Inpatient Management Flashcards
What are the 20 rules of Kirby’s rules for inpatient management?
Fluid balance
Albumin/oncotic pressure
Electrolyte and acid/base
Mentation
Heart rate, rhythm, contractility
Blood pressure
Body temp
Oxygenation and ventilation
RBCs/Haemoglobin
Coagulation cascade
Renal function
GI motility
Nutrition
Glucose
Immune status and antibiotics
Wound healing and bandages
Drug dose and metabolism
Pain control
Nurses - good communication, involve them
TLC
Why is fluid overload detrimental?
the increase in interstitial fluid load increases the diffusion distance for oxygen, nutrients and waste products between the blood and cells. This is particularly detrimental to renal and lung function. Similarly, a fluid deficit is detrimental through affecting perfusion and cellular dehydration promotes catabolism, insulin resistance and cellular stress.
What should be checked regularly to assess hydration and perfusion?
Mucous membranes
Pulse rate and quality
Blood pressure
Peripheral oedema
Chest auscultation and lung ultrasound for pulmonary oedema
What are the possible solutions for incorrect fluid balance?
Changing fluid therapy rates
Diuretics
What is rule 2 of Kirby’s rules for inpatient management
Albumin/oncotic pressure
What are the clinical signs of fluid overload + hypoalbuminea?
Peripheral oedema
Pulmonary oedema on auscultation/ultrasound
Flat caudal vena cava
Low blood pressure (hypotension)
Poor pulses
Patient is also losing fluid inappropriately to interstitial space
What are the solutions to hypoalbuminea?
Food! – need to increase protein intake; feeding tube indicated.
Plasma transfusion for oncotic support.
Synthetic colloids highly controversial – increased risk of acute kidney injury.
What is rule 3 of Kirby’s rules for inpatient management?
Electrolyte and acid/base
What electrolytes are commonly affected in critical illness and what are the clinical signs of these?
K - due to reduced intake:
- weakness, low head carriage
Na - losses, redistribution secondary to hyperglycaemia:
- mentation disturbances - cerebral swelling or dehydration
Cl - with Na losses, or GI loss e.g., vomiting:
How is electrolyte balance monitored in inpatient management?
Blood/gas machine or biochem
What is the treatment for electrolyte imbalance?
Usually supplementation with fluids i.e. ‘spiking’ the bag.
Where electrolytes are high – specific treatment approaches, care with correcting sodium quickly due to rapid osmotic changes leading to either flooding the brain, or dehydrating it.
What are the types and clinical signs of acidaemia?
What are the types and clinical signs of alkalosis?
How is acid/base imbalance diagnosed?
pH (blood gas machine)
PCO2 (blood gas machine)
Clinical signs – RR
What is the treatment for acid/base imbalance?
Appropriate fluid therapy i.e. hartmanns (alkalinising) or saline (acidifying)
Treat the underlying e.g. pain
What is the most likely cause of inappropriate bradycardia in inpatient management?
Hypokalaemia
Describe the assessment of arrythmias in inpatient management
commonly associated with systemic disease, the myocardium is very sensitive. Commonly VTach is seen; have anti-arrythmics available e.g. lidocaine (sodium channel blocker)
Intermittent or continuous ECG monitoring
Describe the assessment of contractility in inpatient management
can be poor with systemic disease e.g. sepsis, or a sign of cardiac disease e.g. DCM/late stage HCM
POCUS will allow you to assess the heart’s fractional shortening/ejection fraction rapidly and determine whether a positive inotrope is needed e.g. pimobendan
Combined with blood pressure may help to confirm output failure
What do systolic and diastolic pressure give an indirect measure of?
Systolic pressure – indirect measurement of cardiac contraction force
Diastolic pressure – indirect measure of vascular tone
How can blood pressure monitoring be used to assess the problem for hypotension?
Low total blood pressure - > consider hypovolaemia
Primarily a low diastolic pressure (big gap) - > consider inappropriate vasodilation i.e. distributive shock (e.g. sepsis/SIRS)
Primarily a low systolic pressure (small gap) - > consider poor contraction force.
What are the causes of hypothermia in inpatient management?
Reduced energy conservation e.g. anaesthesia, wet, exposure
Reduced energy production e.g. starvation/metabolic exhaustion/hypoxia
What are the causes of hyperthermia in inpatient management?
Increased energy conservation e.g. BOAS, hyperthermia on a hot day, exercise
Increased energy production e.g. inflammation/infection -> Pyrexia.
What is the treatment for hypothermia in inpatient care?
Consider the underlying disease
When warming, aim to correct the temperature slowly e.g. 0.5-1oC per hour
Prolonged hypothermia may have reduced metabolic rate and have a protective quality to it – rapid rewarming may result in an energy/metabolic mismatch (Heart and Brain may be particularly susceptible)
Describe the basic monitoring of oxygenation and ventilation for inpatient management
Mucous membrane colour
Resp rate and effort
Pulse oximetry
Lung ultrasound
Describe the advanced monitoring of oxygenation and ventilation for inpatient management
Blood gas analysis:
- Arterial PO2
- Alveolar-arterial oxygen gradient
- FiO2/PaO2 ratio
- May allow identification of Acute Lung Injury (ALI), or Acute Respiratory Distress Syndrome (ARDS)
What is the treatment for poor oxygenation and ventilation in inpatient management?
Oxygen therapy as needed
How can RBCs/haemoglobin be monitored in inpatient management?
