peri operative management of patient

Question 1

Patient is considered febrile when temperature is

Answer 1

> 38ºC

Question 2

what should you do when you have a patient with fever

Answer 2

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

Question 3

what is first line for pain and fever relief

Answer 3

NSAIDs

Question 4

Possible causes of fever that occurs intra operatively while the patient is under GA

Answer 4

pre operative infection
myocardial infarction
drug reaction to anaesthetic agent
organ infarct

Question 5

possible causes of immediate fever ie within 24 hours of surgery

Answer 5

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

Question 6

possible causes of acute fever (24-72 hours after surgery)

Answer 6

UTI
surgical site infection
DVT **
graft rejection

Question 7

possible causes of subacute/delayed fever (<1 week)

Answer 7

surgical site infection 
DVT (remote but still possible)
graft rejection
alcohol/drug withdrawal
embolism
dehydration

Question 8

definition of pain

Answer 8

unpleasant sensory or emotional experience associated with actual or potential tissue damage

Question 9

pain investigation acronym

Answer 9

SOCRATES
Site
Onset
Character eg dull, acute, throbbing
Radiation
Associations
Timing, duration
Exacerbating and relieving factors
Severity

Question 10

medication used for various steps of the pain relief ladder

Answer 10

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

Question 11

what is considered oliguria for various age groups (adult, children, infants)

Answer 11

Adults: <400ml/day
Children: <0.5ml/kg/hr
Infants: <1ml/kg/hr

Question 12

aetiology for oligouria/anuria

Answer 12

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

Question 13

what to look out for in medical history that may explain oliguria

Answer 13

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

Question 14

what can block you from inserting catheter

Answer 14

prostate enlargement
kidney stones
kink in catheter

Question 15

examination of patient with oliguria

Answer 15

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

Question 16

why do we look at drug chart or recent anaesthesia hen investigating oliguria

Answer 16

some drugs cause oliguria
bladder may be anaesthesised by muscle relaxant hence unable to pass urine
acute kidney injury

Question 17

bacteremia vs septicemia

Answer 17

bacteremia is the presence of bacteria in blood

septicemia is the presence of multiple bacteria ACTIVELY DIVIDING

Question 18

what are the clinical signs of systemic inflammatory response syndrome

Answer 18

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

Question 19

what is severe sepsis

Answer 19

SIRS with presumed or confirmed infectious process, with one or more signs of organ dysfunction, hypoperfusion, hypotension

Question 20

risk factors for sepsis

Answer 20

extremes of age
recent surgery
on long term corticosteroids ie immunosuppressed
diabetic, immunocompromised
alcohol abuser

Question 21

clinical presentation in patient with sepsis

Answer 21

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

Question 22

management of sepsis

Answer 22

bloods eg check arterial blood gas
oxygen supplement 
urine dipstsick
ensure iv access 
glucose level

Question 23

cardiovascular conditons associated with diabetes

Answer 23

angina, peripheral vascular disease, postural hypotension

Question 24

neurological conditions associated with diabetes

Answer 24

autonomic neuropathy
neuropathy at extremities, tingling fingers
parasthesia

Question 25

renal conditions associatedw ith diabetes

Answer 25

acute or chronic kidney injury
anemia
hypertension

be careful of drugs you are prescribing

Question 26

skin conditions associated with diabetes

Answer 26

poor wound healing

bed sores

Question 27

management for diabetic patient pre op

Answer 27

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

Question 28

management for diabetic patient post op

Answer 28

once ready to eat/drink, give one dose of short acting insulin. off sliding scale 30min later and return to normal diabetes control regime

Question 29

what is diabetic ketoacidosis

Answer 29

acidemia, blod ph <7.3
due to absolute insulin deficiency, seen in type 1 diabetics
commonly seen in young people

Question 30

clinical presentation of diabetic ketoacidosis

Answer 30

Gradual drowsiness
Fatigue
Ketotic breath
Vomiting and dehydration post op 
Anorexia
Polydipsia
Hyperventilation

Question 31

Clinical presentation of hypoglycemia coma

Answer 31

behavioural changes eg rowdy before going into coma
sweating
racing pulse
seizures

recover almost instantly after giving 20-30g of glucose IV

Question 32

what glucose level considered hyperglycemic hyperosmolar non ketotic HONK coma

Answer 32

> 35mol/L