Acute Care and Perioperative
In GP practice, you have to practice examining the patient and do history at the same time to
save time and call the ambulance! (something that we are not used to at first!)
• After calling the ambulance, you may want to do the following:
o Ascertain who knows about her whereabours?
o Who brought her in and who can meet her at the hospital?
o Do you want me to tell your NOK?
o Tell her what to expect and when to do follow up?
o I would contact you when you are in the hospital?
Altered consciousness that can be easily figured in GP:
• BSL
• Intracranial pressure
• Infection (UTI)
Predictors of death in hospital:
• Conscious state
• RR
Use shock or pre-arrest in dire situations!
Important for periop period:
• Reduced oral fluid intake
• Loss from GIT
• Insensible losses
• Third space losses: inflammatory state -> increased permeability of blood vessels ->
leakage of protein rich fluid
• Surgical drains
• Medications (diuretics)
• Underlying chronic illness
§ Note that all anticoagulants do NOT actually breaks down clots, but only prevent the
propagation of the clot and prevents new ones from forming!
§ In cases where patient is taking DAPT for cardiac reasons and if CTB interval is normal,
can start aspirin (day 2 post event) and then second agent day 7 onwards
Electrocution:
• If there is no arrhythmia or ECG changes within the 1st hour of the electic shock,
there is no need for a monitored bed as likelihood of cardiac damage is low
• However, if it was a high voltage power line elecrocution, MUST have monitored bed
regardless
Tubogram is the injecting of contrast dye via exiting drain, tube or line in the patient to identify
patency of tube, any leakage, wrong placement etc.
PICC line positioning:
• Ideal spot: cavoatrial junction
o 2 vertebral bodies below carina
o Within 1 verterbral body on each side
• Too high: thrombus risk
• Too low: Arrhythmia risk
Excess salivation: Horse radish pills can be very helpful
Pronouncing Death / Certifying death
1. Verify identity with wristband
2. No palpable carotid pulse
3. No breath sounds for 2 mins
4. No heart sounds for 2 min
, 5. Fixed (non-responsive to light) and dilated pupils
6. No response to centralized stimulus (trapezius squeeze, supraorbital pressure,
mandiblar pressure)
7. No motor (withdrawal) response or facial grimace in response to painful stimulus
8. RIP Mr/Ms full name, time of death
Just note that these medications need to be careful when prescribing:
• Prednisolone, potassium
• Insulin
• Narcotics
• Chemotherapy
• Heparin + other anticoagulants
Trauma triad of death:
• Coagulopathy: Causes lactic acidosis
• Hypothermia: Halt coagulation cascade
• Metabolic acidosis: decreases myocardial performance
Preioperative:
• Patient: Inherent features/disease of patient, how fit and healthy for surgery
• Pathology: what is the actual disease? Is there a trigger that we can reverse?
• Procedure: What is the expected procedure, intraoperative course, what can go
wrong
• Personnel: Who needs to be involved, who is overseeing and needs to know what’s
going on?
• Place: Where can the procedure be safely performed, having the resources to deal
with any complications or the procedure itself
Fasting: at the minimum
§ 6 hours without food
§ clear fluid up to 2h before procedure
Herbal medicine:
• Ok to continue perioperatively: Arnica
• Discontinue perooperatively: Feverfew, ginseng, st john wort, tumeric , fish oil, ginger
When doing blood tests, you need to:
1. Know what you are measuring
2. Know why you are doing this
3. Know what to do with the results
4. Know how it relates to other clinical findings
5. Know some of limitations of tests
When taking history:
• Keep broad pathological processes in your head
• Ask for symptoms
• Symptom cluster review
• Reviewing temporal relationship of symptoms
•
Beta blockers should not be stopped acutely prior to surgery as there may be a rebound
effect associated with increased complications.
Brain natriuretic peptide is a neurohormone synthesized in the cardiac ventricles. Levels have
been used to assess prognosis in heart failure and acute coronary syndromes. Preoperative
elevated brain natriuretic peptide levels identify patients undergoing non cardiac surgery at
high risk of cardiac mortality and all cause mortality.
,All patients with peripheral vascular disease should take statins prior to vascular surgery as
studies have shown a 50% risk reduction and a reduction in perioperative cardiac events
Justifiation for blood test:
• U&E:
o Minor surgery: not required, unless previous/likely abnormality (diuretics, Phx
renal imapairment)
o Major surgery: required
• FBE:
o Minor surgery: not usually required, unless indicated by history (anemia)
o Major sugery: required
• CXR:
o RARELY required for most surgeries, unless thoracic surgery or undiagnosed
cardiothoracic condition exists
o Patients with significant lung disease do not routinely get a CXR as well
unless there is signs of infection
• ECG:
o Required in all patients over age of h50yo
o Appropriate in young patients with relevant cardiac history
o Need not perform if last ECG within last 6 months
• Blood group and antibody screen:
o Major surgery: required, or any other surgeries with reasonable prospect of
significant blood loss
o Done at least 2 weeks before surgery
• LFT:
o Done only when history infiates
• PFT:
o Rarely useful
• ECHO, stress ECHO, coronary angiograms
o Orders only after discussion with anesthetist
• APTT, INR, Coags:
o Major surgery: required
o Patients undergoing major regional anesthetic blocks or spinal/epidural
anesthesia
o Done only 1-2d before surgery
A high functioning CDR as defined by McGinn et al states sensitivity minimum of 95% and a
likelihood ratio for negative result of 0.1 or less.
