Fit for surgery school
Works as long as:
- 1. patients attend
- 2. in good time to make a change
Seizures
Check BM and pregnancy status (to r/o eclampsia)
Status epileptics definition:
Status epilepticus is when a seizure lasts longer than 5 minutes or when seizures occur close together and the person doesn’t recover between seizures. Status epilepticus can be convulsive and non-convulsive.
1st line: lorazepam
2nd line 30mg/kg of valoprate or (if CI e.g. pregnant) then levetiracetem then 1g bd. Conveniently they have the same dose
3rd: consider phenytoin, thiopentone
NB thiopentone infusion – causes intravascular movement of K+, so risk of rebound hyperkalaemia. Also WCC and temperature regulation affected so unreliable to use to monitor for infection. May need serial cultures.
CT +/- LP
Check drugs levels, toxicology
Rx of limbic encephalitis: IVIG, plasmaphoresis, corticosteroids
Fever
Normal: 35.6 – 38.2 – diurnal variation. lowest in morning. increases in evening. mean 36.5
cultures it T>= 38.3 (SCCM & IOSA)
Opioid light acute peri-operative pain management
Pre-op counselling, ascertain and manage expectations.
If going to use gabapentin prob need 900-1200mg. Useful for chronic pain/complex patient? Could make very drowsy.
It is possible to do major surgery without opioids.
Dexamethasone – need >= 0.1mg/kg for effect
If using MR oxycodone or morphine then STOP before discharge
An option is clonidine 150mcg made up to 10ml and give 15mcg increments akin to morphine. NB will cause hypotension, so be patient and wait for long enough before giving next dose.
Ketamine. 0.2-0.4mg/kg (10-40mg) at induction, after midazolam, then bolus as needed
Prehabilitation
Peri-op shared decision making
An important question might be along the lines of ‘are there any outcomes for you that would be worse than death?’
