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National Teaching Series Prescribing in Surgery Series DATE: 27/02/2024 TIME: 18:30 Tutor: Dr Aisha Musa Prescribing in Surgery Series 2024Prescribing in Surgery Series 2024 National teaching Prescribing in Surgery Dr Hermione Jemmett Dr Sona Petrosyan Dr Aisha Musa Co-lead for Prescribing in Lead for Prescribing at Co-lead for Prescribing in Surgery series Mind the Bleep Surgery series MEET THE TEAM Prescribingin SurgerySeries2024DISCLAIMER The Prescribing in Surgery for Mind the Bleep has been created by junior doctors who have a passion for teaching, entirely on a voluntary basis. The lecture slides and teaching content are accurate to the best of the tutors’ knowledge. Please note, that neither the tutors nor Mind the bleep take responsibility for any unintentionalinaccuracies. Please kindly refer to the full T&C for your reference: https://www.mindthebleep.com/disclaimer/ Prescribingin SurgerySeries2024Surgical prescribing session Provisional date 1: VTE prophylaxis and analgesia 20/02/24 @ 18.30 2: Fluids and electrolyte imbalances 27/02/24 @ 18.30 3: Antibiotics and blood transfusions06/03/24 @ 18.30 4: Prescribing in pre-op 12/03/24 @ 18.30 5: Diabetes medications 19/03/24 @ 18.30 6: Surgical emergencies 1 09/04/24 @ 18.30 7: Surgical emergencies 2 16/04/24 @ 18.30 8: General surgery, colorectal, urolo23/04/24 @ 18.30 9: T+O, ENT, Paediatrics 30/04/24 @ 18.30 10: Surgical questions in PSA 07/05/24 @ 18.30 Prescribingin SurgerySeries2024Case 1 Case presentation A 70-year-old woman presents to A&E with a 4-day history Of vomiting. PMH: Dementia. MH: Nil. Prescription form On examination: RR 22, O2 Sats 97% on room air, temp 36.5, Infusion fluid Route Volume Duration BP 105/60 HR 120 bpm, HS 1+2+0, chest clear, Capillary refill 3 seconds, reduced skin turgor, dry Mucous membranes Investigations: Na 139 (133-146), K 4.1 (3.5-5.3), Ur 16 (2.5-7.8) Cr 130 (43-71) Question Write a prescription for one IV fluid that is most appropriate for the patient currently? Prescribing in Surgery Series 2024Fluid resuscitation in adults Infusion fluid Route Volume Duration Sodium chloride IV 500 ml 10 min 0.9% solution - Alternative infusion fluids: Ringer’s solution, Plasma-lyte 148, Hartmann’s solution - 500 ml under 15 min NICE, 2017 [1] Prescribing in Surgery Series 2024Case 2 Case presentation A 6-year-old boy presents to the paediatric A&E department with a 3-day history of diarrhoea and Prescription form vomiting. PMH: Nil. MH: Nil. On examination: Infusion fluid Route Volume Duration RR 36, O2 Sats 98% on room air, temp 36.5, BP 90/60 HR 140 bpm, HS 1+2+0, chest clear, Capillary refill 3 seconds, reduced skin turgor, dry Mucous membranes. Weight 15 kg. Investigations: Na 139 (133-144), K 4.1 (3.5-5.4), Ur 12 (1.6-6.0) Cr 85 (43-71) Question Write a prescription for one IV fluid that is most appropriate for the patient currently? Prescribing in Surgery Series 2024Fluid resuscitation in children Infusion fluid Route Volume Duration Sodium chloride IV 150 ml 5 min 0.9% solution 10 ml/kg x 15 kg - Alternative infusion fluids: Ringer’s solution, Plasma-lyte 148, Hartmann’s solution - 10 ml/kg under 10 min NICE, 2020 [2] Prescribing in Surgery Series 2024Case 