All posts by Vishal Dhokia

About Vishal Dhokia

Doctor - anaesthesia and intensive care

Notes from 6th East Mids Critical Care and Peri-op medicine conference

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?’

PICC/Midline insertion tips

Gleaned from our local vascular access expert that I had the pleasure of observing and learning from:

  • Aim for entry in mid third of upper arm
  • Abduct, flex elbow +/- rotate – ask an assistant to hold
  • Drape the WHOLE patient – so you can easily measure estimated distance
  • IN-PLANE – practice & perfect this!
  • Keep the thin wire stylet 2-4cm IN from end of the line – this creates a soft/flexible tip to help correct placement (more important for PICC)
  • Bend the stylet after withdrawal to keep it fixed in its position
  • Rotate gently to help line to ‘follow the flow’ during insertion

Guidelines for peri-op care of patients with dementia

Reference: White et al.

2019 Mar;74(3):357-372. doi: 10.1111/anae.14530. Epub 2019 Jan 11

https://www.aagbi.org/sites/default/files/perioperative_care_of_people_with_dementia.pdf

 

img_1355.jpg

Take home messages:

  • Screen – ‘do you have any concerns about your memory?’
  • Prepare patient, carers and MDT approach
  • Grant carer/relative access to anaesthetic room and recovery if needed
  • Minimum dose and duration of anaesthetic agent as needed. Titrate to BIS. Personally I’d take this as avoidance of GA if possible e.g. using spinal/regional likely to be preferable if it can be achieved safely and effectively
  • Try to avoid: benzos, opioids, cyclizine, tramadol.
  • Cholinesterase inhibitors e.g. rivastigmine: theoretical benefit of stopping day before surgery when neuromuscular blockers may be used… However balance this against risk of worsening cognitive / neuropsychiatric function. My anecdotal experience is of discontinuation causing more harm than good in general, though each case should be judged on an individual basis.
  • Similarities to principles of anaesthetic management of frail and elderly patients in general.

Liver study day @ ICS

Acute liver failure = syndrome of coagulopathy + jaundice + encephalopathy

Reduced glutathione reserves if poor nutrition, neuromuscular disorders

Raised ALT/AST found in 40% of patients taking ‘normal’ max dose of paracetamol 2 weeks.

NAC paracetamol OD. If in doubt of level, GIVE and continue. Giving ANYTIME after significant paracetamol level is beneficial.

In hyperacute ALF cerebral oedema predomiantes. With positive physchotic features i.e. agitated, delirium. Inter cranial hypertension carries high mortality.

Assessment

Viral screen

Autoimmune screen

NH3 – measurable and the trend. >200 predicts ICH. <75 is rare

Treatment

ICH:

Hypertonic saline. 3-30% NaCl. Aim for Na 145-155. Sedate + ventilate, normal CO2, CPP 60-80.

CVVHDF – removing NH3 affords CVS stability, irrespective of renal failure. High volume ultrafiltration

Steroids. Improve CVS stability, no change in outcome.

AoCLF: Terlipressin, Antibx, lactulose, Hb>7, plt > 50, fib >1

Sengstaken Tube:

50ml in stomach balloon then pull back +/- CXR

Then approx 350ml in stomach balloon, then CXR. Rarely need oesophageal balloon

TIPPS – risk of encephalopathy for reduced risk of bleeding.

Principles of some liver units:

Offer 48-72 hours of ‘trial of therapy’ then reassess. Reasonable to offer full support, including renal replacement therapy (‘all or nothing’ approach), then reassess. Though renal failure is a bad prognostic sign, it should not be a self-fulling prophecy.

Good MDT working

Question is : can we get this patient through ICU to discharge to assessment for liver transplant? What is exit/end-game/long term plan?

NAC in non-paracetamol ALF is ‘routine’ (though not in Acute on Chronic Liver failure)

Refer+/-transfer to liver unit early, preferably prior to needing CVVHDF

‘Early trache’

 

SCORING, PROGNOSTICATION, PLANNING

Prognosis in ALF – acuteness? Speed of deterioration is important. Age? Burden of MODS

Markers of high severity: encephalopathy, INR>6.5, creatinine > 600

www.kingsalfpredictor.org

CLIF-SOFA

https://gut.bmj.com/content/gutjnl/early/2017/01/04/gutjnl-2016-312670.full.pdf

Change in SOFA score at 48 hours probably best predictor

Validation of CLIF-C ACLF score to define a threshold for futility of intensive care support for patients with acute-on-chronic liver failure

https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2156-0

http://www.efclif.com

Advanced Care Planning required patient focussed care and goal setting. doi:10.1002/hep.29731

