The Medical Tune Up

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The Medical Tune Up

• Dr. Debra Pugh
• MD, FRCPC
• Internal Medicine

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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

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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

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Case 1

• The nurse asks you what you want to do about the
  patients oral hypoglycemics and insulin on
  admission

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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

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DM in the Surgical Patient

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

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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

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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

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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

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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

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Start insulin infusion
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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

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Case 2

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

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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

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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

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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

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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.

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Delirium

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

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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

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Risk Factors for Delirium

• 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

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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

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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

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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

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Case 3

• 2 days later some routine labs reveal that your
  patients Cr has increased to 320 (from baseline
  of 180)

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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

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Approach to Renal Failure
Pre-Renal
Renal
Post-Renal
Hypovolemia Renal perfusion
ATN GN AIN Renovascular
Prostatic Bilateral ureteric
Review meds Contrast Urine RM (Casts,Protein Blo
od)
Foley cathether Renal U/S
Assess volume status FENa
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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

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Approach to ARF

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

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Approach to ARF

• Assess for acute indications for dialysis
• Hyperkalemia (if high ask for EKG)
• Acidosis
• Volume overload
• Uremic Pericarditis

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Approach to ARF

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

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Approach to ARF

• Urine R M
• Hematuria, Proteinuria
• Casts
• Granular ATN
• WBC AIN
• RBC GN, vasculitis

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Approach to ARF

• Serum and urine electrolytes (FENa)
• Urine Na x Plasma Cr x 100
• Plasma Na x Urine Cr
• lt 1 suggest volume depletion
• IV fluids if indicated

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Approach to ARF

• Rule out post-renal causes
• Insert Foley Catheter
• Renal U/S

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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 gt 1
• Consistent with ATN, probably related to contrast
  dye

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Contrast-induced nephropathy

• Incidence increases as GFR decreases
• Renal failure starts almost immediately
• Recovery begins within 3-5 days

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Contrast-induced nephropathyRisk Factors

• Renal insufficiency (GFR lt 60ml/min)
• Diabetic nephropathy
• Advanced CHF
• High dose contrast
• Multiple Myeloma

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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

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Case 4

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

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Case 4

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

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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

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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

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Differential Diagnosis

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

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Initial Management

• ABCs
• Order investigations
• EKG
• CXR
• ABG
• Labs
• CBC, Lytes, Urea, Cr, Cardiac Enzymes

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Pulmonary Edema
Vascular redistribution
Peribronchial cuffing
Kerly B Line
Cardiomegaly
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Treating Acute Pulmonary Edema

• LMNOP
• Oxygen
• Lasix
• Nitrates
• Morphine
• Positioning, Positive Pressure (BIPAP)
• Intubation (hopefully avoidable)

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Determining Cause CHF

• Iatrogenic (stopping patients diuretics,
  aggressive IV fluids)
• Echo (systolic/diastolic dysfunction, valvular
  dysfunction)
• Ischemia/Infarction
• Arrhythmia

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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

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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).

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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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Commonest causes Post-op

• Euvolemic (SIADH) 42
• Hypervolemic 21
• Hyperglycemia 21
• Hypovolemia 8
• Renal failure 8

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Measure serum osmolality
Isotonic
Hypertonic
Hypotonic
Hyperglycemia Mannitol
Hyperproteinemia Hyperlipidemia
Hypervolemic
Euvolemic
Hypovolemic
Renal losses GI losses Third spacing
CHF Cirrhosis Nephrotic
SIADH Psychogenic Endocrine Drugs
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Approach to Hyponatremia

• Serum lytes and osmolality
• Glucose
• Volume status
• Urine lytes and osmolality

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Approach to Hyponatremia

• Serum lytes, glucose, and osmolality
• Usually hypotonic
• If isotonic consider pseudohyponatremia
• If hypertonic consider hyperglycemia, mannitol

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Approach to Hyponatremia

• Volume status
• If hypotonic, assess volume status

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Approach to Hyponatremia

• Urine lytes and osmolality
• Normal response to hyponatremia is to suppress
  ADH secretion low urine osmolality
• Urine Na will be low if hypovolemia
• Interpret with caution if on diuretics
• In SIADH
• Urine osmolality gt 100, usually gt 300
• Urine Na gt 20, usually gt 40

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Treatment of Hyponatremia

• Avoid rapid correction due to risk of central
  pontine myelinolysis
• Correct by 0.5-1 mEq/hour

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Treatment of Hyponatremia

• Hyervolemic
• Fluid and Na restrict
• Diuretics
• Euvolemic
• Fluid restriction
• 1.5 litres/d

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Treatment of Hyponatremia

• Hypovolemic
• IV NS
• Usually about 75cc/hr
• Change in serum Na infusate Na serum Na
• total body water 1
• Estimates the effect of 1 litre of any infusate
  on serum Na
• NS 154 mmol/litre

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Treatment of Hyponatremia

• Hypertonic saline in extreme cases
• i.e. Seizure
• Assistance from ICU or Internal Medicine

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Back to the patient

• Examination reveals dry MM, flat JVP
• Serum Na is 122, Serum osmolality is low
• Urine osmolality is 150, Urine Na is lt10
• Consistent with hypovolemic hyponatremia, likely
  secondary to aggressive diuresis
• The patient is treated with IV NS at 75cc/hr with
  40 mEq KCl/litre

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Case 6

• The patients nurse calls you with a critical
  potassium of 6.8

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What would you do for this patient?

• Stat ECG
• Stop any potassium-containing medications or IV
  fluids
• Stop medications that can contribute to
  hyperkalemia (ACE-I, Spironolactone)
• Stabilize myocardium and treat hyperkalemia

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Prolonged PR
Peaked T waves
Short QT
Also widened QRS, sine wave, eventual v. fib
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Treatment of Hyperkalemia

• Stabilizing the myocardium
• Antagonism of membrane actions of K
• 1 amp Calcium Gluconate

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Treatment of Hyperkalemia

• Shifting K into cells
• Insulin Glucose
• 10 units R IV ½ amp D50W
• Sodium bicarbonate
• Beta-2 adrenergic agonists
• Ventolin

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Treatment of Hyperkalemia

• Removal of K from the body
• Cation exchange resin
• Kayexelate 30 g
• Loop or thiazide diuretic
• Dialysis if severe

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Back to the patient

• The patient is found to have an IV solution
  containing potassium which is stopped. You
  stabilize him with calcium gluconate, insulin and
  glucose and he receives Kayexelate. The ECG
  changes resolve and repeat potassium is normal.