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PRESCRIBING Part B Bassant AbdelfadeelObjectives ◦ To re-cap the basic principles of safe prescribing and fluid prescriptions ◦ To learn: ◦ To safely and appropriately prescribe palliative care (Last Days of Life) medications, ◦ To review medication in AKI, ◦ To review medications in pre- and post-operative settings, and ◦ To prescribe blood products ◦ To practise applying this learning to tackling common clinical scenariosPRINCIPLES OF SAFE PRESCRIBING Systematic APPROACH 1. Confirm patient identity 2. Check allergy status 3. Consider indications and contraindications 4. Write prescription, including: ◦ Name ◦ Dose ◦ Route ◦ Start date / Stop or review date / Duration ◦ Regular / PRN / STAT ◦ Frequency / Maximum frequency or dose ◦ Indication ◦ Continued / Changed / New ◦ Signature and contact details 5. Check prescriptionBASIC PRINCIPLES All drug prescriptions must be: ◦ Legible ◦ IN CAPITALS ◦ An approved (generic) name eg. salbutamol not Ventolin® ◦ Without abbreviations ◦ UnambiguousPRESCRIBING IN RENAL IMPAIRMENTSCENARIO 1 Mrs Lee is an 89-year-old woman who was admitted to ED with a fall and long lieSCENARIO 1 Mrs Lee is an 89-year-old woman who was admitted to ED with a fall and long lie History: ◦ ambulance which arrived at 3pm, arrival into ED at 10pm. Anuric for >24hoursorSCENARIO 1 Mrs Lee is an 89-year-old woman who was admitted to ED with a fall and long lie History: ◦ HPC – mechanical fall at 8pm, found by careers at 7am the next day, called for ambulance which arrived at 3pm, arrival into ED at 10pm. Anuric for >24hours ◦ PMH – HTN, Heart failure, CKD, T2DM, Malignant otitis externa, chronic back pain.SCENARIO 1 Mrs Lee is an 89-year-old woman who was admitted to ED with a fall and long lie History: ◦ HPC – mechanical fall at 8pm, found by careers at 7am the next day, called for ambulance which arrived at 3pm, arrival into ED at 10pm. Anuric for >24hours ◦ PMH – HTN, Heart failure, CKD, T2DM, Malignant otitis externa, chronic back pain. ◦ DHx – Ramipril, Furosemide, Bendroflumethiazide, Metformin, Sitagliptin, Gentamicin, and NaproxenSCENARIO 1 Mrs Lee is an 89-year-old woman who was admitted to ED with a fall and long lie History: ◦ HPC – mechanical fall at 8pm, found by careers at 7am the next day, called for ambulance which arrived at 3pm, arrival into ED at 10pm. Anuric for >24hours ◦ PMH – HTN, Heart failure, CKD, T2DM, Malignant otitis externa, chronic back pain. ◦ DHx – Ramipril, Furosemide, Bendroflumethiazide, Metformin, Sitagliptin, Gentamicin, and Naproxen ◦ SHx – Lives alone. Ex-smoker. No alcohol.SCENARIO 1 Mrs Lee is an 89-year-old woman who was admitted to ED with a fall and long lie History: ◦ HPC – mechanical fall at 8pm, found by careers at 7am the next day, called for ambulance which arrived at 3pm, arrival into ED at 10pm. Anuric for >24hours ◦ PMH – HTN, Heart failure, CKD, T2DM, Malignant otitis externa, chronic back pain. ◦ DHx – Ramipril, Furosemide, Bendroflumethiazide, Metformin, Sitagliptin, Gentamicin, and Naproxen ◦ SHx – Lives alone. Ex-smoker. No alcohol. Examination: ◦ NEWS 0: RR 20, SpO2 98% on air, BP 96/37, HR 107, confused, Temp 36.1 ◦ Appears clinically stable.SCENARIO 1 Mrs Lee is an 89-year-old woman who was admitted to ED with a fall and long lie History: ◦ HPC – mechanical fall at 8pm, found by careers at 7am the next day, called for ambulance which arrived at 3pm, arrival