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The Medical Tune UpThe Medical Tune UpDr. Debra PughDr. Debra Pugh
MD, FRCPCMD, FRCPC
Internal MedicineInternal Medicine
ObjectivesObjectives
Review basic approach to managing Review basic approach to managing common medical issues in surgical common medical issues in surgical patientspatients
Managing DM peri-opManaging DM peri-op The Confused PatientThe Confused Patient Approach to ARFApproach to ARF Acute DyspneaAcute Dyspnea Managing Electrolyte abnormalitiesManaging Electrolyte abnormalities
Case 1Case 1
You are admitting a 70 year old man for You are admitting a 70 year old man for cholecystectomy after a recent episode of cholecystectomy after a recent episode of gallstone pancreatitisgallstone pancreatitis
Past Med Hx: DM II, CAD, HTN, COPDPast Med Hx: DM II, CAD, HTN, COPD Rx: ASA, ACE-I, beta-blocker, statin, Rx: ASA, ACE-I, beta-blocker, statin,
Metformin, insulin, inhaled bronchodilatorsMetformin, insulin, inhaled bronchodilators
Case 1Case 1
The nurse asks you what you want to do The nurse asks you what you want to do about the patient’s oral hypoglycemics and about the patient’s oral hypoglycemics and insulin on admissioninsulin on admission
DM in the Surgical PatientDM in the Surgical Patient
Peri-operative mortality is increased in Peri-operative mortality is increased in patients with DMpatients with DM
Most deaths from heart disease and Most deaths from heart disease and infectioninfection
Poor wound healing and increased Poor wound healing and increased frequency of wound infectionsfrequency of wound infections
DM in the Surgical PatientDM in the Surgical Patient
Ideally BS 4-6Ideally BS 4-6 Peri-operatively the goal is to avoid Peri-operatively the goal is to avoid
excessive highs or lowsexcessive highs or lows Reasonable goal is BS < 11-14 to avoid Reasonable goal is BS < 11-14 to avoid
problems with wound healing and infectionproblems with wound healing and infection Intensive glucose control in ICU settingIntensive glucose control in ICU setting
DM in the Surgical PatientDM in the Surgical Patient
Stresses of surgeryStresses of surgery ↑ ↑ catecholamines and cortisolcatecholamines and cortisol ↑↑gluconeogenesisgluconeogenesis ↑ ↑ glucagon release and ↓ insulin releaseglucagon release and ↓ insulin release ↑ ↑ muscle glucose usemuscle glucose use Drugs can ↑ insulin resistanceDrugs can ↑ insulin resistance
Can all lead to hyperglycemiaCan all lead to hyperglycemia
The Basics: DMThe Basics: DM
Type II (on oral agents only)Type II (on oral agents only) Hold meds the morning of ORHold meds the morning of OR If long-acting (glitazones) stop for 48-72 If long-acting (glitazones) stop for 48-72
hrshrs IV glucoseIV glucose Monitor BS q 6 hMonitor BS q 6 h Consider insulin infusionConsider insulin infusion
The Basics: DM PreopThe Basics: DM Preop
Type I or Type II on Insulin (If minor procedure)Type I or Type II on Insulin (If minor procedure) 1/3 to ½ of usual dose of insulin the morning of 1/3 to ½ of usual dose of insulin the morning of
surgerysurgery IV D5W with 20 meq KCl at 100 cc/hIV D5W with 20 meq KCl at 100 cc/h Monitor glucose q 1-2 hMonitor glucose q 1-2 h Use sliding scale q 4-6 h Use sliding scale q 4-6 h After procedure give usual evening dose of After procedure give usual evening dose of
insulin if eatinginsulin if eating
The Basics: DMThe Basics: DM
Type I or Type II on Insulin (longer Type I or Type II on Insulin (longer procedures)procedures)
Insulin infusionInsulin infusion Run with IV 2/3 + 1/3 or D5WRun with IV 2/3 + 1/3 or D5W Hourly glucoscansHourly glucoscans
Start insulin infusion Start insulin infusion
If BS If BS Insulin R units/hrInsulin R units/hr
