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The Medical Tune Up

The Medical Tune Up. Dr. Debra Pugh MD, FRCPC Internal Medicine. Objectives. Review basic approach to managing common medical issues in surgical patients Managing DM peri-op The Confused Patient Approach to ARF Acute Dyspnea Managing Electrolyte abnormalities. Case 1.

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The Medical Tune Up

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  1. The Medical Tune Up Dr. Debra Pugh MD, FRCPC Internal Medicine

  2. Objectives • Review basic approach to managing common medical issues in surgical patients • Managing DM peri-op • The Confused Patient • Approach to ARF • Acute Dyspnea • Managing Electrolyte abnormalities

  3. Case 1 • You are admitting a 70 year old man for cholecystectomy after a recent episode of gallstone pancreatitis • Past Med Hx: DM II, CAD, HTN, COPD • Rx: ASA, ACE-I, beta-blocker, statin, Metformin, insulin, inhaled bronchodilators

  4. Case 1 • The nurse asks you what you want to do about the patient’s oral hypoglycemics and insulin on admission

  5. DM in the Surgical Patient • Peri-operative mortality is increased in patients with DM • Most deaths from heart disease and infection • Poor wound healing and increased frequency of wound infections

  6. DM in the Surgical Patient • Ideally BS 4-6 • Peri-operatively the goal is to avoid excessive highs or lows • Reasonable goal is BS < 11-14 to avoid problems with wound healing and infection • Intensive glucose control in ICU setting

  7. DM in the Surgical Patient • Stresses of surgery • ↑ catecholamines and cortisol • ↑gluconeogenesis • ↑ glucagon release and ↓ insulin release • ↑ muscle glucose use • Drugs can ↑ insulin resistance • Can all lead to hyperglycemia

  8. The Basics: DM Type II (on oral agents only) • Hold meds the morning of OR • If long-acting (glitazones) stop for 48-72 hrs • IV glucose • Monitor BS q 6 h • Consider insulin infusion

  9. The Basics: DM Preop Type I or Type II on Insulin (If minor procedure) • 1/3 to ½ of usual dose of insulin the morning of surgery • IV D5W with 20 meq KCl at 100 cc/h • Monitor glucose q 1-2 h • Use sliding scale q 4-6 h • After procedure give usual evening dose of insulin if eating

  10. The Basics: DM Type I or Type II on Insulin (longer procedures) • Insulin infusion • Run with IV 2/3 + 1/3 or D5W • Hourly glucoscans

  11. Start insulin infusion

  12. Back to the patient • You order ½ the dose of his usual morning dose of insulin • You ask for frequent glucoscans and write an order for a sliding scale of insulin • His Metformin is held the morning of the procedure

  13. Case 2 • The patient is now POD # 2 for open cholecystectomy • Called to assess for new onset of confusion

  14. Case 2 • Past Med Hx: DM II, CAD, HTN, COPD • Rx: ASA, ACE-I, beta-blocker, statin, Metformin, insulin, inhaled bronchodilators • Demerol for post-op pain • LMWH for DVT prophylaxis

  15. Case 2 • According to nurse, the patient seemed lucid earlier that day • On arrival, the patient appears confused and is not oriented to either time or place • Unable to provide a history or answer questions appropriately

  16. Case 2 • On examination • Vitals are stable and patient is afebrile • Patient is alert but inattentive • Mucus membranes are dry, JVP flat • No focal neurologic deficits • Chest clear • Normal heart sounds, no murmurs • Abdomen benign, wound looks fine

  17. Delirium • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. • Change in cognition/new perceptual disturbance that is not better accounted for by dementia. • Develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. • Presumed to be caused by a medical condition, substance intoxication, or medication side effect.

  18. Delirium • Common • 10-50% of elderly surgical patients • Results in prolonged hospitalization • High mortality (14% at 1 month, 22% at 6 months)

  19. Confusion Stuctural Non-structural • CVA • Tumor • Blood • Seizure • Trauma • Abscess • Infection • CNS, other • Metabolic • Na, Ca, Liver, Renal • Endocrine • Thyroid, Glucose, • Drugs and Toxins • Also withdrawal • Hypercapnia • Hypoxia

  20. Polypharmacy Untreated pain Opioids (esp Demerol) Infection Immobility Bladder catheters Frequent room changes ICU stay No windows in room No eyeglasses or hearing device Dementia or organic brain disease Advanced age Malnutrition Risk Factors for Delirium

  21. Working up Delirium • History and physical examination • Review medications, history of EtOH or benzos • Labs • CBC, Urinalysis, Lytes, calcium, glucose, LFTs, Cr, ABG, CXR, • +/- Tox screen, +/- Drug levels • Other investigations as needed • CT head, EEG, LP

  22. Prevention and Treatment of Delirium • Treat underlying cause • Maintain hydration • Avoid restraints; mobilize if possible • Treat pain • Reduce noise • Orienting stimuli (window, clock, calendar) • Reassurance, bedside sitter, familiar faces • Neuroleptics if necessary • Benzodiazepines, as adjunct

  23. Back to the Patient • Investigations reveal dehydration and a UTI and he is started on antibiotics and IV fluids • Demerol replaced with Dilaudid plus regular Acetaminophen and NSAIDs • His family brings in his eyeglasses as well as his wristwatch and agree to stay with him as much as possible while he is confused