into ED at 10pm. Anuric for >24hours ◦ PMH – HTN, Heart failure, CKD, T2DM, Malignant otitis externa, chronic back pain. ◦ DHx – Ramipril, Furosemide, Bendroflumethiazide, Metformin, Sitagliptin, Gentamicin, and Naproxen ◦ SHx – Lives alone. Ex-smoker. No alcohol. Examination: ◦ NEWS 0: RR 20, SpO2 98% on air, BP 96/37, HR 107, confused, Temp 36.1 ◦ Appears clinically stable. ◦ A – patent, own ◦ B – equal expansion, good bilateral air entry ◦ C – CRT 3 seconds, HS regular I+II+0, CXR – pulmonary oedema ◦ D – confused, BM 6.2 ◦ E – abdomen SNT, dry mucous membranes, pitting oedema bilaterally, ongoing reduced hearing L ear from malignant OE visible on otoscopeSCENARIO 1 Bloods Today 3 mo ago 1 year ago Mrs Lee is an 89-year-old woman who was admitted to ED with a fall and long lie History: Hb 121 123 120 ◦ HPC – mechanical fall at 8pm, found by careers at 7am the next day, called for ambulance which arrived at 3pm, arrival into ED at 10pm. Anuric for >24hours WCC 8.2 14.9 6.4 ◦ PMH – HTN, Heart failure, CKD, T2DM, Malignant otitis externa, chronic back pain. ◦ DHx – Ramipril, Furosemide, Bendroflumethiazide, Metformin, Sitagliptin, Gentamicin, andatelets 298 354 222 Naproxen ◦ SHx – Lives alone. Ex-smoker. No alcohol. Examination: ◦ NEWS 0: RR 20, SpO2 98% on air, BP 96/37, HR 107, confused, Temp 36.1 eGFR 9 50 46 ◦ Appears clinically stable. Na 134 131 134 ◦ A – patent, own ◦ B – equal expansion, good bilateral air entry K 6.2 4.5 5.0 ◦ C – CRT 3 seconds, HS regular I+II+0, CXR – pulmonary oedema ◦ D – confused, BM 6.2 Urea 20.6 6.1 8.2 ◦ E – abdomen SNT, dry mucous membranes, pitting oedema bilaterally, ongoing reduced hearing L ear from malignant OE visible on otoscope Creatinine 251 98 93 Creatine pH 7.36, Kinase: HCO 21 3- 10,392 SCENARIO 1 on VBG Bloods Today 3 mo ago 1 year ago Mrs Lee is an 89-year-old woman who was admitted to ED with a fall and long lie History: Hb 121 123 120 ◦ HPC – mechanical fall at 8pm, found by careers at 7am the next day, called for ambulance which arrived at 3pm, arrival into ED at 10pm. Anuric for >24hours WCC 8.2 14.9 6.4 ◦ PMH – HTN, Heart failure, CKD, T2DM, Malignant otitis externa, chronic back pain. ◦ DHx – Ramipril, Furosemide, Bendroflumethiazide, Metformin, Sitagliptin, Gentamicin, andatelets 298 354 222 Naproxen ◦ SHx – Lives alone. Ex-smoker. No alcohol. Examination: eGFR 9 50 46 ◦ NEWS 0: RR 20, SpO2 98% on air, BP 96/37, HR 107, confused, Temp 36.1 ◦ Appears clinically stable. Na 134 131 134 ◦ A – patent, own ◦ B – equal expansion, good bilateral air entry K 6.2 4.5 5.0 ◦ C – CRT 3 seconds, HS regular I+II+0, CXR – clear ◦ D – confused, BM 6.2 Urea 20.6 6.1 8.2 ◦ E – abdomen SNT, dry mucous membranes, pitting oedema bilaterally, ongoing reduced hearing L ear from malignant OE visible on otoscope Creatinine 251 98 93AKI – what to treat Correct volume depletion Hyperkalaemia Check for acidosis Check drug chartAKI – what to treat C orrect volume depletion Hyperkalaemia Cautious fluid challenge with dynamic assessment ◦ Check axillary region/leg lift test with tricky fluid balances ◦ Start small (250ml bolus if known cardiac failure) ◦ Always monitor saturations/for any signs of decompensation Check for acidosis Check drug chartAKI – what to treat C orrect volume depletion Hyperkalaemia Cautious fluid challenge with dynamic assessment ◦ Check axillary region/leg lift test with tricky fluid balances ◦ Start small (250ml bolus if known cardiac