0-40-4 No insulin; treat hypoglycemiaNo insulin; treat hypoglycemia
4.1-84.1-8 1 u/hr1 u/hr
8.1-108.1-10 2 u/hr2 u/hr
10.1-1210.1-12 4 u/hr4 u/hr
12.1-1412.1-14 6 u/hr6 u/hr
14.1-1614.1-16 8 u/hr8 u/hr
16.1-1816.1-18 10 u/hr10 u/hr
> 18> 18 10 u/hr and call MD10 u/hr and call MD
Back to the patientBack to the patient
You order ½ the dose of his usual morning You order ½ the dose of his usual morning dose of insulindose of insulin
You ask for frequent glucoscans and write You ask for frequent glucoscans and write an order for a sliding scale of insulinan order for a sliding scale of insulin
His Metformin is held the morning of the His Metformin is held the morning of the procedureprocedure
Case 2 Case 2
The patient is now POD # 2 for open The patient is now POD # 2 for open cholecystectomycholecystectomy
Called to assess for new onset of Called to assess for new onset of confusionconfusion
Case 2Case 2
Past Med Hx: DM II, CAD, HTN, COPDPast Med Hx: DM II, CAD, HTN, COPD Rx: ASA, ACE-I, beta-blocker, statin, Rx: ASA, ACE-I, beta-blocker, statin,
Metformin, insulin, inhaled bronchodilatorsMetformin, insulin, inhaled bronchodilators Demerol for post-op painDemerol for post-op pain LMWH for DVT prophylaxisLMWH for DVT prophylaxis
Case 2Case 2
According to nurse, the patient seemed According to nurse, the patient seemed lucid earlier that daylucid earlier that day
On arrival, the patient appears confused On arrival, the patient appears confused and is not oriented to either time or placeand is not oriented to either time or place
Unable to provide a history or answer Unable to provide a history or answer questions appropriatelyquestions appropriately
Case 2Case 2
On examinationOn examination Vitals are stable and patient is afebrileVitals are stable and patient is afebrile Patient is alert but inattentivePatient is alert but inattentive Mucus membranes are dry, JVP flatMucus membranes are dry, JVP flat No focal neurologic deficitsNo focal neurologic deficits Chest clearChest clear Normal heart sounds, no murmursNormal heart sounds, no murmurs Abdomen benign, wound looks fineAbdomen benign, wound looks fine
DeliriumDelirium
Disturbance of consciousness with reduced Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.ability to focus, sustain, or shift attention.
Change in cognition/new perceptual disturbance Change in cognition/new perceptual disturbance that is not better accounted for by dementia.that is not better accounted for by dementia.
Develops over a short period of time (usually Develops over a short period of time (usually hours to days) and tends to fluctuate during the hours to days) and tends to fluctuate during the course of the day.course of the day.
Presumed to be caused by a medical condition, Presumed to be caused by a medical condition, substance intoxication, or medication side effect.substance intoxication, or medication side effect.
DeliriumDelirium
CommonCommon 10-50% of elderly surgical patients10-50% of elderly surgical patients
Results in prolonged hospitalizationResults in prolonged hospitalization High mortality (14% at 1 month, 22% at 6 High mortality (14% at 1 month, 22% at 6
months)months)
ConfusionConfusion
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
Risk Factors for Delirium Risk Factors for Delirium
PolypharmacyPolypharmacy Untreated painUntreated pain Opioids (esp Opioids (esp
Demerol)Demerol) InfectionInfection ImmobilityImmobility Bladder cathetersBladder catheters Frequent room Frequent room
changeschanges
ICU stayICU stay No windows in roomNo windows in room No eyeglasses or No eyeglasses or
hearing devicehearing device Dementia or organic Dementia or organic
brain diseasebrain disease Advanced ageAdvanced age MalnutritionMalnutrition
