Perioperative Events
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Perioperative Events
CP40042010-2011
Dr P Chalmers
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Objectives
• Fluid management• Blood loss resuscitation• Electrolyte imbalance• Critical events Sudden life threatening events
Hypoxia Collapse Hypotension +/-impaired consciousness
• Respiratory Insufficiency/depression• Cardiac events• Shock hypovolaemic/septic• Anaphylaxis
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Fluid replacement• Replace existing deficit: 50% deficit in 1st hr, 25% in 2nd hr, 25% in 3rd hr• Maintain fluid balance 2mls/kg/hr• Replace surgical loss: no trauma nil minimal trauma superficial procedure 4ml/kg/hr moderate eg hernia 6ml/kg/hr major abdo,thoracic surgery 8-15mls/kg/hr blood transfusion blood loss>20%EBV
EBV =70mls/kg adult 5L
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Estimated blood lossesClass 1 Class 2 Class 3 Class 4
Blood loss (mls) <750 750 -1500 1500 - 2000 >2000
Blood loss % blood vol <15% 15 – 30% 30 – 40% >40%
HR <100 >100 >120 >140
BP Normal Normal Decreased Decreased
Pulse pressure Normal /inc Decreased Decreased Decreased
RR 14-20 20-30 30-40 >35
urine output ml/hr>30 20-30 5-15 negligible
CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic
Fluid replacement Crystalloid Crystalloid and/or colloid
Crystalloid, colloid and blood
Crystalloid, colloid and blood
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Fluid Rescucitation
• ADULT 1-2I of rapid crystalloid infusion
• (PAEDIATRIC 20ml/kg)
• Then assess response
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Responses to initial fluid resuscitation
Rapid response
Transient response
No response
Clinical assessment
Vital signs return to normal
Haemodynamic improvement not sustained
No change in cardiovascular instability
Estimated blood loss
10-20% 20-40% >40%
Fluids Crystalloid
+/- colloid
Crystalloid, colloid and blood
Blood
Blood prep G&H +/- Xmatch
Type-specific Emergency blood
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Electrolyte Imbalance
• Hyponatraemia <130mmols/l
• Hypernatraemia >145mmol/l
• Hypokalaemia <3.5mmols/l
• Hyperkalaemia >5.6 mmols/l
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Electrolyte Imbalance
Clinical situations more likely to occur in the perioperative period
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Hyponatraemia
Causes: Diuretics GIT lossesBurnsCorticosteroid withdrawal
Cardiac failureTURP
Excess dextrose infusionSIADH: postoperative pain, Lung infection+COPD
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Hyponatraemia• <130mmols/l: lethargy• <125mmols/l: confusion• <110mmols/l: coma• +/- GIT symptoms
• Hypovolaemic: loss of Na + H20 R/ 0.9% NaCl
• Normovolaemic: loss of Na + rel increased water
R/ water restriction
• Hypervolaemic: inc in body Na and H20
R/ diuretics and water restriction
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Correction of electrolyte disorders
Hyponatraemia Aim for a change of 0.5-1mmol/L/hr
Na requirement=TBW X(target Na-actual Na)
Beware central pontine myelinolysis
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Hypernatraemia
• >145mmols/l relative water deficit
Causes• Elderly water deprivation• Hyperosmolar diabetic coma• Diabetes Insipidus head injury
• S&S thirst irritability, hyperreflexia, seizure, coma
• +/- pulm oedema
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Hypernatraemia
• Hypovolaemic R/ 0.9%NaCl then water• Hypervolaemic R/ Diuretics• Normovolaemic R/ 5% dextrose or water• (Desmopressin for DI)
Aim for a change of 0.5 - 1mmol/L/hr Beware cerebral oedema
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HYPOKALAEMIA
• <3.5MMOLS/L
CAUSES:
Diuretics
• GIT losses
• Diabetics on insulin
• Beta agonist meds
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Hypokalaemia
• Poor muscle tone <2mmols/l Resp failure
• Intestinal ileus
• Tachyarrthymias
• ECG U waves, flat T,s
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Correction of electrolyte disorders
• Hypokalaemia
• <2.5mmols/l R/ 20-40mmols KCl in I litre N saline over 8Hrs (replace at 30mmols /hr max with ECG monitoring)
• 2.5-3.5mmols/L oral replacement therapy 80-120mmols/day
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Hyperkalaemia
• >5.6mmols/l
• Rhabdomyolysis
• Burns
• Suxamethonium
• Renal failure
• ACE inhibitors
• Diuretics spironolactone
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Hyperkalaemia
• peak T wideQRS prolonged PR loss of P waves
• Tachyarrthymias
• Cardiac arrest
• Poor muscle tone
• N & V diarrhoea
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Hyperkalaemia
• <6mmols/l restrict K
• >6.5 mmols/l or ECG changes
10 units Insulin and 50ml 50%dextroseCalcium Gluconate 10mls 0f 10% over 2 min ß agonistsK binding resinDialysis
