General Medicine

Question 1

Longcase strategy for Pre-operative Management? - What are the areas to consider? (5)

Answer 1

Firstly choose areas to discuss

1. Cardio-Respiratory risk (assess for fitness of surgery & Mx)**
2. Anticoagulation Mx
3. Diabetes Mx
4. Steroid Mx
5. Device Mx

Question 2

Fitness for surgery - perioperative cardiovascular risk?

Issue e.g.

Perioperative Mx of planned OT in context of a) multiple comorbidities, b) anticoagulation, c) diabetes

What to write on the card for a) and what you’d say? (5)

Answer 2

1. I am concerned about the Risk that this Operation poses for this patient’s peri-operative health & post-operative morbidity
2. I believe that the risk is low/mod/high due to the presence/absence of (3 or more → intermediate risk)

• IHD
• CCF
• Stroke
• TIIDM
• Advanced CKD
• High-risk surgery

3. Therefore, I would (or not) proceed to non-invasive testing (Myocardial perfusion imaging) and if the patient has +ve stress test, consider a diagnostic angiogram.
4. Discuss whether I’d proceed with proposed surgery or fix cardiac issues and explain why. Discuss with the patient and involve MDT. Book ICU bed.
5. Regardless, I would involve

• Dietician to optimise nutrition early on, since malnutrition is associated with adverse post-operative outcome and pneumonia
• PT: to educate lung expanding maneuvers, inspiratory muscle training, incentive spirometry - pre-op time is the best time to teach them
• Minimise other risk factors: e.g. cease smoking, exercise (if patient is able to)

6. Post-operative

• Pain: Panadol QID (LFT 1st), Avoid NSAIDs, commence on regular Opioid and monitor for breakthroughs
• Strict bowel chart & prevent constipation
• PT: to direct early mobilisation, incentive spirometry

Question 3

What is MET and how can it be used to assess perioperative morbidity/mortality?

Answer 3

Metabolic Equivalent Time.

1 MET = basic ADLs only

4 = able to climb a flight of stairs without symptoms.

Max = 10 (can do strenuous exercise).

<4 MET is an indicator of high-risk

So a key question to ask the patient: can you climb a flight of stairs without any symptoms? If answer is no, high-risk.

Question 4

What is your approach to managing this patient’s anticoagulation in preparation for surgery? (4)

Answer 4

Goals:

• Minimise the period of anticoagulation interruption whilst minimising risk of bleeding peri/post op.

Quantify the risk:

• CHADS2VASC - the risk of TE is…
• Type of operation (risk of bleeding) - the risk of bleeding is…

Bridging - needed or not:

Timing of Recommencement

Question 5

A 76-year-old female with non-valvular atrial fibrillation, hypertension, and prior stroke three months ago, receiving warfarin, requires elective hip replacement with neuraxial anesthesia; renal function is normal, and weight is 75 kg.

What is your anticoagulation strategy? – both pre & post op

Answer 5

This patient has a very high thromboembolic risk (CV score = 6) and a high bleeding risk (major orthopaedic surgery) - hence I would bridge her warfarin in this case.

• Cease warfarin 5 days before the procedure (last dose on OT day -6)
• Commence treatment dose LMWH 3 days prior (e.g. clexande 75mg BD)
• Omit PM dose of clexane a day before surgery

Post-op

• Start warfarin within 24 hours of surgery (usual dose)
• Prophylactic clexane within 24 hours (e.g. 40mg SC Clexane)
• Once haemostasis is secured, start treatment dose clexane in day 2-3 post op – continue until INR is therapeutic

Question 6

What is your approach to managing this patient’s warfarin who is on it for mechanical heart valve?

Answer 6

Generally, bridging is required

Approach

• Cease warfarin 2-4 days prior to the procedure (aim = INR <1.5 for major surgical procedure)
• If on Aspirin, continue unless v. high risk of bleeding (NSx, prostate – if so cease 5 days before)
• Start UFH or LMWH when INR <2 (usually ~2 days prior to OT)
• LMWH – last dose = 24 hours before, UMH 4-6 hours before

Afterward

• Recommence warfarin 12-24 hours post op (when adequate haemostasis)
• Post op bridging (basically approach depends on bleeding risk post-op)
  
  • Start UFH or LMWH in 24 hours if haemostasis achieved, low risk bleeding
  • If high risk of bleeding: start 2-3 days after procedure and when haemostasis is secure
  • Consider completely avoiding giving UFH or LMWH

Question 7

Peri-op diabetes Mx?