Working up DeliriumWorking up Delirium
History and physical examinationHistory and physical examination Review medications, history of EtOH or Review medications, history of EtOH or
benzosbenzos LabsLabs
CBC, Urinalysis, Lytes, calcium, glucose, CBC, Urinalysis, Lytes, calcium, glucose, LFTs, Cr, ABG, CXR,LFTs, Cr, ABG, CXR,
+/- Tox screen, +/- Drug levels+/- Tox screen, +/- Drug levels Other investigations as neededOther investigations as needed
CT head, EEG, LPCT head, EEG, LP
Prevention and Treatment of Prevention and Treatment of DeliriumDelirium
Treat underlying causeTreat underlying cause Maintain hydrationMaintain hydration Avoid restraints; mobilize if possibleAvoid restraints; mobilize if possible Treat painTreat pain Reduce noiseReduce noise Orienting stimuli (window, clock, calendar)Orienting stimuli (window, clock, calendar) Reassurance, bedside sitter, familiar facesReassurance, bedside sitter, familiar faces Neuroleptics if necessaryNeuroleptics if necessary Benzodiazepines, as adjunctBenzodiazepines, as adjunct
Back to the PatientBack to the Patient
Investigations reveal dehydration and a Investigations reveal dehydration and a UTI and he is started on antibiotics and IV UTI and he is started on antibiotics and IV fluidsfluids
Demerol replaced with Dilaudid plus Demerol replaced with Dilaudid plus regular Acetaminophen and NSAIDsregular Acetaminophen and NSAIDs
His family brings in his eyeglasses as well His family brings in his eyeglasses as well as his wristwatch and agree to stay with as his wristwatch and agree to stay with him as much as possible while he is him as much as possible while he is confusedconfused
Case 3Case 3
2 days later some routine labs reveal that 2 days later some routine labs reveal that your patient’s Cr has increased to 320 your patient’s Cr has increased to 320 (from baseline of 180)(from baseline of 180)
Case 3Case 3What do you want to know?What do you want to know?
MedicationsMedications ASA, ACE-I, beta-blocker, statin, Metformin, ASA, ACE-I, beta-blocker, statin, Metformin,
narcotics, acetaminophen, LMWHnarcotics, acetaminophen, LMWH NSAIDs q4h for post-op painNSAIDs q4h for post-op pain
Contrast dyeContrast dye CT head with contrast during delirium work-upCT head with contrast during delirium work-up
Urine output Urine output MinimalMinimal
Volume statusVolume status EuvolemicEuvolemic
Indications for urgent dialysisIndications for urgent dialysis
Pre-Renal Renal Post-Renal
HypovolemiaRenal perfusion
ATNGNAIN
Renovascular
Prostatic Bilateral ureteric
Approach to Renal FailureApproach to Renal Failure
Assess volume statusFENa
Review medsContrastUrine R&M (Casts,ProteinBlood)
Foley cathetherRenal U/S
Commonest causes of ARF in Commonest causes of ARF in hospitalized patientshospitalized patients
ATN 45%ATN 45% Contrast dye, shockContrast dye, shock
Pre-Renal 21%Pre-Renal 21% Diuretics, CHF, ACE-I, NSAIDsDiuretics, CHF, ACE-I, NSAIDs
Acute on Chronic 13%Acute on Chronic 13% Obstruction 10%Obstruction 10% GN or vasculitis 4%GN or vasculitis 4% AIN 2%AIN 2%
Antibiotics, NSAIDSAntibiotics, NSAIDS
Approach to ARFApproach to ARF
Assess if acute indications for dialysisAssess if acute indications for dialysis Review medications Review medications Urine R & MUrine R & M Serum and urine electrolytes (FENa) Serum and urine electrolytes (FENa) Foley catheter, Renal U/SFoley catheter, Renal U/S
Approach to ARFApproach to ARF
Assess for acute indications for dialysisAssess for acute indications for dialysis Hyperkalemia (if high ask for EKG)Hyperkalemia (if high ask for EKG) AcidosisAcidosis Volume overloadVolume overload Uremic PericarditisUremic Pericarditis
Approach to ARFApproach to ARF
