Tx
DDx — 5Ws
if 1st few hrs = ?normal systemic response to surgical trauma
Wind — pneumonia, atelectasis
Water — UTI or line infection
Wound – surgical site infection
anastomotic leak
walk — DVT, PE
wounder drugs — drug/antibiotic fever, transfusion reaction
Tx
Hx & Exam – to see which is most likely + take the timeline into consideration
1st day post-op = atelectasis most likely
presentation: rattling cough or trapped mucus
Tx
chest physiotherapy (24 hr on call)
analgesia
supplementary O2
incentive spirometry
also could be anastomotic leak
but if >5 days = ?surgical site infection
check EWS to see if ?sepsis – if need be sepsis 6
approach + Tx of post-op PE
Case: patient is day 4 post-op
O/E: tachycardic, desaturating, pleuritic chest pain
approach
my impression = most likely PE
but other DDx incl = pneumonia, atelectasis, pneumothorax, MI
ABCDEs
supplementary O2 – esp since desaturating
check for PMH of COPD
decide acc to severity – ideally 4L via nasal prongs (can take Hx)
focused Hx
when started
when was surgery, what surgery
on VTE prophylaxis
any lower limb pain swelling
exam
signs of consolidation
signs of DVT – red unilateral swollen lower limb
check notes + kardex
any COPD, anticoagulation
pre-existing pneumonia
PMH IHD and interventions
order Ix
bedside
ECG – ?right heart strain, r/o MI
ABG — since desaturating
bloods
FBC
CRP
U&E
troponin
d-dimers (but likely raised since post-op)
coag profile
imaging
venous duplex US — ?DVT
CXR — r/o pneumonia, pneumothorax
CTPA (gold std) — as long as clear CXR + no contrast allergy, ESRD
modified well’s score — decide if PE likely or unlikely
Tx
acute Tx
ABCDs — alr done
if haemodynamically stable = apixaban/rivaroxaban
if cancer or ESRD = LMWH + warfarin or LMWH + dabigatran
if warfarin = start both LMWH & warfarin together — once INR 2-3 can stop LMWH
if haemodynamically unstable = UFH +/- thrombolysis
if C/I to anticoagulation = pulmonary embolectomy or IVC filter
monitor vitals — esp if giving thrombolysis
long term: inpatient vs outpatient acc to PESI score (pulmonary embolism severity index)
what do you think of anticoagulation post-op
balance between risk of clotting and bleeding from the anticoagulation
if clotting = PE is potentially life threatening
bleeding is also potentially life threatening —- risk of complications + potentially re-intervention
if it is day 3/4 post-op — usually anticoagulation would be beneficial
always consult senior for advice
anticoagulant of choice = LMWH or UFH
short half life
reversal agent available = protamine sulphate
post-op hypotension — approach + Tx
impression = shock
hypovolaemic shock
esp 1st 24 hrs — impt to r/o bleeding
cardiogenic shock — MI or massive PE
septic shock
ABCDEs
2 wide bore 14-16G IV Cannulas
500ml bolus Hartmanns solution over 10-15 mins
if PMH HF or small frail elderly = consider 250ml or consult senior help
assess BP and vitals after each bolus – repeat up to 3-4x
call for senior — esp if not responding after 2 boluses
may require blood products, HDU/ICU admission, vasopressors, activation of massive transfusion protocol
focused Hx
what surgery, when, any complications
any PMH heart issues, lung etc
signs of infection — fever, malaise
exam
assess volume status
cap refill time, vitals (HR, RR, BP)
clinical signs of dehydration — dry mucous membranes, reduced skin turgor, oedema
U/O charting
feel peripheries — cold = ?hypovolaemic or cardiogenic; warm = ?septic
consult the american college of surgeons classess of acute haemorrhage to guide extent of blood loss
check notes + kardex
how did the surgery go — any major blood loss
kardex: any anticoagulation
Ix
bedside
ABG + lactate — ?end organ dysfunction if raised lactate
bloods
FBC
U&E
Coag profile
GXM 4 units
sepsis 6
Tx of hypovolaemic shock
acc to cause — may require re-intervention in theatre
ensure ongoing maintenance fluid is prescribed — which is …
if NPO consider nutritional supplements too
day 5 post-op patient + O/E: fever + hypotension — approach + Tx
impression = septic shock
ABCDEs
is it sepsis?
EWS >7 = escalate to senior help
SIRS criteria —- >2 = SIRS
temp <36 or >38
HR >90
RR >20
WCC <4k or >12 k
glucose >7.7 + no DM
acute change in mental status
focused Hx — LUCAS (for source of infection)
Lungs
Urine
CNS
Abdomen
Skin
physical exam – find for possible source
surgical site
respi tract
urosepsis
central line
sepsis 6 — within 1st hr
take 3
bloods
blood cultures
insert urinary catheter
bloods incl
ABG + lactate
FBC
U&E
CRP
other Ix
urine dipstick + C&S
covid 19 swab
give 3
supplementary O2
fluid resus
empirical Abx
Tx
empirically acc to likely source of infection + PMH & local guidelines
eg. tazocin IV