  24. Case 3 • 2 days later some routine labs reveal that your patient’s Cr has increased to 320 (from baseline of 180)

  25. Case 3What do you want to know? • Medications • ASA, ACE-I, beta-blocker, statin, Metformin, narcotics, acetaminophen, LMWH • NSAIDs q4h for post-op pain • Contrast dye • CT head with contrast during delirium work-up • Urine output • Minimal • Volume status • Euvolemic • Indications for urgent dialysis

  26. Approach to Renal Failure Pre-Renal Renal Post-Renal Hypovolemia Renal perfusion ATN GN AIN Renovascular Prostatic Bilateral ureteric Review meds Contrast Urine R&M (Casts,Protein Blood) Foley cathether Renal U/S Assess volume status FENa

  27. Commonest causes of ARF in hospitalized patients • ATN 45% • Contrast dye, shock • Pre-Renal 21% • Diuretics, CHF, ACE-I, NSAIDs • Acute on Chronic 13% • Obstruction 10% • GN or vasculitis 4% • AIN 2% • Antibiotics, NSAIDS

  28. Approach to ARF • Assess if acute indications for dialysis • Review medications • Urine R & M • Serum and urine electrolytes (FENa) • Foley catheter, Renal U/S

  29. Approach to ARF • Assess for acute indications for dialysis • Hyperkalemia (if high ask for EKG) • Acidosis • Volume overload • Uremic Pericarditis

  30. Approach to ARF • Stop medications • ACE-I • NSAIDs • Metformin (risk of lactic acidosis) • LMWH • Consider different antibiotic • Dose-adjust medications as needed • Antibiotics

  31. Approach to ARF • Urine R & M • Hematuria, Proteinuria • Casts • Granular – ATN • WBC – AIN • RBC – GN, vasculitis

  32. Approach to ARF • Serum and urine electrolytes (FENa) Urine Na x Plasma Cr x 100 Plasma Na x Urine Cr • < 1% suggest volume depletion • IV fluids if indicated

  33. Approach to ARF • Rule out post-renal causes • Insert Foley Catheter • Renal U/S

  34. Back to the patient • He has no acute indication for dialysis • Urine R & M reveals several granular casts • Renal U/S reveals no evidence obstruction • FENa is > 1% • Consistent with ATN, probably related to contrast dye

  35. Contrast-induced nephropathy • Incidence increases as GFR decreases • Renal failure starts almost immediately • Recovery begins within 3-5 days

  36. Contrast-induced nephropathyRisk Factors • Renal insufficiency (GFR < 60ml/min) • Diabetic nephropathy • Advanced CHF • High dose contrast • Multiple Myeloma

  37. Contrast-induced nephropathyPrevention • Mucomyst 600mg PO BID for 2 days • Hydration • 3 amps of bicarb in 1 litre of D5W at 3.5ml/kg/hr for 1 hour pre and 1.2ml/kg/hr for 6 hours post contrast

  38. Case 4 • A few days later, you are called to see the patient for sudden onset of dyspnea

  39. Case 4 • On arrival patient appears to be in moderate respiratory distress • Reports SOB. Denies chest pain, cough, hemoptysis, or calf pain

  40. Case 4 • Sats 92% FiO2 .50, RR 30, HR 120, BP 170/90, afebrile • Alert, talking in short sentences • Sitting up in bed, using accessory muscles • JVP elevated • Crackles heard bilaterally • Normal S1/S2, S3 present, no murmur • No leg edema, no calf asymmetry

  41. Case 4 • Past Med Hx: DM II, CAD, HTN, COPD • Rx: ASA, beta-blocker, statin, insulin, inhaled broncholdilators • Dilaudid, Acetaminophen for post-op pain • DVT prophylaxis

  42. Differential Diagnosis • CHF • PE • Pneumonia or aspiration • COPD/Asthma • Mucus Plugging • Cardiac ischemia, arrhythmia • Other (pneumo or hemothorax, tamponaade, effusion, anemia, acidosis)

  43. Initial Management • ABCs • Order investigations • EKG • CXR • ABG • Labs • CBC, Lytes, Urea, Cr, Cardiac Enzymes

  44. Pulmonary Edema Vascular redistribution Peribronchial cuffing Kerly B Line Cardiomegaly

  45. Treating Acute Pulmonary Edema LMNOP • Oxygen • Lasix • Nitrates • Morphine • Positioning, Positive Pressure (BIPAP) • Intubation (hopefully avoidable)

  46. Determining Cause CHF • Iatrogenic (stopping patient’s diuretics, aggressive IV fluids) • Echo (systolic/diastolic dysfunction, valvular dysfunction) • Ischemia/Infarction • Arrhythmia

  47. Back to the Patient • EKG revealed no evidence of ischemia • No rise in cardiac enzymes • Echo revealed EF 35%, aortic sclerosis • Patient had received several litres of NS and his diuretics had been stopped on admission • Improved with diuresis

  48. Case 5 • The patient has been recovering from his surgery and is no longer in CHF. He is almost ready to go home but routine bloodwork reveals hyponatremia (Na 122).

  49. Hyponatremia • Common • Incidence 4.4% post-op • Why do patients get hyponatremic post-op? • Fluid shifts • IV fluid, third spacing, irrigation • Stress of surgery (increased ADH) • Hyperglycemia

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