Stop medications Stop medications ACE-I ACE-I NSAIDsNSAIDs Metformin (risk of lactic acidosis)Metformin (risk of lactic acidosis) LMWHLMWH Consider different antibioticConsider different antibiotic
Dose-adjust medications as neededDose-adjust medications as needed AntibioticsAntibiotics
Approach to ARFApproach to ARF
Urine R & MUrine R & M Hematuria, Proteinuria Hematuria, Proteinuria CastsCasts
Granular – ATNGranular – ATN WBC – AINWBC – AIN RBC – GN, vasculitisRBC – GN, vasculitis
Approach to ARFApproach to ARF
Serum and urine electrolytes (FENa) Serum and urine electrolytes (FENa)
Urine Na x Plasma CrUrine Na x Plasma Cr x 100 x 100
Plasma Na x Urine CrPlasma Na x Urine Cr
< 1% suggest volume depletion< 1% suggest volume depletion IV fluids if indicatedIV fluids if indicated
Approach to ARFApproach to ARF
Rule out post-renal causesRule out post-renal causes Insert Foley CatheterInsert Foley Catheter Renal U/SRenal U/S
Back to the patientBack to the patient
He has no acute indication for dialysisHe has no acute indication for dialysis Urine R & M reveals several granular Urine R & M reveals several granular
castscasts Renal U/S reveals no evidence obstructionRenal U/S reveals no evidence obstruction FENa is > 1%FENa is > 1% Consistent with ATN, probably related to Consistent with ATN, probably related to
contrast dyecontrast dye
Contrast-induced nephropathyContrast-induced nephropathy
Incidence increases as GFR decreasesIncidence increases as GFR decreases Renal failure starts almost immediatelyRenal failure starts almost immediately Recovery begins within 3-5 daysRecovery begins within 3-5 days
Contrast-induced nephropathyContrast-induced nephropathyRisk FactorsRisk Factors
Renal insufficiency (GFR < 60ml/min)Renal insufficiency (GFR < 60ml/min) Diabetic nephropathyDiabetic nephropathy Advanced CHFAdvanced CHF High dose contrastHigh dose contrast Multiple MyelomaMultiple Myeloma
Contrast-induced nephropathyContrast-induced nephropathyPreventionPrevention
Mucomyst 600mg PO BID for 2 daysMucomyst 600mg PO BID for 2 days HydrationHydration 3 amps of bicarb in 1 litre of D5W at 3 amps of bicarb in 1 litre of D5W at
3.5ml/kg/hr for 1 hour pre and 1.2ml/kg/hr 3.5ml/kg/hr for 1 hour pre and 1.2ml/kg/hr for 6 hours post contrastfor 6 hours post contrast
Case 4Case 4
A few days later, you are called to see the A few days later, you are called to see the patient for sudden onset of dyspneapatient for sudden onset of dyspnea
Case 4Case 4
On arrival patient appears to be in On arrival patient appears to be in moderate respiratory distressmoderate respiratory distress
Reports SOB. Denies chest pain, cough, Reports SOB. Denies chest pain, cough, hemoptysis, or calf painhemoptysis, or calf pain
Case 4Case 4
Sats 92% FiO2 .50, RR 30, HR 120, BP 170/90, Sats 92% FiO2 .50, RR 30, HR 120, BP 170/90, afebrileafebrile
Alert, talking in short sentencesAlert, talking in short sentences Sitting up in bed, using accessory musclesSitting up in bed, using accessory muscles JVP elevatedJVP elevated Crackles heard bilaterallyCrackles heard bilaterally Normal S1/S2, S3 present, no murmur Normal S1/S2, S3 present, no murmur No leg edema, no calf asymmetryNo leg edema, no calf asymmetry
Case 4Case 4
Past Med Hx: DM II, CAD, HTN, COPDPast Med Hx: DM II, CAD, HTN, COPD Rx: ASA, beta-blocker, statin, insulin, Rx: ASA, beta-blocker, statin, insulin,
inhaled broncholdilatorsinhaled broncholdilators Dilaudid, Acetaminophen for post-op painDilaudid, Acetaminophen for post-op pain DVT prophylaxisDVT prophylaxis
Differential DiagnosisDifferential Diagnosis
CHFCHF PEPE Pneumonia or aspirationPneumonia or aspiration COPD/AsthmaCOPD/Asthma Mucus PluggingMucus Plugging Cardiac ischemia, arrhythmiaCardiac ischemia, arrhythmia Other (pneumo or hemothorax, tamponaade, Other (pneumo or hemothorax, tamponaade,
