Tag Archives: peri-op medicine

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?’

Age Anaesthesia Meeting

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