peri operative management of patient Flashcards
Patient is considered febrile when temperature is
> 38ºC
what should you do when you have a patient with fever
retake vitals
oxygen supplement
pain relief
paracetamol/NSAIDS
urine dipstick. culture testing to check for bacteremia
ECG to check for cardiac problems that may be manifesting as fever
hold off on antibiotics until you know the cause
what is first line for pain and fever relief
NSAIDs
Possible causes of fever that occurs intra operatively while the patient is under GA
pre operative infection
myocardial infarction
drug reaction to anaesthetic agent
organ infarct
possible causes of immediate fever ie within 24 hours of surgery
acute bacterial infection eg clostridium perfringens, streptococcal group A infection
malignant hyperthermia
drug reaction to aaesthetic
myocardial infarction
transfusion reaction ** (fever and rash are early sings, important to rule out)
surgical trauma
possible causes of acute fever (24-72 hours after surgery)
UTI
surgical site infection
DVT **
graft rejection
possible causes of subacute/delayed fever (<1 week)
surgical site infection DVT (remote but still possible) graft rejection alcohol/drug withdrawal embolism dehydration
definition of pain
unpleasant sensory or emotional experience associated with actual or potential tissue damage
pain investigation acronym
SOCRATES Site Onset Character eg dull, acute, throbbing Radiation Associations Timing, duration Exacerbating and relieving factors Severity
medication used for various steps of the pain relief ladder
step 1 mild to moderate pain
non opiods eg aspirin, NSAIDs
step 2 moderate to severe pain
mild opioids eg codeine with or without non opioids
step 3 severe pain
strong opioids eg morphine with or without non opioids
what is considered oliguria for various age groups (adult, children, infants)
Adults: <400ml/day
Children: <0.5ml/kg/hr
Infants: <1ml/kg/hr
aetiology for oligouria/anuria
prerenal (going into kidney)
- dehydration
- vascular collapse
- decreased cardiac output
renal
- structural damage eg kidney stones, lack of glomerular filtration
post renal
- fibrosis, scarring, damage of the urethra
- mechanical/structural obstrction
what to look out for in medical history that may explain oliguria
diarrhea and vomiting
long term NSAID use – cause afferent kidney vessels to constrict in caliper
heart failure, diabetic, hypertension (pre renal)
hematouria, renal stone (obstructive)
prostate enlargement
what can block you from inserting catheter
prostate enlargement
kidney stones
kink in catheter
examination of patient with oliguria
input-output chart bed side ultrasound urine dipstick/culture and sensitivity with mid stream urine to look for infection drug chart review, recent anaesthesia FBC/creatinine, looking for sepsis
why do we look at drug chart or recent anaesthesia hen investigating oliguria
some drugs cause oliguria
bladder may be anaesthesised by muscle relaxant hence unable to pass urine
acute kidney injury
bacteremia vs septicemia
bacteremia is the presence of bacteria in blood
septicemia is the presence of multiple bacteria ACTIVELY DIVIDING
what are the clinical signs of systemic inflammatory response syndrome
extremes of temperature <36, >38.3
heart rate >9-bpm
respiratory rate >20 breaths/min
pco2 <4.3kpa
white cell count >12x10^9 cells or decreased wbc
acute altered mental state eg angry, confused, malaise
what is severe sepsis
SIRS with presumed or confirmed infectious process, with one or more signs of organ dysfunction, hypoperfusion, hypotension
risk factors for sepsis
extremes of age recent surgery on long term corticosteroids ie immunosuppressed diabetic, immunocompromised alcohol abuser
clinical presentation in patient with sepsis
tachy cardia, tachypnoea
look unwell, fever, chills, rigor, sweating
cyanosis
peripheral shutdown, but hyperdyanmic circulation (cold in peripheries)
hypotension with postural drop
drop in gcs
management of sepsis
bloods eg check arterial blood gas oxygen supplement urine dipstsick ensure iv access glucose level
cardiovascular conditons associated with diabetes
angina, peripheral vascular disease, postural hypotension
neurological conditions associated with diabetes
autonomic neuropathy
neuropathy at extremities, tingling fingers
parasthesia
renal conditions associatedw ith diabetes
acute or chronic kidney injury
anemia
hypertension
be careful of drugs you are prescribing
skin conditions associated with diabetes
poor wound healing
bed sores
management for diabetic patient pre op
admit one day before the operation
do work up eg ECG, hba1c, urine analysis, chest x ray
on morning of operation, take morning baseline glucose and make sure <13mmol/L
start long acting insulin and off short acting insulin
withhold food and fluids so that no pulmonary aspiration of stomach contents under GA
start sliding scale once patient nil by mouth, check glucose level 2 hourly
management for diabetic patient post op
once ready to eat/drink, give one dose of short acting insulin. off sliding scale 30min later and return to normal diabetes control regime
what is diabetic ketoacidosis
acidemia, blod ph <7.3
due to absolute insulin deficiency, seen in type 1 diabetics
commonly seen in young people
clinical presentation of diabetic ketoacidosis
Gradual drowsiness Fatigue Ketotic breath Vomiting and dehydration post op Anorexia Polydipsia Hyperventilation
Clinical presentation of hypoglycemia coma
behavioural changes eg rowdy before going into coma
sweating
racing pulse
seizures
recover almost instantly after giving 20-30g of glucose IV
what glucose level considered hyperglycemic hyperosmolar non ketotic HONK coma
> 35mol/L