effusion, anemia, acidosis)effusion, anemia, acidosis)
Initial ManagementInitial Management
ABCsABCs Order investigationsOrder investigations
EKGEKG CXRCXR ABGABG LabsLabs
CBC, Lytes, Urea, Cr, Cardiac EnzymesCBC, Lytes, Urea, Cr, Cardiac Enzymes
Kerly B LineCardiomegaly
Vascular redistribution
Peribronchial cuffing
Pulmonary EdemaPulmonary Edema
Treating Acute Pulmonary EdemaTreating Acute Pulmonary Edema
LMNOPLMNOP OxygenOxygen LasixLasix NitratesNitrates MorphineMorphine Positioning, Positive Pressure (BIPAP)Positioning, Positive Pressure (BIPAP) Intubation (hopefully avoidable)Intubation (hopefully avoidable)
Determining Cause CHFDetermining Cause CHF
Iatrogenic (stopping patient’s diuretics, Iatrogenic (stopping patient’s diuretics, aggressive IV fluids)aggressive IV fluids)
Echo (systolic/diastolic dysfunction, Echo (systolic/diastolic dysfunction, valvular dysfunction)valvular dysfunction)
Ischemia/InfarctionIschemia/Infarction ArrhythmiaArrhythmia
Back to the PatientBack to the Patient
EKG revealed no evidence of ischemiaEKG revealed no evidence of ischemia No rise in cardiac enzymesNo rise in cardiac enzymes Echo revealed EF 35%, aortic sclerosisEcho revealed EF 35%, aortic sclerosis Patient had received several litres of NS Patient had received several litres of NS
and his diuretics had been stopped on and his diuretics had been stopped on admissionadmission
Improved with diuresisImproved with diuresis
Case 5Case 5
The patient has been recovering from his The patient has been recovering from his surgery and is no longer in CHF. He is surgery and is no longer in CHF. He is almost ready to go home but routine almost ready to go home but routine bloodwork reveals hyponatremia (Na 122).bloodwork reveals hyponatremia (Na 122).
HyponatremiaHyponatremia
Common Common Incidence 4.4% post-opIncidence 4.4% post-op
Why do patients get hyponatremic post-Why do patients get hyponatremic post-op?op? Fluid shiftsFluid shifts
IV fluid, third spacing, irrigationIV fluid, third spacing, irrigation Stress of surgery (increased ADH)Stress of surgery (increased ADH) HyperglycemiaHyperglycemia
Commonest causes Post-opCommonest causes Post-op
Euvolemic (SIADH) – 42%Euvolemic (SIADH) – 42% Hypervolemic – 21%Hypervolemic – 21% Hyperglycemia – 21%Hyperglycemia – 21% Hypovolemia – 8%Hypovolemia – 8% Renal failure – 8%Renal failure – 8%
Hypervolemic
Isotonic
Euvolemic Hypovolemic
Measure serum osmolality
HypertonicHypotonic
HyperproteinemiaHyperlipidemia
HyperglycemiaMannitol
CHFCirrhosisNephrotic
SIADHPsychogenicEndocrine
Drugs
Renal lossesGI losses
Third spacing
Approach to HyponatremiaApproach to Hyponatremia
Serum lytes and osmolalitySerum lytes and osmolality GlucoseGlucose Volume statusVolume status Urine lytes and osmolalityUrine lytes and osmolality
Approach to HyponatremiaApproach to Hyponatremia
Serum lytes, glucose, and osmolalitySerum lytes, glucose, and osmolality Usually hypotonicUsually hypotonic If isotonic consider pseudohyponatremiaIf isotonic consider pseudohyponatremia If hypertonic consider hyperglycemia, If hypertonic consider hyperglycemia,
mannitolmannitol
Approach to HyponatremiaApproach to Hyponatremia
Volume statusVolume status If hypotonic, assess volume statusIf hypotonic, assess volume status
Approach to HyponatremiaApproach to Hyponatremia
Urine lytes and osmolalityUrine lytes and osmolality Normal response to hyponatremia is to Normal response to hyponatremia is to
suppress ADH secretion: low urine osmolalitysuppress ADH secretion: low urine osmolality Urine Na will be low if hypovolemiaUrine Na will be low if hypovolemia Interpret with caution if on diureticsInterpret with caution if on diuretics