THE BEST CDR Is those of HIGH SENSITIVITY (100%) and As high as possible of
specificity. A LR- of 0.1 will be more useful in clinical practice.
ALWAYS SEE ALL PATIENTS WITH FRESH EYES AND NOT BE LEAD INTO A
DIAGNOSIS!
NOTE: Intraarterial is ONLY for monitoring and NOT for drug admistration:
Delivery of meds into artery can cause:
• Paresthesia
• Severe pain
• Motor dysfunction
• Compartment syndrome
• Gangrene
• Amputation
For reasons that are NOT Fully understood
LONG ACTING meds: Larger dose less frequently
SHORT ACTING meds: Smaller dose more frequently
STOP Fishoil and everything that starts with G:
• Ginseng
, • Ginger
• Garlic
• Gingko nuts
And many more… This is because they all have anticoagulant properties
Note that patients on long term steroids often require stress dose of hydrocortisone
(50-100mg) to manage hypotension due to adrenal suppression
A remaining very small propotion includes miscellaneous areas such as CSF, pleural
and peritoneal fluids.
Volume intake: 1.5-2.5 L /day
Output: Urine: 1ml/kg/hr (1700ml if 70kg)
Insensible loss: 300-500ml (sweat, faeces, respiratory)
IV fluids available:
Saline
Dextrose
4% dextrpse + 1/5 saline
Hartmann (compound sodium lactate)
Plasmalyte
In patients with suspected dehydration/overhydraition, you are very worried about VOLUME
STATE.
Intravascular signs:
• JVP changes
• HR (tachycardia)
• BP (hypotension)
• Capillary refill
Extravascular:
• Mucus membranes
• Edema/ascites
• Skin turgor
• Eye signs
• Crackles/intersitial fluids
Osmolality: Osmotic pressure exerted by a solute proportional to numeber of
molecules per unit weight.
Normal: 285-295 mosm/kg
Calculated= 2(sodium) + urea + glucose (>380mOsm/L, lethargy and coma occurs)
Osmolal gap = Measured – calculated osmolality. An increased gap due to increased low
molecular weight solute (alcohol, glycol, ketones and unmeasured electrolyte/sugars)
In GP practice, you have to practice examining the patient and do history at the same time to
save time and call the ambulance! (something that we are not used to at first!)
• After calling the ambulance, you may want to do the following:
o Ascertain who knows about her whereabours?
o Who brought her in and who can meet her at the hospital?
o Do you want me to tell your NOK?
o Tell her what to expect and when to do follow up?
o I would contact you when you are in the hospital?
Altered consciousness that can be easily figured in GP:
• BSL
• Intracranial pressure
• Infection (UTI)
Predictors of death in hospital:
• Conscious state
• RR
Use shock or pre-arrest in dire situations!
Important for periop period:
• Reduced oral fluid intake
• Loss from GIT
• Insensible losses
• Third space losses: inflammatory state -> increased permeability of blood vessels ->
leakage of protein rich fluid
• Surgical drains
• Medications (diuretics)
• Underlying chronic illness
§ Note that all anticoagulants do NOT actually breaks down clots, but only prevent the
propagation of the clot and prevents new ones from forming!
§ In cases where patient is taking DAPT for cardiac reasons and if CTB interval is normal,
can start aspirin (day 2 post event) and then second agent day 7 onwards
Electrocution:
• If there is no arrhythmia or ECG changes within the 1st hour of the electic shock,
there is no need for a monitored bed as likelihood of cardiac damage is low
• However, if it was a high voltage power line elecrocution, MUST have monitored bed
regardless
Tubogram is the injecting of contrast dye via exiting drain, tube or line in the patient to identify
patency of tube, any leakage, wrong placement etc.
PICC line positioning:
• Ideal spot: cavoatrial junction
o 2 vertebral bodies below carina
o Within 1 verterbral body on each side
• Too high: thrombus risk
• Too low: Arrhythmia risk
Excess salivation: Horse radish pills can be very helpful
Pronouncing Death / Certifying death
1. Verify identity with wristband
2. No palpable carotid pulse
3. No breath sounds for 2 mins
4. No heart sounds for 2 min
, 5. Fixed (non-responsive to light) and dilated pupils
6. No response to centralized stimulus (trapezius squeeze, supraorbital pressure,
mandiblar pressure)
7. No motor (withdrawal) response or facial grimace in response to painful stimulus
8. RIP Mr/Ms full name, time of death
Just note that these medications need to be careful when prescribing:
• Prednisolone, potassium
• Insulin
• Narcotics
• Chemotherapy
• Heparin + other anticoagulants
Trauma triad of death:
• Coagulopathy: Causes lactic acidosis
• Hypothermia: Halt coagulation cascade
• Metabolic acidosis: decreases myocardial performance
Preioperative:
• Patient: Inherent features/disease of patient, how fit and healthy for surgery
• Pathology: what is the actual disease? Is there a trigger that we can reverse?