failure) ◦ Always monitor saturations/for any signs of decompensation Check for acidosis Mild: pH 7.30-7.36, or HCO3>20 Moderate: pH 7.20-7.29, or HCO 30-19 Check drug chart Severe: pH<7.20, or HCO <30 1. Helps decide how urgently to call the med reg/need for an ITU review- may need RRT 2. Obtain a quick K+ resultAKI – what to treat C orrect volume depletion Hyperkalaemia Cautious fluid challenge with dynamic assessment Treat if K+ >6.5 or ECG changes ◦ Check axillary region/leg lift test with tricky fluid balances 1 line if ECG changes: 30mL calcium gluconate ◦ Start small (250ml bolus if known cardiac failure) ◦ Always monitor saturations/for any signs of IV over 5-10mins decompensation ◦ Repeat if ECG changes are persistent Check for acidosis Then: Insulin dextrose IV Mild: pH 7.30-7.36, or HCO3>20 Then: Salbutamol 10-20mg nebs Moderate: pH 7.20-7.29, or HCO 30-19 Severe: pH<7.20, or HCO <30 Check drug chart 1. Helps decide how urgently to call the med reg/need for an ITU review- may need RRT 2. Obtain a quick K+ resultAKI – what to treat C orrect volume depletion Hyperkalaemia Cautious fluid challenge with dynamic assessment Treat if K+ >6.5 or ECG changes ◦ Check axillary region/leg lift test with tricky fluid balances ◦ Start small (250ml bolus if known cardiac failure) 1 line if ECG changes: 30mL calcium gluconate IV over 5-10mins ◦ Always monitor saturations/for any signs of decompensation ◦ Repeat if ECG changes are persistent Check for acidosis Then: Insulin dextrose IV Mild: pH 7.30-7.36, or HCO3>20 STOP Consider Then: Salbutamol 10-20mg nebs stopping Moderate: pH 7.20-7.29, or HCO 30-19 NSAIDs Metformin Check drug chart: Severe: pH<7.20, or HCO <30 Aminoglyc Lithium osides Digoxin 1. Helps decide how urgently to call the med reg/need for ACE-I an ITU review- may need RRT ARB Diuretics 2. Obtain a quick K+ resultManaging an AKI: things to do before calling med reg Managing an AKI: things to do before calling med reg 1. Bloods: including baseline creatinine, inflammatory markers, CK 2. Drug chart: on any nephrotoxic meds? STOP Consider 3. VBG: look at pH, K+, HCO3+ stopping 4. Urine dipstick- blood, protein, nitrates, leucocytes NSAIDs Metformin Aminoglycosid Lithium 5. Obs chart- you will be asked BP! es Digoxin 6. Fluid balance- how much fluid in/out? a. Any clinical evidence of overload? ACE-I b. If oligo/anuric: bladder scan to exclude obstructive cause ARB Diuretics 7. Request renal USS: if no identifiable pre-renal cause found RRT: urgent requirement if refractory… !!!!Acidosis, hyperkalaemia, pulmonary oedema, ingestion, encephalopathy/uraemia How long to hold the medications for Things to thinks about What to monitor o Has the AKI resolved? oBloods results – eGFR and creatinine back to baseline oUrine output oDoes the patient need these drugs? oBP, fluid status, pain oGP to follow up on discharge if neededPRESCRIBING IN END OF LIFE CARE SCENARIO 2 Mr Jones is a 96-year-old man who has dementia, end stage for treatment with a community-acquired pneumonia.been admitted After 5 days of IV abx there has been no improvement to his symptoms, he is drowsy for most of the day and is confused if he is awake, and he does not wish to eat or drink. His NEWS score is consistently at 10 in the last 48 hours: RR 30, Saturation 92% on 1 L oxygen, HR 86, BP 94/56, confused, temp 36.5 After a discussion with his family and the consultant and the nurse, it was felt that Mr Jones