In SIADHIn SIADH Urine osmolality > 100, usually > 300Urine osmolality > 100, usually > 300 Urine Na > 20, usually > 40Urine Na > 20, usually > 40
Treatment of HyponatremiaTreatment of Hyponatremia
Avoid rapid correction due to risk of central Avoid rapid correction due to risk of central pontine myelinolysispontine myelinolysis
Correct by 0.5-1 mEq/hourCorrect by 0.5-1 mEq/hour
Treatment of HyponatremiaTreatment of Hyponatremia
HyervolemicHyervolemic Fluid and Na restrictFluid and Na restrict DiureticsDiuretics
EuvolemicEuvolemic Fluid restrictionFluid restriction 1.5 litres/d1.5 litres/d
Treatment of HyponatremiaTreatment of Hyponatremia
HypovolemicHypovolemic IV NSIV NS Usually about 75cc/hrUsually about 75cc/hr
Change in serum Na = Change in serum Na = infusate Na – serum Nainfusate Na – serum Na
total body water +1total body water +1
Estimates the effect of 1 litre of any infusate on serum NaEstimates the effect of 1 litre of any infusate on serum Na
NS = 154 mmol/litreNS = 154 mmol/litre
Treatment of HyponatremiaTreatment of Hyponatremia
Hypertonic saline in extreme casesHypertonic saline in extreme cases i.e. Seizure i.e. Seizure Assistance from ICU or Internal MedicineAssistance from ICU or Internal Medicine
Back to the patientBack to the patient
Examination reveals dry MM, flat JVPExamination reveals dry MM, flat JVP Serum Na is 122, Serum osmolality is lowSerum Na is 122, Serum osmolality is low Urine osmolality is 150, Urine Na is <10Urine osmolality is 150, Urine Na is <10 Consistent with hypovolemic Consistent with hypovolemic
hyponatremia, likely secondary to hyponatremia, likely secondary to aggressive diuresisaggressive diuresis
The patient is treated with IV NS at The patient is treated with IV NS at 75cc/hr with 40 mEq KCl/litre75cc/hr with 40 mEq KCl/litre
Case 6Case 6
The patient’s nurse calls you with a The patient’s nurse calls you with a critical critical potassium of 6.8potassium of 6.8
What would you do for this patient?What would you do for this patient?
Stat ECGStat ECG Stop any potassium-containing Stop any potassium-containing
medications or IV fluidsmedications or IV fluids Stop medications that can contribute to Stop medications that can contribute to
hyperkalemia (ACE-I, Spironolactone)hyperkalemia (ACE-I, Spironolactone) Stabilize myocardium and treat Stabilize myocardium and treat
hyperkalemiahyperkalemia
Treatment of HyperkalemiaTreatment of Hyperkalemia
Stabilizing the myocardiumStabilizing the myocardium Antagonism of membrane actions of K+Antagonism of membrane actions of K+ 1 amp Calcium Gluconate1 amp Calcium Gluconate
Treatment of HyperkalemiaTreatment of Hyperkalemia
Shifting K+ into cellsShifting K+ into cells Insulin + GlucoseInsulin + Glucose
10 units R IV + ½ amp D50W10 units R IV + ½ amp D50W
Sodium bicarbonateSodium bicarbonate Beta-2 adrenergic agonistsBeta-2 adrenergic agonists
VentolinVentolin
Treatment of HyperkalemiaTreatment of Hyperkalemia
Removal of K+ from the bodyRemoval of K+ from the body Cation exchange resinCation exchange resin
Kayexelate 30 g Kayexelate 30 g
Loop or thiazide diureticLoop or thiazide diuretic Dialysis if severeDialysis if severe
Back to the patientBack to the patient
The patient is found to have an IV solution The patient is found to have an IV solution containing potassium which is stopped. containing potassium which is stopped. You stabilize him with calcium gluconate, You stabilize him with calcium gluconate, insulin and glucose and he receives insulin and glucose and he receives Kayexelate. The ECG changes resolve Kayexelate. The ECG changes resolve and repeat potassium is normal.and repeat potassium is normal.