Take home messages:
- Make a TO BE list rather than a TO DO list
- how would the best version of oneself go in to work? – energetic, creative, resilient, positive, confident, upbeat, happy
- Zig Ziggler
- Vipassana Vendatta
- Can choose to be positive vs be a mood hoover
- Do not moan. ‘get over it’ choose to be positive, be grateful
- If you did know the answer what would it be? If we were the best team, how would we act?
- ratio of good/praise to bad/negativity:
- 1:1 high risk
- 2:1 at risk
- 3:1 – minimum for good relationship
- 6:1 – high performing team
- 8:1 – children
- 1st FOUR MINUTES = be the best self.
- Reframing positively e.g. ‘was it good, great or amazing?’
- Appreciative enquiry – meeting and discussing what went WELL
The Art of Being Brilliant – mentoring update
Risk factors for increased morbidity & mortality:
- Peak VO2<15 ml/kg/min
- Anaerobic threshold <10-11 ml/kg/min
- Ventilatory equivalent (measured at AT) >35-40. Breathing hard to meet demands!
‘Apple’ fat distribution (central obesity)
Metabolic syndrome (3 of central obesity, hyper-tension, cholesterol, sugars, lipids)
Pre-op: STOPBANG >5 = high risk of disordered breathing/OSA
AR: Consider test dose of 50mcg fentanyl pre-induction for sensitivity for opioids
RSI: No evidence
Drug dosing: Ideally use LBW. Practically IBW + few kg. For all drugs except suxamethonium and neostigmine
Position: Reverse trendelenburg with pillow under shoulders for tragus above sternum, rather than break in the bed
Extubation: consider NPA with lidocaine
Post-op: avoid ‘tying’ to the bed e.g. with a-line, infusions
Take home messages:
In the elderly, hypotension is BAD. Keep MAP>55 and systolic no more than 10% less than baseline systolic. Consider running pressor infusion c.f. obstetric spinals
Always consider regional, BIS, no/less opioids (though not at expense of adequate analgesia)
Consider heavy prilocaine for hips & knee – if surgeon is experienced/quick
Oxycodone > morphine
Predict and treat delirium. HELP principles. Might be context specific therefore do better in own home. Involve geriatricians.
New anticoagulants – ideally need 73 hours but is balance of risk (given that mortality with #NOF increases per day)
Prehabilitation (exercise!). Not just walking. Remember strength training (stand from siting) and balance (stand on one leg with eyes closed)
EPOCH take home themes: data = power, engage and involve everybody, have a systems thinking approach, develop leadership & project management skills
Use frailty scoring systems e.g. Edmonton Frail Score
5 practices of exemplary leadership:
– Challenge the process
– Inspire a shared vision
– Enable others to act
– Model the way
– Encourage the heart
From Kouzes and Posners leadership challenge
Pregnant women have lower oncotic pressure so have a lower threshold for pulmonary oedema.
TTP. Do not give platelets. Femoral vascath & plasma exchange.
Placental abruption. Causes DIC so give blood products early and aggressively.
To do regional in bleeding diathesis? If diathesis is corrected then its fine.
Renal disease in pregnancy:
- In pregnancy normal values are Cr 50/Ur 3.3 (compared to 70/4)
- Treat the cause
- Avoid NSAIDs/toxins
- Keep on dry side (as pul oedema is worse than AKI)
- Talk to nephrologist
- Hypertensives do worse than normotensives
Cannot bronchi down a size 7.0 ETT so use a larger size if possible.
Beware cardiac disease in pregnancy.
Of cardiologist ask what effects change in HR, preload, afterload, contractility will have on heart/lesion.
Cat 1 GA section: decide/plan wether to proceed or wake up in event of failed intubation.
Intracapsular, undisplaced fracture – Cannulated screw – minimally invasive
Intracapsular, displaced – cemented hemiarthroplasty – fat embolism, BCIS
Extracapsular, (displaced) – DHS – blood loss +++