is unlikely to improve, and is now actively dying. The consultant has updated Mr Jones’ TEP form and has asked you to stop his regular medications and start him on the “anticipatory” medicationsAnticipatory medications Symptoms Medication Starting dose Route of delivery Pain/breathlessness Morphine 2.5-5mg hourly Subcut Fentanyl (for eGFR 25-50mcg hourly <30) Agitation/delirium Haloperidol 2.5-5mg s/c max 10mg/24h Subcut Midazolam 6.25mg 2 hrly 12.5- Levomepromazine 50mg/24h Nausea + vomiting Levomepromazine 6.25mg 2 hrly Subcut Cyclizine 50mg Max TDS Ondansetron 4-8mg Max TDS Respiratory tract Hyoscine butylbromide / 200mcg 2h max Subcut secretions Glycopyrronium 1200mcg/24h Opiates Initiating morphine – trial immediate release Convert to 24h modified release BD/12h morphine ◦ Gives greatest flexibility e.g., 2-5mg IR ormorph ● MST: add up total in 24h/divide by 2 4hrly ● make morphine dose available as PRN ◦ Works in 20mins, lasts 4h (1/6 -1/10 of 24h dose, max 6 ◦ 1/6 of total daily dose for each breakthrough dose doses/24h, assess after 30-60min) ◦ Severe renal impairment: may need to increase the I/R dosing interval (eg. To 6-8 hourly), or select aSwitching opioids (should ALWAYS only different opioid (oxycodone better in CKD). Seek be one 1 strong opioid): advice 1. Oral morphine to oral oxycodone: divise by 1.5-2 Increase the dose by 30% (safe + effective) 2. Oral morphine to subcut morphine: divide o A dose increment of < 30% adds very little by 2 increase to analgesia 3. Oral codeine/tramadol to oral morphine: o Dose increments of > 50% could lead to toxicity divide by 10 o Seek specialist advise if unsureAnti-emetics Higher neuro GI causes: Chemoreceptor: causes: -gastric stasis due to autonomic -drugs- opioids, -ventricular ICP neuropathy, drugs (opioids), antibiotics, ssri, nsaids -psychiatric mechanical obstruction -hyperCa, Mg, Na -sensory pain -hypercalcaemia -renal/liver disease -constipation -sepsis Syringe driver oUsed to administer subcutaneous infusion of a drug(s) over a 24 hour period oNot always required in end of life care: add the medication required oPrescribe the dose of a drug to be infused over 24 hrs oGET ADVICE FROM PALLIATIVE CARE oBefore you start a patient on a subcutaneous syringe driver, you need to first know how much of each medication the patient has used in the past 24hours oPRNs may still be required despite a syringe driver o Help to aid symptoms o Help with further SCSD formulationsPRESCRIBING PERI- OPERATIVELYSCENARIO 3 You are the surgical FY1 on take working nights. You receive a patient from A&E Mrs Rachel Browning, 58yr old woman presented with severe abdo pain and vomiting. Bowels not opened for two days, not passing flatus. Can’t keep any food or fluids down.SCENARIO 3 You are the surgical FY1 on take working nights. You receive a patient from A&E Mrs Rachel Browning, 58yr old woman presented with severe abdo pain and vomiting. Bowels not opened for two days, not passing flatus. Can’t keep any food or fluids down. PMH: lap appendicectomy, total abdominal hysterectomy + BSO, recent DVT, hypertension and high cholesterol, T2DM, raised BMI (37) DH: Rivaroxaban, atorvastatin, lisinopril, metformin NKDA. Recently stopped Ellest-Solo (estradiol) Why?SCENARIO 3 You are the surgical FY1 on take working nights. You receive a patient from A&E Mrs Rachel Browning, 58yr old woman presented with severe abdo pain and vomiting. Bowels not opened for