3 Case presentation A 22-year-old man is admitted on to the medical ward for aspiration pneumonia. PMH: Cerebral palsy. MH: Baclofen Prescription form On examination: RR 12, O2 Sats 98% on room air, temp 36.5, Infusion fluid Route Volume Duration BP 140/80 HR 70 bpm, HS 1+2+0, crackles heard on auscultation. He is judged to have an unsafe swallow. Weight 80 kg. Investigations: Na 141 (133-146), K 4.3 (3.5-5.3), Ur 6.8 (2.5-7.8) Cr 60 (54-90) He has already had Sodium chloride 0.9%/potassium chloride 0.3% (40 mmol/L) 1000 ml over 12 hours. Question Write a prescription for one IV fluid most appropriate for the patient currently, whilst he is NBM? Prescribing in Surgery Series 2024Fluid maintenance in adults- daily requirements NICE, 2017 [3] Prescribing in Surgery Series 2024Fluid maintenance in adults- fluid infusion bags Maintenance fluid duration: - 8-12 hourly bags Fluid infusion bags available: - sodium chloride 0.9%/potassium chloride 0.15% 1000 ml - sodium chloride 0.9%/potassium chloride 0.3% 1000 ml - glucose 5%/potassium chloride 0.15% 1000 ml - glucose 5%/potassium chloride 0.3% 1000 ml BNF- NICE, 2024 [4] Composition of above bags: - sodium chloride 0.9% 1000 ml- contains 154 mmol Na/Cl - potassium chloride 0.15% 1000 ml- contains 20 mmol K - potassium chloride 0.3% 1000 ml- contains 40 mmol K - glucose 5% 1000 ml- contains 50 g glucose [5] Prescribing in Surgery Series 2024Fluid maintenance in adults- Composition of commonly used crystalloids NICE, 2016 [5] Prescribing in Surgery Series 2024Fluid maintenance in adults Daily requirement 1 Bag given Requirements for 2 bag 2 bag 25-30 ml/kg- water 1 mmol/kg- K/Na/Cl Sodium chloride Glucose 5%/potassium 50-100 g- Glucose 0.9%/potassium chloride chloride 0.3% solution 0.3% 1000 ml over 12 1000 ml Weight is 80 kg hours Over 8-12 hours 25 ml/kg x 80 kg = 2000 ml 1000 ml water 1000-1400 ml water 1000 ml water 30 ml/kg x 80 kg = 2400 ml 2000-2400 ml water 1 mmol/kg x 80 kg= 154 mmol Na/Cl No more needed 80 mmol Na/Cl 1 mmol/kg x 80 kg= 40 mmol K 40 mmol k 40 mmol k 80 mmol K 50-100 g Glucose 50-100 g glucose 50 g glucose Prescribing in Surgery Series 2024Case 4 Case presentation A 56-year-old woman presents to A&E with 2-day history of diarrhoea, which she said started after eating takeaway. Prescription form PMH: Hypertension. MH: Amlodipine 5 mg PO daily On examination: Infusion fluid Route Volume Duration RR 12, O2 Sats 99% on room air, temp 36.2, BP 140/80 HR 80 bpm, HS 1+2+0, chest clear, Weight 80 kg Investigations: Na 131 (133-146), K 3.2 (3.5-5.3), Ur 5.4 (2.5-7.8) Cr 60 (43-71) Question Write a prescription for one IV fluid that is most appropriate for the patient currently? Prescribing in Surgery Series 2024Fluid maintenance and replacement in adults NICE, 2017 [6] NICE, 2017 [6] Prescribing in Surgery Series 2024Fluid maintenance and replacement in adults Infusion fluid Route Volume Duration Sodium chloride IV 1000 ml 4-6 hours 0.9%/potassium chloride 0.3% solution - It is better to prescribe Infusion fluid containing potassium chloride 0.3% solution instead of potassium chloride 0.15% solution because: ➢ Weight is 80 kg so daily requirement of potassium is 80 mmol (1 mmol/kg x 80 kg) ➢ And is also losing ‘30-70 mmol potassium’ because of