Other thoughts

When looking at creatinine and AKI consider underlying muscle mass (which is likely to be low)

Hepatorenal syndrome: urinary Na+ low. Terlipressin + Albumin

ATN: urinary Na+ high

SBP if WCC>250/mm3

Normal liver -> NAFLD –(inflammation/scarring)-> NASH -> cirrhosis

https://www.basl.org.uk

Nutrition

Aim to reduce protein breakdown as it is a catabolic state. Refeeding occurs due to gluocose load rather than protein. Unusual requirement is 25-30kcal/kg/day. In decompensated liver disease it is 35-40kcal/kg/day. Protein 1.2-1.5g/kg/day.

ESPEN guidelines:

https://www.espen.org/guidelines-home/espen-guidelines

https://www.espen.org/files/ESPEN-Guidelines/ESPEN_Guideline_on_clinical_nutrition_in_-ICU.pdf

5th East Midlands Critical Care Conference – take home notes

**

Leadership & Management – Merrill & Reid Social behaviour types/personalities. Know who you are and who you are dealing with.

http://www.ucd.ie/t4cms/Personality%20Categories.pdf

https://www.gotoquiz.com/your_personality_1

**

Anaesthesia for PH/protecting RV – Goldilocks. Not overloaded, not undefiled, must be just right.

Pulmonary Hypertension: sPAP>40mmHg, mPAP>25. sPAP = RAP + 4x[TRVmax]^2

Mort 5%

ECG: strain pattern. RAD. ST depression V1- V4

On echo: TR Vmax = underestimate.

RHS: TAPSE<15mm, RV thickness >5mm (in diastole)

Tips: Open, not laparoscopic surgery. A-line + CVC. Avoid ketamine/des/N2O (as they increase PVR). fiO2 0.6, PEEP 5-8. PaCo2 4-4.5. Warm everything. Post-op HDU/ICU. Phone a friend – local/own PH unit. Should they be for full MOS? What is disease trajectory? Beware NYHA Class 3-4.

Signs of problems: High CVP + low BP, low SpO2, reduced end organ perfusion. Consider cautious fluid bolus 150-200ml OR diuretic. Optimise ventilation, Keep in SR (Amiodarone +/- DCCV), avoid b-blocker. Start norad +/- vasopressin. Then adrenaline. Then milrinone. Then iNO, epoprostenol

**

Liver failure.

Think: Is it the culprit or a bystander? Is it treatable? What further investigations (imaging, bloods, bx) will help?

Mortality: encephalopathy > ascites + bleed > other

Citrate RRT seems to be safe. However need to consider low Ca2+:Ca2+ ratio. Monitor for accumulation + toxicity

Use albumin for high volume replacement. Evidence only for paracentesis.

Adrenal dysfunction, so consider steroid (hydrocortisone 50mg qds) if increasing vasoconstrictor.

In GI bleeed -> start NG feed early (despite ‘protein load’ )

Prophylaxis antibiotics

Early TIPS

**

Obesity

BM ventilation usually is biggest challenge. DL usually is ok – though increased difficult predicted in neck circ > 40 cm (especially > 50cm) + MP3. Apples worse than pears.

Proposed induction strategy:

Pre-O2 in ramped position, fiO2 0.8, PEEP 5-10

Early iGel instead of BMV

Muscle relaxant

Video laryngoscopy

If predicted difficult DL/VL + can’t access neck think AFOI

**

Need patient centred (not doctor centred) outcome measures. Ideally standardised.

**

On fatigue. Samn Perelli scoring system.

**

Vitamin D

In UK all population at risk of Vit D def which increases mortality which can be treated/reversed with treatment. Jury is out on ICU treatment of Vit D, however screening and treatment may be prudent/pragmatic.

VITDAL – ?

Currently in progress VITALISE, VIOLET

Vit D3 better than cholicalciferol.

Should we screen pre-op?

**

Frailty.

Consider having electronic frailty index (based on Rockwood method). Works with EMIS and SystemOne.

Assessment methods: Gait speed, Clinical Frailty Score, Edmonton Frailty Score

 

Some stuff on Procalcitonin

Bottomline:

<0.2 unlikely to be bacterial sepsis (though has a lag-time of 2-4 hours from onset)

>0.5 likely to be bacterial sepsis

<0.5 consider stopping antibiotics

Pro-calcitonin guided antibiotic therapy may confer slight survival benefit and reduced lower antibiotic duration i.e. better stewardship

 

Links:

https://lifeinthefastlane.com/ccc/procalcitonin/

https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2125-7