periop management of patient

Question 1

when is a patient febrile

Answer 1

above 38 degrees

clinical sign and not a diagnosis

Question 2

if patient fever, what do you do

list 7 things

Answer 2

retake vital signs
oxygen supplement
pain relief (triggers for problems), give paracetamol, NSAID for pain and fever relieve
urin dipstick (tells you urinary tract inf), or culture and sensitivity (blood)
ECG (elderly mainly)
Chest X-ray (pneumonia)
antibiotics maybe

Question 3

what are the onset and probable causes of fever in a post operative patient

Answer 3

intraoperative
immediate (24hr):
acute: 24-72
subacute: <1week

Question 4

what can cause intraop fever

Answer 4

inf: preop infection,
drugs: anesthetic agent,
vascular: myocardial infarction, organ infarct,
others: heat insulation

Question 5

what can cause post op immediate fever

Answer 5

inf: clostridum perfringen, strp group A
infl: ***transfusion reaction, surgical trauma, subarachnoid haemorrhage
drug: drug reaction, malignant hyperthermia
vascular: fat embolism, myocardial infarction
others: hyperthyroidsm

Question 6

what can cause acute fever

Answer 6

inf: surgical site infection, aspiration pneumonia, UTI, catheter assoc infection, otitis media
infl: atelectasis, graft rejection, allergy, pancreatitis
drug: drug fever
vascular: *** deep vein thrombosis
others: hyperadrenalism, dehydration

Question 7

what can cause subacute fever

Answer 7

inf: **surgical site inf, UTI, infected prosthesis or graft, subacute bacterial endocarditis
infl: graft rejection
drug: drug or alcohol withdrawal
vascular: Deep vein thrombosis, pulmonary embolism, cavernous sinus thrombosis
others: dehydration

Question 8

pain def

Answer 8

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

Question 9

how to check pain? steps to ask patient **

SOCRATES

Answer 9

site, onset, character, radiation, assoc, timing, exacerbating factors, severity (visual analog score to compare)

Question 10

if patient pain, whats the drugs to give

Answer 10

step 1 mild to mod pain: aspirin, NSAID, paracetamol
step 2 mod to severe pain: codeine + others?
step 3 sev pain: refer to other peeps, strong opioids

Question 11

oliguria/anuria def

Answer 11

adults: less than 400ml/day
children: less than 0.5ml/kg/hr
infants: less than 1ml/kg/hr

anuria is no urine at all

Question 12

aetiology of oliguria

Answer 12

pre-renal: dehydration, vascular collapse, decreased cardiac output
renal: structural renal damage
post renal: mechanical/structural obstruction

Question 13

if patient with oliguria has diarrhea and vomiting

Answer 13

suspect prerenal

Question 14

if patient taking NSAID long term

Answer 14

contricts vessels

Question 15

if patient has diabetes/heart failure/hypertention

Answer 15

pre-renal

Question 16

if patient has haematuria or renal stones or prostate enlargement

Answer 16

renal obstructive cause

Question 17

what to check when patient oliguria

Answer 17

examination
I/O chart
urine dip stick (mid stream urine)
drug chart review/recent anaesthetic (cos bladder is aneasthesized then acute kidney injury)
FBC/creatine +/- ABG (looking for sepsis)
bedside bladder ultrasound

Question 18

what to do when patient oliguria

Answer 18

unblock the cathether/resite
fluid challenge 250-500ml in 30 min but careful later patient heart failure
I/O chart
review and monitor signs 1-2 hourly

Question 19

definition of bacteraemia

Answer 19

presence of bacteria in the blood

Question 20

definition of septicaemia

Answer 20

multiple bacteria, actively dividing
systemic response leading to organ failure (systemic inflammatory response syndrome)
circulatory collapse, metabolic and perfusion derangement

Question 21

whats severe sepsis

Answer 21

sepsis with one or more signs of organ dysfunction, hypoperfusion, hypotension

Question 22

what are some risk factors of sepsis

Answer 22

immunosuppressed
extremes of age
recent surgery
diabetic
alcohol abuser (organ damage)
corticosteroids, post chemo

Question 23

sepsis clinical presentation

Answer 23

looking unwell
fever, chills, rigours, sweating
tachycardia, tachypnoea, cyanosis
peripheral shutdown, hyper-dynamic circulation
***hypotension with postural drop (reduce cerebral perfusion)
drop in Glasgow Coma Scale

Question 24

management of sepsis

Answer 24

blood
iv access
oxygen supplement
urine test
glucose level (esp if patient not eating)
blood culture
xray (chest and op site)

Question 25

what to do as an on call do

Answer 25

medical urgency
inform primary team and 2nd on-call
keep High Dependency and SICU informed
very close monitoring (15min)

Question 26

what to do when patient has diabetes

Answer 26

history: duration and types of drugs and other complications
renal effects: drugs with renal clearance
healing status: diabetic foot, compromised healing

Question 27

if diabetic patient needs to come for surgery, what to do when they’re admitted one day early

Answer 27

ECG, chest x-ray
urine analysis of protein, bacteria, ketone,
full blood count, renal panel, fasting glucose, HbA1c

Question 28

what do do for diabetic patient on day of op

Answer 28

morning baseline glucose below 13mmol/L, give electrolytes
give long acting insulin, off short acting
start sliding scale once nil by mouth
ensure hydration
check glucose every 2 hourly
once ready to eat, go back to normal regime

Question 29

what happens in ketoacidosis

Answer 29

for type 1 diabetics, acidemia (pH<7.3), hyperglycaemia, ketonaemia
life threathening
ketone breathe smells like durian

Question 30

what happens when patient hypoglycaemia coma

Answer 30

behavioral changes, sweating, racing pulse, fast onset, give 20-30g glucose (200-300ml 10% dextrose)
patient should recover instantly

Question 31

HONK

Answer 31

hyperglycaemic hyperosmolar non-ketotic coma

type 2 DM in elderly, dehydration and glucose >25mol/l