diarrhoea ➢ So better to prescribe potassium chloride 0.3% solution (contains 40 mmol k), than potassium chloride 0.15% solution (contains 20 mmol K) - When prescribing fluids for maintenance and replacement: Instead of 8-12 hourly bags, prescribe 4-6 hourly bags to replace loss/deficit Prescribing in Surgery Series 2024Case 5 Case presentation An 11-year-old girl is admitted to the paediatric ward and treated for tonsilitis with clarithromycin. PMH: Rheumatic fever. MH: Nil. Allergy: Penicillin On examination: RR 12, O2 Sats 99% on room air, temp 36.5 BP 130/80 HR 80 bpm, HS 1+2+0, chest clear. Weight 35 kg. Investigations: Na 139 (133-144), K 4.2 (3.5-5.4), Ur 5.4 (1.6-6.0) Cr 40 (29-53) Question Calculate the 24-hour maintenance fluid requirement for this patient? Prescribing in Surgery Series 2024Fluid maintenance in children BNFc- NICE, 2024 [8] NICE, 2020 [7] Prescribing in Surgery Series 2024Fluid maintenance in children Weighs 35 kg so… BNFc- NICE, 2024 [8] First 10 kg: 10 kg x 100 ml= 1000 ml Next 10 kg: 10 kg x 50 ml= 500 ml Remaining weight (15 kg): 15 kg x 20 ml= 300 ml Total fluid maintenance= 1800 ml (over 24 hours) Prescribing in Surgery Series 2024Case 6 Case presentation An 80-year-old woman is admitted to the trauma and orthopaedics ward after surgery for her NOF fracture. Prescription form Ward doctors have been asked to see the patient as she became unconscious after the ward round. PMH: Type 2 Diabetes. MH: Metformin 500 mg PO three times daily Infusion fluid Route Volume Duration With meals. On examination: RR 12, O2 Sats 95% on room air, temp 36.5, BP 140/70 HR 90 bpm, HS 1+2+0, chest clear. Blood glucose test 1.3 mmol/l She is unresponsive to glucagon after 10 minutes. Question Write a prescription for one IV fluid that is most appropriate for the patient currently? Prescribing in Surgery Series 2024Hypoglycaemia BNF- NICE, 2024 [9] Infusion fluid Route Volume Duration Glucose 10% IV 150-200 ml 15 min OR Glucose 20% IV 75-100 ml 15 min Prescribing in Surgery Series 2024Hypoglycaemia BNF- NICE, 2024 [9] Prescribing in Surgery Series 2024Case 7 Case presentation A 45-year-old man is being treated in A&E for burns secondary to a house fire. During admission, he suddenly Prescription form develops palpitations and chest pain. PMH: Eczema. MH: Nil. Infusion fluid Route Volume Duration On examination: RR 12, O2 Sats 97% on room air, temp 36.5, BP 140/70 HR 100 bpm, HS 1+2+0, chest clear. Investigations: Na 140 (133-146), K 6.6 (3.5-5.3), Ur 7.6 (2.5-7.8) Cr 85 (54-90) ECG- tall tented t wave, flattened p waves Question Write a prescription for one IV fluid that is most appropriate for the patient currently? Prescribing in Surgery Series 2024Hyperkalaemia BNF- NICE, 2024 [10] Prescribing in Surgery Series 2024Hyperkalaemia Infusion Route Volume Duration fluid Calcium IV 10 ml 5 min chloride 10% OR Calcium gluconate IV 30 ml *10 min 10% BNF- NICE, 2024 [12] The Renal Association, 2020 [11] Prescribing in Surgery Series 2024Case 8 Case presentation A 30-year-old woman presents to A&E with myalgia and generalised weakness. PMH: Acne vulgaris MH: Benzoyl Prescription form Peroxide. On examination: Infusion fluid Route Volume Duration RR 12, O2 Sats 96% on room air, temp 36.5, BP 140/70 HR 