Mucous membranes
Respiratory Rate
Heart Rate
Haematology/PCV (not a marker for transfusion in acute bleeds - PCV will still be normal in acute bleeds)
Blood Smear
Saline Agglutination Test
What is the treatment for low RBCs/haemoglobin
Oxygen therapy as needed
Transfusion if needed:
- pRBCs ideally
- Whole Blood Donor
What is the effect of disruption to the endothelial glycocalyx?
Disruption of the endothelial glycocalyx (protective layer of blood vessels endothelium) and exposure of the endothelium can stimulate coagulation cascade, or other disease factors, or administration of colloids. In severe situations this can result in disseminated intravascular coagulation (DIC).
How can the coagulation cascade be monitored in inpatient management?
Mucous membranes - Petechiae
Bleeding from IV Canula sites
Increased RR/RE – e.g. pulmonary thromboembolism (PTE)
Primary coagulation tests – Platelet counts and BMBT
Secondary haemostasis tests – coagulation factors (PT, APTT)
Fibrinolysis tests – D-dimers, and FDPs
Global coagulation test – Thromboelastography (TEG)
What is the treatment for a poor coagulation cascade in inpatient management?
Fresh Frozen Plasma transfusion for coagulation factors
Platelet transfusion
Other supportive care e.g. oxygen therapy for PTE.
How can renal function be monitored in inpatient management?
Fluid balance and urine output:
- An acute increase or decrease in urine output can both be a sign
- Consider a U-cath in very sick patients
Urinalysis – urine specific gravity, cytology
Biochemistry – Urea, Creatinine, Phosphate and Potassium
Why should renal function be monitored in inpatient management?
Acute Kidney Injury and reduced renal function is common in critical illness.
What is the treatment for impaired renal function in inpatient management?
Hyperkalaemia treated as a priority
Maintaining fluid balance through ins/outs
Avoid fluid overload
Diuretics (e.g. furosemide) to encourage urine output if overload developing
Why should GI motility be monitored during inpatient management?
Ileus can also be a problem, and resultant gastrointestinal disruption can complicate disease, including the risk for bacterial translocation and worsening bacterial ‘load’ on the patient.
How can GI motility be monitored?
Signs of vomiting/diarrhoea
Body condition score
Body weight
Muscle condition score
What is the treatment for impaired GI motility?
Food!
Appropriate gastrointestinal diet, feeding tube if indicated.
Reduce other medications if you can – e.g. opiates
Anti-emetics/anti-nausea medications (e.g. maropitant, ondansetron)
Prokinetic agents if obstruction ruled out (e.g. metoclopramide)
Appetite stimulants controversial as they mask the problem.
How can nutrition be monitored in inpatient management?
Signs of vomiting/diarrhoea
Body condition score
Body weight
Muscle condition score
How can poor nutrition be treated in inpatient management?
Food!
Calculating the RER
Modifying this based on response, i.e. worsening BCS/MCS despite appropriate RER
Feeding tubes if indicated
What are the causes of hypoglycaemia in inpatient management?
Increased usage/storage – increased metabolic rate, septicaemia, insulinoma, xylitol
Increased loss – renal losses
Lack of intake – nutritional or malabsorption
What are the causes of hyperglycaemia in inpatient management?
Reduced usage – Diabetes mellitus / DKA, insulin resistance
Increased mobilisation – stress, TBI
How can glucose be monitored in inpatient management?
Blood glucose checks
Signs of weakness, reduced mentation, wobbly, ‘look drunk’
What is the treatment for hypo/hyperglycaemia in inpatient management?
Hypoglycaemia – food and glucose supplementation if needed. Treat the underlying.
Hyperglycaemia – treat the underlying.
Why is it important to assess immune status in critically ill patients?
Critical illness can dampen down immune response, so be aware of the risk of secondary infection even when dealing with a disease that is not primarily infectious.
How can immune status and antibiotics be monitored?
Gastrointestinal signs indicating GI disruption
WBC counts – particularly left shift neutrophilia
Hypoglycaemia
Temperature
Surgical sites/canula sites
Urinalysis – e.g. UTI (common in diabetics)
How can an impaired immune status be treated in inpatient management?
Find the source if you can and control
Sample – culture and sensitivity
Appropriate antibiosis if needed
Why does wound healing and bandages need to be monitored in inpatient manages?
wounds (surgical or traumatic) can be a source of infection and problems if not appropriately cared for
- monitor catheter placements + surgical sites etc.
How can drug dosage and metabolism be monitored in inpatient management?
Liver function tests – Urea, Bile Acids
Liver damage tests – ALT, ALP, GGT, GLDH
Renal function – Urea, Creatinine, Phosphate, Potassium
Be aware of individual drug side effects, and specific signs to look for
Why is drug dosage and metabolism important to consider in inpatient management?
Critical illness affects organ function and, as a result, metabolic pathways and speed of metabolism
How can you minimise the risks of drugs in inpatient care?
Tempering of drug dosages based on effect, regular monitoring of their need, e.g.:
- Pain scores for analgesic drugs
- Blood pressure for vasopressors
- Signs of nausea for anti-emetics
Aim for the lowest effective dose
How can pain be treated in inpatient management?
Opiates
- Full Mu e.g. methadone, morphine, fentanyl
NSAIDS
- Take care if concerns re blood pressure and renal blood supply / function
Local anaesthetics
- Local blocks, or systemic administration e.g. lidocaine constant rate infusion
NMDA receptor antagonists
- Ketamine (CRI) or amantadine
Others e.g. Alpha-2 agonists, gabapentin