• Procedure: What is the expected procedure, intraoperative course, what can go
wrong
• Personnel: Who needs to be involved, who is overseeing and needs to know what’s
going on?
• Place: Where can the procedure be safely performed, having the resources to deal
with any complications or the procedure itself
Fasting: at the minimum
§ 6 hours without food
§ clear fluid up to 2h before procedure
Herbal medicine:
• Ok to continue perioperatively: Arnica
• Discontinue perooperatively: Feverfew, ginseng, st john wort, tumeric , fish oil, ginger
When doing blood tests, you need to:
1. Know what you are measuring
2. Know why you are doing this
3. Know what to do with the results
4. Know how it relates to other clinical findings
5. Know some of limitations of tests
When taking history:
• Keep broad pathological processes in your head
• Ask for symptoms
• Symptom cluster review
• Reviewing temporal relationship of symptoms
•
Beta blockers should not be stopped acutely prior to surgery as there may be a rebound
effect associated with increased complications.
Brain natriuretic peptide is a neurohormone synthesized in the cardiac ventricles. Levels have
been used to assess prognosis in heart failure and acute coronary syndromes. Preoperative
elevated brain natriuretic peptide levels identify patients undergoing non cardiac surgery at
high risk of cardiac mortality and all cause mortality.
,All patients with peripheral vascular disease should take statins prior to vascular surgery as
studies have shown a 50% risk reduction and a reduction in perioperative cardiac events
Justifiation for blood test:
• U&E:
o Minor surgery: not required, unless previous/likely abnormality (diuretics, Phx
renal imapairment)
o Major surgery: required
• FBE:
o Minor surgery: not usually required, unless indicated by history (anemia)
o Major sugery: required
• CXR:
o RARELY required for most surgeries, unless thoracic surgery or undiagnosed
cardiothoracic condition exists
o Patients with significant lung disease do not routinely get a CXR as well
unless there is signs of infection
• ECG:
o Required in all patients over age of h50yo
o Appropriate in young patients with relevant cardiac history
o Need not perform if last ECG within last 6 months
• Blood group and antibody screen:
o Major surgery: required, or any other surgeries with reasonable prospect of
significant blood loss
o Done at least 2 weeks before surgery
• LFT:
o Done only when history infiates
• PFT:
o Rarely useful
• ECHO, stress ECHO, coronary angiograms
o Orders only after discussion with anesthetist
• APTT, INR, Coags:
o Major surgery: required
o Patients undergoing major regional anesthetic blocks or spinal/epidural
anesthesia
o Done only 1-2d before surgery
A high functioning CDR as defined by McGinn et al states sensitivity minimum of 95% and a
likelihood ratio for negative result of 0.1 or less.
THE BEST CDR Is those of HIGH SENSITIVITY (100%) and As high as possible of
specificity. A LR- of 0.1 will be more useful in clinical practice.
ALWAYS SEE ALL PATIENTS WITH FRESH EYES AND NOT BE LEAD INTO A
DIAGNOSIS!
NOTE: Intraarterial is ONLY for monitoring and NOT for drug admistration:
Delivery of meds into artery can cause:
• Paresthesia
• Severe pain
• Motor dysfunction
• Compartment syndrome
• Gangrene
• Amputation
For reasons that are NOT Fully understood
LONG ACTING meds: Larger dose less frequently
SHORT ACTING meds: Smaller dose more frequently
STOP Fishoil and everything that starts with G:
• Ginseng
, • Ginger
• Garlic
• Gingko nuts
And many more… This is because they all have anticoagulant properties
Note that patients on long term steroids often require stress dose of hydrocortisone
(50-100mg) to manage hypotension due to adrenal suppression
A remaining very small propotion includes miscellaneous areas such as CSF, pleural
and peritoneal fluids.
Volume intake: 1.5-2.5 L /day
Output: Urine: 1ml/kg/hr (1700ml if 70kg)
Insensible loss: 300-500ml (sweat, faeces, respiratory)
IV fluids available:
Saline
Dextrose
4% dextrpse + 1/5 saline
Hartmann (compound sodium lactate)
Plasmalyte
In patients with suspected dehydration/overhydraition, you are very worried about VOLUME
STATE.
Intravascular signs:
• JVP changes
• HR (tachycardia)
• BP (hypotension)
• Capillary refill
Extravascular:
• Mucus membranes
• Edema/ascites
• Skin turgor
• Eye signs
• Crackles/intersitial fluids
Osmolality: Osmotic pressure exerted by a solute proportional to numeber of
molecules per unit weight.
Normal: 285-295 mosm/kg
Calculated= 2(sodium) + urea + glucose (>380mOsm/L, lethargy and coma occurs)
Osmolal gap = Measured – calculated osmolality. An increased gap due to increased low
molecular weight solute (alcohol, glycol, ketones and unmeasured electrolyte/sugars)