90 bpm, HS 1+2+0, chest clear. Investigations: Na 140 (133-146), K 2.2 (3.5-5.3), Ur 5.4 (2.5-7.8) Cr 60 (43-71) ECG- ST depression, prominent U wave Question Write a prescription for one IV fluid that is most appropriate for the patient currently? Prescribing in Surgery Series 2024Hypokalaemia BNF, 2024 [13] Max rate without ECG monitoring is 10 mmol/hr [14] Potassium 0.3% contains 40 mmol k So shortest duration without ECG monitoring is 4 hours. Infusion fluid Route Volume Duration Sodium chloride IV 1000ml 4 hours 0.9%/potassium chloride 0.3% solution Prescribing in Surgery Series 2024Case 9 Case presentation A 60-year-old man presents to A&E with nausea, constipation and painful bones. PMH: Nil. MH: Calcium Prescription form supplements. On examination: Infusion fluid Route Volume Duration RR 12, O2 Sats 98% on room air, temp 37, BP 140/80 HR 80 bpm, HS 1+2+0, chest clear. Investigations: Ca 3.5 (2.14-2.51), Na 142 (133-146), K 4.4 (3.5-5.3), Ur 5.7 (2.5-7.8), Cr 60 (54-90) Question Write a prescription for one IV fluid that is most appropriate for the patient currently? Prescribing in Surgery Series 2024Hypercalcemia BNF, 2024 [15] - When prescribing fluids for maintenance and replacement: Instead of 8-12 hourly bags, prescribe 4-6 hourly bags to replace loss/deficit Infusion fluid Route Volume Duration Sodium chloride 0.9% IV 1000ml 4-6 hours Prescribing in Surgery Series 2024Case 10 Case presentation A 38-year-old woman presents to A&E with perioral paraesthesia and muscle cramps. PMH: Anxiety. MH: Prescription form Sertraline. On examination: RR 12, O2 Sats 98% on room air, temp 36.5, Infusion fluid Route Volume Duration BP 140/70 HR 90 bpm, HS 1+2+0, chest clear. Trousseau’s sign positive. Chvostek’s sign positive. Investigations: Ca 1.5 (2.14-2.51) Na 141 (133-146), K 4.3 (3.5-5.3), Ur 6.3 (2.5-7.8) Cr 60 (43-71) ECG- prolonged QT Question Write a prescription for one IV fluid that is most appropriate for the patient initially? Prescribing in Surgery Series 2024Hypocalcaemia BNF, 2024 [16] BNF, 2024 [17] Prescribing in Surgery Series 2024Hypocalcaemia Therefore, initially we give: Infusion fluid Route Volume Duration Calcium gluconate 10 IV 10- 20 ml 5- 10 min % Prescribing in Surgery Series 2024Hypocalcaemia NHS West Kent, 2022 [18] Prescribing in Surgery Series 2024References [1] NICE (2017) 1.3 Resuscitation, Intravenous fluid therapy in adults in hospital. Available at: th https://www.nice.org.uk/guidance/cg174/chapter/recommendations#resuscitation-2 (Accessed: 17 February 2024) [2] NICE (2020) 1.3 Fluid resuscitation, Intravenous fluid therapy in children and young people in hospital. Available at: https://www.nice.org.uk/guidance/ng29/chapter/Recommendations#fluid-resuscitation-2 (Accessed: 17 February 2024) [3] NICE (2017) 1.4 Routine maintenance, Intravenous fluid therapy in adults in hospital. Available at: th https://www.nice.org.uk/guidance/cg174/chapter/Recommendations#routine-maintenance-2 (Accessed: 17 February 2024) [4] NICE (2024) BNF, NICE Sodium chloride with glucose. Available at: https://bnf.nice.org.uk/drugs/sodium-chloride-with-glucose/ (Accessed: 17 February 2024) [5] NICE (2017) Composition of commonly used crystalloids. Available at: https://www.nice.org.uk/guidance/cg174/resources/composition-of-commonly-used-crystalloids-table-191662813 (Accessed: 17 th February 2024) [6] NICE (2017) 1.5 Replacement and redistribution, Intravenous fluid therapy in adults in hospital. Available at: https://www.nice.org.uk/guidance/cg174/chapter/recommendations#replacement-and-redistribution (Accessed: 17 February 2024)h [7] NICE (2020) 1.4 Routine maintenance, Intravenous fluid therapy in children and young people in hospital. Available at: th https://www.nice.org.uk/guidance/ng29/chapter/Recommendations#routine-maintenance-2 (Accessed: 18 February 2024) [8] NICE (2024) BNFc, NICE Fluids and electrolytes, Parenteral preparations for fluids and electrolyteimbalance. Available at: https://bnfc.nice.org.uk/treatment-summaries/fluids-and-electrolytes/#parenteral-preparations-for-fluid-and-electrolyte-imbalance (Accessed: 18 February 2024) [9] NICE (2024) BNF, NICE Medical emergenciesin the community, Hypoglycaemia. Available at: https://bnf.nice.org.uk/treatment- summaries/medical-emergencies-in-the-community/#hypoglycaemia (Accessed: 18 February 2024) Prescribing in Surgery Series 2024References [10] NICE (2024) BNF, NICE Fluids and electrolytes,Oral preparations for fluid and electrolyte imbalance. Available at: httth://bnf.nice.org.uk/treatment-summaries/fluids-and-electrolytes/#oral-preparations-for-fluid-and-electrolyte-imbalance (Accessed: 18 February 2024) [11] Alfonzo, A. et al. (2020) Clinical Practice Guidelines Treatment of Acute Hyperkalaemia in Adults. Available at: https://ukkidney.org/sites/renal.org/files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE%20- th %20JULY%202022%20V2_0.pdf (Accessed: 18 February 2024) [12] NICE (2024) BNF, NICE Calcium gluconate, Important safety information. Available at: https://bnf.nice.org.uk/drugs/calcium- gluconate/#important-safety-information (Accessed 24 February 2024) [13] NICE (2024) BNF, NICE Fluids and electrolytes,Parenteral preparations for fluid and electrolyteimbalance. Available at: https://bnf.nice.org.uk/treatment-summaries/fluids-and-electrolytes/#parenteral-preparations-for-fluid-and-electrolyte-imbalance (Accessed: 18 February 2024) [14] Specialist pharmacy service (2020) How should intravenous (IV) potassium chloride be administered in adults? Available at: https://www.sps.nhs.uk/articles/how-should-intravenous-iv-potassium-chloride-be-administered-in-adults/ (Accessed: 19 February 2024) [15] NICE (2024) BNF, NICE Calcium imbalance, Severe hypercalcaemia. Avathable at: https://bnf.nice.org.uk/treatment- summaries/calcium-imbalance/#severe-hypercalcaemia (Accessed: 19 February 2024) [16] NICE (2024) BNF, NICE Calcium imbalance, Calcium supplements. Available at: https://bnf.nice.org.uk/treatment- summaries/calcium-imbalance/#calcium-supplements (Accessed: 19 February 2024) th [17] NICE (2024) BNF, NICE Calcium gluconate. Available at: https://bnf.nice.org.uk/drugs/calcium-gluconate/ (Accessed: 19 February 2024) [18] West Kent Interface formulary, NHS west Kent Clinical Commissioning Group (2022) QUICK GUIDE: TREATMENT OF ACUTE HYPOCALCAEMIA IN ADULT. Available at: https://www.formularywkccgmtw.co.uk/media/1686/hypocalcaemia-quick-guide.pdf (Accessed: 19 February 2024) Prescribing in Surgery Series 2024Feedback form