Answer 7

If the procedure is long/complex (>2 meals skipped) - IV insulin + Glucose infusion as per local protocol. Watch BSL 1-2 hourly, monitor K and Bicarbonate.

If short/simple procedure;

1. A night before, consider reducing evening basal insulin by 25% if history of hypo or low baseline BSL levels.
2. WH rapid/short-acting insulin mane.
3. I would prefer changing intermediate-acting or pre-mixed insulin to long-acting (e.g. Lanctus)
4. Give 1/2 or 2/3 of total morning dose insulin (short+intermediate+long) as long-acting in the morning
5. Start 4% dex 1/5th NS at 100mls per hour to avoid metabolic changes of starvation
6. Monitor BSLs hourly and supplemental insulin as required
7. Reinstate back to usual insulin once patient is eating well.
8. If infusion, remember to give S/C insulin (2h) before stopping infusion. Continue IV dex to prevent hypo.

Question 8

Management of Hip pain?

Answer 8

Difficult Mx issue that requires continued support and MDT approach

Goals:

• Identify cause/rule out sinister pathology
• Improve function / symptoms
• Prevent complications - fall and #

Identify the cause/secondary contributors

• DDx: state 3 most likely the cause. R/v previous investigations.
• TEST - e.g. OA
  
  • T: XR hip to look for LOSS
  • E: inflammatory markers, serology, BMD, ALP, CMP, bone scan, other imaging

Improve function / symptoms

• Non-pharm
  
  • Manage expectations: explain to the patient that we may not cure but improve function and tolerance
  • Exercise: increased activity improves pain and function
  • PT: goals of muscle strengthening, flexibility, aerobic fitness.
  • Graded exercise therapy (so we don’t over do it)
  • Hydrotherapy
  • Mind-body interventions (Yoga / Taichi)
  • TENS (transcutaneous electrical nerve stimulation)
  • CBD
  • Regular motivation, praises, encouragement
• Pharm
  
  • WHO analgesic ladder
  • Start with dose + breakthrough - to identify the appropriate dose
  • Paracetamol (check LFTs)
  • Codeine
  • Tramadol (opiate, serotonergic, nor-adrenergic): 50mg TDS - monitor serotonin syndrome (if on TCA/SSRI/SNRI)
  • Tapentadol (mu agonist, norad R): 50mg BD to 250mg BD - monitor serotonin syndrome (if on TCA/SSRI/SNRI), abuse, dependency
  • Targin - monitor constipation, falls, confusion
  • Buprenorphine (Norspan), Fentanyl (Durogesic) patch - not for acute
  • Neuropathic pain
    
    • Gabapentin (100mg)/Pregabalin (75mg)
    • Duloxetine 30mg OD
    • Amitriptyline 10mg nocte, increase every 7 days
• Steroid injection
• Operation

Prevent complications

• Falls precautions, prevention programs (stepping on)
• Hip protectors
• Vitamin D (>75) & Calcium replacement
• Monitor for OP: 2 yearly DEXA, if T -<2.5, commence anti-resorptive

Question 9

Managing falls Risk

Answer 9

Goals

• Prevent falls
• Prevent complications of falls
• Optimise bone health

Prevent falls

• Patient factors
  
  • Falls prevention education
  • Treat visual impairment + appropriate glasses + treat any e.g. cataracts
  • Exercise: gait, balance, strength training, tai-chi (combines strength + balance)
  • Optimise nutrition: healthy, balanced diet, involve dietician for supplementation
  • Walking aids
  • Manage foot & footwear issues, non-slip shoes
• Medical factors
  
  • Rationalize medications: especially psychotropic medications
  • Address postural hypotension (fludrocortisone, midodrine)
• Environmental factors - engage OTs
  
  • ​Hand rails in stairs
  • Grab rails in bathrooms
  • lightning
  • Slip resistance surfacing
  • Non-slip bathmats
  • Vital calls

Optimise bone health

• Screen of Osteoporosis: DEXA, Vitamin D, Ca/Phos/ALP, PTH
• WB exercises - aim 30min, 3 times/week
• Adequate Calcium intake: 1200mg/day from diet (3-4 serves of calcium daily), if not, Calcium 0.5-1g/d
• Vitamin D replacement
• Anti-resorptive (T
• Teriparatide