Prescribing at Hosp Admission

Question 1

When prescribing at the stage of hospital admission, what 5-step approach should be taken?

Answer 1

1. Support life
2. Treat the acute illness
3. Relieve symptoms
4. Prevent complications
5. Manage co-morbidities

Question 2

How do you support life?

Answer 2

Encompasses physiological support​

• Resuscitation → ALS, fluid resus, organ support
• Oxygen →
  
  • Target SpO₂ range: 94-89% or 88-92%?
  • Initial delivery device + FiO₂: non-rebreathing mask (provides highest poss conc of O₂), venturi (for more controlled therapy), nasal cannulae (not critically ill, comfortable)
    ​
• Hydration + Nutrition →
  
  • IV water and electrolyte provision
  • Acute vitamin supplementation
  • Nutritional supplements

Question 3

How do you treat the acute illness?

Answer 3

Focus on disease-specific treatment

Question 4

In regards to relieving symptoms, how might one relieve pain?

Answer 4

• Non-opioid
• Weak opioid
• Strong opioid

WHO analgesic ladder developed to suit chronic pain. For acute pain, maybe better to start at top of the ladder and work way down.

Eg. For a pt with mod-severe acute pain, might start them on regular paracetamol and add morphine PRN (breakthrough anaglesia). In some pts may be place for weak opioid in between, but generally least useful step on the ladder.

Question 5

How is the symptom fever managed?

Answer 5

• Best managed by non-pharm measures eg. external cooling
• paracetamol works well (and multi-use)

Question 6

How do you manage nausea?

Answer 6

• Complicated prescribing area
• Lots of drugs available
• Consider oral vs IV
• Oral ondansetron (safe, well tolerated)
• Also provide an IV option in case they can’t tolerate

Question 7

How do you manage constipation?

Answer 7

• Can have a whole range of knock on effects
• Never underestimate
• Start with regular stimulant eg. Senna
• Combine with regular softener eg. Sodium docusate
• Consider, if foecal impaction, PRN glycerol suppository (rectal)

Question 8

What is meant by “preventing complications” when prescribing?

Answer 8

Complications of:

• illness → eg. secondary cardiac and vascular effects of ACS
• treatment → eg. GI bleeding after anti-thrombotics
• hospital admission → risk of VTE

Question 9

What is a renowned complication/risk of hospital admission that you should always be aware of?

Answer 9

• VTE
• thrombosis risk vs bleeding risk
• weigh risk between two
• when risk of thrombosis high and risk of bleeding low → prescribe pharmacological prophylaxis eg. dalteparin 5000 units SC daily
• follow local hospital guidelines

Question 10

We must not forget the pt might have other comorbidities. How do we manage these?

Answer 10

• Identify missed opportunities to improve treatment of these things, can enact during hosp admission, although discuss before prescribing
• Review +/- prescribe usual medicines
• Options for usual meds → prescribe? withhold? stop?
  
  • document + communicate to GP!