Problem 5: Peri-Operative Medicine Management Flashcards
Describe the diagnosis
Neck of femur fracture is #NOF.
There are two main types of fracture in the hip; intra capsular and extra capsular .
Symptoms are pain, not able to lift or rotate leg, being unable to stand or weight bear, bruising and swelling around the hip area, a shorter leg on the injured side, leg turns outwards more than the injured side.
Discuss the plan for this patient. Are there any guidelines available on this
X-rays first
MRI if hip fracture is suspected despite negative hip X-rays
If MRI not within 24 hours or is contraindicated then CT scan
Analgesia: pain should be reviewed immediately upon admission and within 30 mins of initial administration, hourly on ward until settled and regularly as part of routine observations.
Paracetamol every 6 hours, additional opioids if paracetamol alone is not enough. Consider adding nerve blocks if not controlled or to limit opioid use.
Paracetamol 6 hourly post operation and additional opioids. NSAIDs are not recommended.
Offer patients choice of spinal or general anesthesia after discussing the risks and benefits . Consider intra-operative nerve blocks for all patients undergoing surgery.
Offer patients a physiotherapy assessment and mobilisation on the say after surgery.Offer patients mobilisation at least once a day and ensure regular physiotherapy review.
Give a rationale regarding which medicines should be stopped prior to surgery
Beta-blockers should be continued because they can suppress tachycardia and increased blood pressure provoked by anesthesia and surgery.
Medications are all fine (patient not taking an ACEi or ARB)
Warfarin must be stopped. INR needs to be reversed (so that major bleeding does not occur). Stop warfarin atleast 5 days before a planned surgery. Oral or IV administration of vitamin K is expected to reverse warfarin 4-6 hours after administration. 0.5mg IV vitamin k would be used to reduce the INR from 5 to a lower level of around 2-3.
PCC is prothrombin complex concentrate and is made up of clotting factors II, VII, IX, X. Combining vitamin K and PCC can reverse urgently.
Note that the doctor has documented that the patient is Nil by Mouth (NBM) for surgery. Explain what this means
Nil by mouth is a medical instruction to withhold food and drink from a patient for various reasons (this INCLUDES medication);
- pre or post surgery
- when bowel has is non-functional
- the patient is unable to swallow safely
- nausea and vomiting may also inhibit the uptake of fluids and nutrition.
No patient should have fluids withheld for more than 10 hours (elderly are particularly at risk).
During general anaesthetic patients are at risk of aspirating their stomach contents therefore minimum fasting periods for scheduled surgery are 6 hours solid food, 4 hours breast milk, 2 hours for water or dilute drinks.
When reviewing a patient’s medication during the nbm period, describe the issues that need to be considered
Patients coagulation must be considered i.e. over anti-coagulation is a bleeding risk but immobility in hospital is also a thromboembolism risk.
Medication that needs to be taken with food cannot be.
Oral formulations need to be changed to IV or withheld etc.
Warfarin considerations of reversing the anti-coagulant effects and bridging of this anti-coagulation.
According to NICE, what things are corrected to avoid delay in surgery?
Anaemia, anticoagulation, volume depletion, electrolyte imbalance, uncontrolled diabetes, heart failure, acute chest infection and correctable cardiac arrhythmias
Explain the surgery that the patient will undergo for #NOF
Replacement anthroplasty (total hip replacement) for patients with displaced intracapsular fracture. Offered if the patient could walk independently or with a stick before the fracture, no cognitively impaired, medically fit for anesthesia. .
