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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


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


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


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

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.


Viral screen

Autoimmune screen

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



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’



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

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


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

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


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:

Some stuff on Procalcitonin


<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