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Critical events
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Critical events
SUDDEN ONSET OF:• HYPOXIA and/or• CARDIOVASCULAR COLLAPSE and/or• IMPAIRED CONSCIOUSNESS
• (primarily resp :hypoxia before collapse• Primarily cardiovas: pt unwell, signs of impaired
peripheral perfusion, pallor clammy anxious, restless, hypotension then hypoxia)
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Initial Management
• Assess level of consciousness
• A airway
• B breathing
• C circulation
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• Respiratory depression: RR <10/min SaO2 <90%
• Respiratory obstruction: silent /stridor /
gurgling sounds
• Impaired muscle tone: shallow respirations
poor muscle tone
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Blood Gases
Normal Respiration(on room air): PaO2 12-14.7kPa PaCO2 4.53 -6.1kPa
Respiratory Insufficiency: PaO2 <13kPa on O2
PaCO2 >6 kPa
Respiratory failure: PaO2 <8kPa PaCO2 >6.7 kPa
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Cardiovascular Instability Shock
• Dehydration
• Inadequate fluid replacement
• Blood loss
• Sepsis
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Patient Sketch
• 55 yr old male following open cholecysyetectomy history of asthma and hypertension
• Onset of resp distress, L sided chest pain worse on inspiration
• Cyanosis, confusion,tachycardia, hypotension
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Differential diagnosis
• Tension pneumothorax
• PE
• AMI +/-arrthymias
• Aspiration pneumonia
• VT
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Aspiration Pneumonia
• Particulate material
• Volume
• pH <7.0 chemical burn of the airway and chemical pneumonitis
• Infective pneumonia
• Anaerobes pseudomonas
• CPAP bronchodilators +/-antibiotics
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Patient Sketch
• 40 year old male with anteroposterior resection of sigmoid colon and rectum for carcinoma
• 2hrs postop
• Anxious, pale, sweaty,
• RR 22/min
• HR 110/min BP120/80 85/60
• SaO2 94%
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Patient Sketch
• Female following stab wound in abdo with a penetrating injury of the colon
• 2 days postop. Feeling unwell,fully conscious and orientated, looking flushed, warm clammy extremities
• Tachypnoea
• PR 110/min BP 110/80
• Temp 38.5
• WBC 3.8x109/l
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SIRSSystemic Inflammatory response syndrome
• Tachypnoea >18/min
• Tachycardia >100/min
• Temp <360C or>380C
• WBC <4x109/l or >12 x109/l
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Overview of MOF and care of the critically ill patient
• Monitoring
• Bloods
• Systemic MO care
• Management of underlying cause
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Patient Sketch
• Stridor
• Facial Swelling
• Pt receiving iv antibiotics/difene
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Anaphylaxis
• ABC• Stop administration of the trigger if applicable• Call for help• Oxygen• Adrenaline 50micrograms every 30sec (0.5mls
of1:10,000)
OR 0.5 - 1mg im every10min)• IV access
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Subsequent management
• Antihistamine chlorphenamime10-20mg slow iv• SteroidsHydrocortisone100-300mg iv• Consider cardiovascular support
adrenaline/noradrenaline ivi 0.05 – 0.1 μgram/kg/min (4-8mls/hr of 6mg in 60mls saline)
• BGA• Consider Bronchodilators
• (Consider:Autoimmune assay Epipen Medic alert bracelet)
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Critical events
• Airway obstruction tongue/ larnygospasm/oedema• Delayed resp depression due to intrathecal /epidural
/iv/im opioids• Inadequate reversal of muscular blockade• Aspiration pneumonia• Pneumothorax• Pulmonary Embolism• Pulmonary oedema• Myocardial ischaemia/infarction / arrthymias• CVA• Hypovolaemic shock• Septic Shock• Anaphylaxis
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Head Injury
• Concern for anaesthetist• To prevent secondary damage due to
hypoxia, hypercarbia and impaired cerebral perfusion
• Assessment of LOC
AVPU
GCS 8 or lessintubationScottish Intercollegiate Guidelines Network SIGN
Guideline 46 Early Management of Head Injury http://www.sign.ac.uk/guidelines/fulltext/46/index.html
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Principles of managementA. Maintain good oxygenation
Increased FiO2 SaO2 >95% Hb>10g/dlIntubation and ventilation: if GCS 8 or less
and/or PaO2 <13kPa on oxygen and/or PaC2 <3.5kPa or > 6kPa
B. Maintain cerebral perfusionCPP=MAP-ICP (70 mm Hg)1.Maintain MAP at 90 mmHg (use inotropes if necessary)2.Maintain ICP 7-15mm Hg (N=<20mmHg) Head up posture Dexamethasone / mannitol / diuretics3. Maintain PaCO2 4.5 – 5 kPa
C. Reduce cerebral metabolism and O2 demand: Thiopentone Active Cooling