Peri operative care.txt
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. What would you like to do?
Give 5 ways of preventing a post op PE ?
- TEDS (thromboembolic deterrent stockings)
- Pneumatic calf compression
- LMW Heparin at prophylactic dose
- stop HRT, pill pre op
- ask about FH of thromboembolism and consider for inv for thrombophilia
Give 5 symptoms of PE?
- pleuritic chest pain
Give 8 signs of PE
- raised JVP
- pleural effusion
- pleural rub
what signs of a cause of PE would you look for?
- DVT - swollen leg
- scar from recent surgery
what are the main RF for PE? in categories
- surgery: major abdo, pelvis, hip or knee replacement
- obstetrics: late pregnancy, post partum, C section, pill, HRT
- Lower limb problems: fractures, varicose veins (valves not working)
- Prolonged bed rest, reduced mobility
- Previous PE
What is the treatment for a PE?
- 1. LMW heparin (dalteparin SC)
- 2. start oral warfarin 10mg
- stop heparin when INR is >2
- continue warfarin for a minimum of 3 months, aiming for INR: 2-3
what would you consider if pt develops emboli despite adequate anticoagulation?
vena caval filter
which test may help EXCLUDE a PE?
D dimer test - do in pts with a low clinical probability of PE, to exclude it. NB it cannot prove there is a PE though
What are the signs of a PE on CXR?
- often normal!
- decreased vascular markings
- small pleural effusion
- wedge shaped area of infarction
what are the 2 most sensitive and specific tests for diagnosing PE?
- VQ perfusion scan
- CT pulmonary angiography
what are the signs on ECG of a PE?
- RV strain pattern in V1 to V3: dominant R wave, inverted T wave, ST depression
- rare: SI, QIII, TIII: deep S waves in I, pathological Q waves in III, inverted T waves in III
With anaphylaxis do you get facial pallor or flushing?
What are the cardiovascular effects of anaphylaxis?
what are the respiratory effects of anaphylaxis?
for an anaphylactic reaction, what must you immediately administer and hOW MUCH?
What are the signs of anaphylaxis in terms of ABC and skin?
- airway: swelling, hoarseness, stridor
- breathing: O2 sats < 92, cyanosis, rapid breathing, wheeze, confusion, fatigue
- circulation: pale, clammy, low BP, faintness, drowsy/coma
- Rash, facial flushing
Once adrenaline given, what other measures can be taken?
- lie patient FLAT, raise legs
- establish airway and 2 iv access
- high flow oxygen
- iv fluid challenge: 500mL crystalloids NOT COLLOIDS
- anti-histamine: chlorphenamine 10mg
- steroids: iv hydrocortisone 200mg
What things do you need to monitor in anaphylaxis
- pulse oximetry
- blood pressure
A 72-year-old man who underwent AAA repair presents with a very low urine output postoperatively. His BP is stable. what is the diagnosis?
Acute tubular necrosis
Name a major type of intrinsic renal failure and what causes it?
- Acute tubular necrosis
- ischaemia: due to hypoperfusion
- nephrotoxins: drugs (aminoglycosides, amphoterecin B, tetracyclines), radiological contrast agents, uric acid crystals, Hburia in rhabdomyolysis, myeloma
A 54-year-old man has just had a hernia operation and is in the recovery room when he is found to be very restless despite a smooth recovery. There seems to be a swelling in his lower abdomen. whats the diagnosis?
urinary retention: clues restless post op
A 68-year-old man underwent a total cystectomy. During the first postoperative night he was not producing a satisfactory urine output despite adequate hydration. You involved a senior colleague, and after adequate resuscitation the patient’s urine output slowly picked up. Now, the following day, he has started diuresing. diagnosis?
ATN: clue diuresis after adequate resuscitation
What happens to the urea:creatinine ration in dehydration?
goes up, i.e. as there is a lower body water content, the urea concentration goes up
With a patient undergoing hemicolectomy and needing prep bowel prep what are all the sources of fluid loss?
- 1. NBM: pre op starvation - dehydration
- 2. bowel prep fluid loss
- 3. daily fluid requirement
- 4. intraoperative blood and fluid loss
- 5. fluid loss from through evaporation of open laparotomy wound 1L in 1h
- 6. insensible losses: increased with fever
- 7. losses in drains via NG tube
- 8. post op vomiting and diarrhoea
- 9. haemorrhage: primary - at time of op, reactionary in first 48h due to bv rupture or unseal
- 10. post op paralytic ileus with accum of intraluminal fluid
- 11. septic shock with dilated vessels and leakage of fluid out into interstitial space
- 12. third space losses e.g. pancreatitis fluid accum in peritoneal cavity
What is the stress response to surgery?
- neurohumoral response (Catecholamines, ADH, cortisol, aldosterone) in direct proportion to the magnitude of surgery
- leads to catabolic state with salt and water retention and potassium loss
What are your daily requirements of Na, K and water?
- water: 3L
- Na: 150mmols
- K: 60mmols
What are the signs if you give too much iv fluid to a patient? (3 categories)
- signs of R heart failure: tachycardia, increased JVP, PERIPHERAL oedema
- signs of L heart failure: tachycardia, breathless, wheeze (cardiac wheeze), PULMONARY oedema
- electrolyte imbalance: check U&Es
What are the signs if you give too little fluid and which fluid compartments suffer accordingly? (2 categories)
- dehydration (depletion of ICF): thirst, dry mucous membranes, headache, listlessness, decreased skin turgor
- hypovolaemia (depletion of intravasc compartment): tachycardia, tachypnoea, clammy, anxiety, low BP, reduced UO, delayed cap refill, decreased pulse pressure
What are the signs of acute loss of 15%
What are the signs of acute loss of 15-30%
What are the signs of acute loss of > 40%
What would you like to do?
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