periop management of patient Flashcards
when is a patient febrile
above 38 degrees
clinical sign and not a diagnosis
if patient fever, what do you do
list 7 things
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
what are the onset and probable causes of fever in a post operative patient
intraoperative
immediate (24hr):
acute: 24-72
subacute: <1week
what can cause intraop fever
inf: preop infection,
drugs: anesthetic agent,
vascular: myocardial infarction, organ infarct,
others: heat insulation
what can cause post op immediate fever
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
what can cause acute fever
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
what can cause subacute fever
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
pain def
unpleasant sensory or emotional experience associated with actual or potential tissue damage
how to check pain? steps to ask patient **
SOCRATES
site, onset, character, radiation, assoc, timing, exacerbating factors, severity (visual analog score to compare)
if patient pain, whats the drugs to give
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
oliguria/anuria def
adults: less than 400ml/day
children: less than 0.5ml/kg/hr
infants: less than 1ml/kg/hr
anuria is no urine at all
aetiology of oliguria
pre-renal: dehydration, vascular collapse, decreased cardiac output
renal: structural renal damage
post renal: mechanical/structural obstruction
if patient with oliguria has diarrhea and vomiting
suspect prerenal
if patient taking NSAID long term
contricts vessels
if patient has diabetes/heart failure/hypertention
pre-renal
if patient has haematuria or renal stones or prostate enlargement
renal obstructive cause
what to check when patient oliguria
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
what to do when patient oliguria
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
definition of bacteraemia
presence of bacteria in the blood
definition of septicaemia
multiple bacteria, actively dividing
systemic response leading to organ failure (systemic inflammatory response syndrome)
circulatory collapse, metabolic and perfusion derangement
whats severe sepsis
sepsis with one or more signs of organ dysfunction, hypoperfusion, hypotension
what are some risk factors of sepsis
immunosuppressed extremes of age recent surgery diabetic alcohol abuser (organ damage) corticosteroids, post chemo
sepsis clinical presentation
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
management of sepsis
blood iv access oxygen supplement urine test glucose level (esp if patient not eating) blood culture xray (chest and op site)
what to do as an on call do
medical urgency
inform primary team and 2nd on-call
keep High Dependency and SICU informed
very close monitoring (15min)
what to do when patient has diabetes
history: duration and types of drugs and other complications
renal effects: drugs with renal clearance
healing status: diabetic foot, compromised healing
if diabetic patient needs to come for surgery, what to do when they’re admitted one day early
ECG, chest x-ray
urine analysis of protein, bacteria, ketone,
full blood count, renal panel, fasting glucose, HbA1c
what do do for diabetic patient on day of op
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
what happens in ketoacidosis
for type 1 diabetics, acidemia (pH<7.3), hyperglycaemia, ketonaemia
life threathening
ketone breathe smells like durian
what happens when patient hypoglycaemia coma
behavioral changes, sweating, racing pulse, fast onset, give 20-30g glucose (200-300ml 10% dextrose)
patient should recover instantly
HONK
hyperglycaemic hyperosmolar non-ketotic coma
type 2 DM in elderly, dehydration and glucose >25mol/l