two days, not passing flatus. Can’t keep any food or fluids down. PMH: lap appendicectomy, total abdominal hysterectomy + BSO, recent DVT, hypertension and high cholesterol, T2DM, raised BMI (37) DH: Rivaroxaban, atorvastatin, lisinopril, metformin NKDA. Recently stopped Ellest-Solo (estradiol) Why? Observations: RR 22, Sats 97% on RA, HR 102 bpm, BP 109/78 mmHg, Temp 37.2C, alert = NEWS 4SCENARIO 3 CONTINUED Exam findings: Cool peripheries, dry mucus membranes, tachycardic, tachypnoeic. Looks unwell ◦ Generalised abdominal distension ◦ Tender on palpation and percussion, worse peri-umbilically ◦ Tympanic resonance on percussion ◦ Guarding present ◦ Minimal bowel sounds, absent in LUQ and LLQSCENARIO 3 CONTINUED Exam findings: Cool peripheries, dry mucus membranes, tachycardic, tachypnoeic. Looks unwell ◦ Generalised abdominal distension ◦ Tender on palpation and percussion, worse peri-umbilically ◦ Tympanic resonance on percussion ◦ Guarding present ◦ Minimal bowel sounds, absent in LUQ and LLQ AXR in A&ESCENARIO 3 CONTINUED Exam findings: Cool peripheries, dry mucus membranes, tachycardic, tachypnoeic. Looks unwell ◦ Generalised abdominal distension ◦ Tender on palpation and percussion, worse peri-umbilically ◦ Tympanic resonance on percussion ◦ Guarding present ◦ Minimal bowel sounds, absent in LUQ and LLQ AXR in A&E Diagnosis: Small bowel obstruction (SBO) Immediate management Fluids Analgesia Antiemetics “Drip & suck”Immediate management Fluids – resuscitation and maintenance ◦ Fluid bolus challenge: 500ml Saline or Hartmann’s, recheck BP after bolus; second bolus may be required. (250ml bolus for elderly or compromised cardiac function) ◦ Slow IV fluids as maintenance and once serum electrolytes are known e.g. 8 hourly bag 0.9% NaCl + 40mmol KCl, followed by 8 hourly bag Hartmann’s Analgesia AntiemeticsImmediate management Fluids – resuscitation and maintenance ◦ Fluid bolus challenge: 500ml Saline or Hartmann’s, recheck BP after bolus; second bolus may be required. (250ml bolus for elderly or compromised cardiac function) ◦ Slow IV fluids as maintenance and once serum electrolytes are known e.g. 8 hourly bag 0.9% NaCl + 40mmol KCl, followed by 8 hourly bag Hartmann’s Analgesia ◦ IV paracetamol (1g QDS), IV morphine (2-10mg 2-4 hourly) – always prescribe Naloxone! 400mcg in 100mcg aliquots ◦ PR Diclofenac (100mg 18 hourly) AntiemeticsImmediate management Fluids – resuscitation and maintenance ◦ Fluid bolus challenge: 500ml Saline or Hartmann’s, recheck BP after bolus; second bolus may be required. (250ml bolus for elderly or compromised cardiac function) ◦ Slow IV fluids as maintenance and once serum electrolytes are known e.g. 8 hourly bag 0.9% NaCl + 40mmol KCl, followed by 8 hourly bag Hartmann’s Analgesia ◦ IV paracetamol (1g QDS), IV morphine (2-10mg 2-4 hourly) – always prescribe Naloxone! 400mcg in 100mcg aliquots ◦ PR Diclofenac (100mg 18 hourly) Antiemetics ◦ IV Ondansetron 4-8mg TDS, Cyclizine 50mg TDS ◦ IM Prochlorperazine 12.5mg ◦ AVOID METOCLOPRAMIDE in bowel obstruction!Immediate management Ryles tube – large bore NGT ◦ Aspirate fluid then leave on free drainage ◦ Close fluid input-output monitoring “Drip and suck”Immediate management Ryles tube – large bore NGT ◦ Aspirate fluid then leave on free dr“Drip and suck” ◦ Close fluid input-output monitoring ALWAYS THINK VTEImmediate management Ryles tube – large bore NGT ◦ Aspirate fluid then leave on free drainage “Drip and suck” ◦ Close fluid input-output monitoring VTE risk reduction: LMWH and TED stockings ◦ High risk for VTE: dehydration and immobility ◦ Accurate patient weight ◦ Low molecular weight heparin (LMWH) e.g. Enoxaparin or Dalteparin prophylactic dose based on weight ◦ If already on anticoagulation, will need TREATMENT dose LMWH ◦ TEDs on all surgical patients – if contraindicated, consider flowtrons/compression bootsRegular medications Prescribe regular medications – consider change of route or alternative if NBM ◦ Best to prescribe all regular medications and ‘hold’ those that cannot be taken, to avoid regular medicines being missed during hospital stay Mrs Browning: Rivaroxaban, atorvastatin, lisinopril, metformin What would you like to do with Mrs Browning reg meds?Regular medications Prescribe regular medications – consider change of route or alternative if NBM ◦ Best to prescribe all regular medications and ‘hold’ those that cannot be taken, to avoid regular medicines being missed during hospital stay Mrs Browning: Rivaroxaban, atorvastatin, lisinopril, metformin ◦ Rivaroxaban: convert to treatment dose LMWH ◦ Atorvastatin: hold until able to eat & drink ◦ Lisinopril: hold until able to eat & drink ◦ If raised BP, can consider IV Labetalol, IV Hydralazine – always consult Med Reg ◦ Metformin: hold until able to eat & drink ◦ Regular capillary blood glucose checksScenario 3 continued CT scan confirms SBO- likely adhesional Conservative management not successful, pain very severe – decision taken to go to theatre two days after admission Mrs Browning has not eaten food for four days You are asked to book the patient on the emergency theatre list for the next morning, and to ‘make sure she’d ready for theatre’Pre-op prescribing principles Always get an accurate patient weight ◦ Important for accurate prescribing: analgesia (Paracetamol), LMWH, antibiotics (Gentamicin) NBM/clear fluids only – this does not include regular oral medications! ◦ No food/milky drinks 6 hours prior to general anaesthetic Slow IV fluids ◦ Even though patients can have free fluids, often a reluctance/unable to drink ◦ Correct electrolyte imbalances; do not overload with fluids! ±3L /day if unable to drink Anticoagulants ◦ Switch from DOAC (Apixaban, Rivaroxaban) or Warfarin to treatment dose LMWH as soon as admitted to hospital. Omit LMWH dose the night before if surgery is in the morning; reduce dose to prophylactic if needed prior to surgery If insulin-dependant diabetic, will require a ‘sliding scale’ Variable Rate IV Insulin Infusion (VRIII) ◦ Aim to do diabetics first on the list if possible Oral antidiabetics Day prior to admission Day of surgery (morning operation) Day of surgery (afternoon operation) Metformin Take as normal If taken OD/ BD - take as normal If taken OD/ BD - take as normal If taken TDS, omit lunchtime dose If taken TDS, omit lunchtime dose Sulfonylureas e.g gliclazide Take as normal If taken OD (morning) - omit dose that day If taken OD in the morning - omit dose that day If taken BD - omit morning dose If taken BD - omit both doses that day DPP IV inhibitors (-gliptins) Take as normal Take as normal Take as normal GLP-1 analogues (-tides) Take as normal Take as normal Take as normal SGLT-2 inhibitors (-flozins) Take as normal Omit on the day of surgery Omit on the day of surgery OD insulins (e.g. Lantus) Reduce dose by 20% Reduce dose by 20% Reduce dose by 20% BD Biphasic (e.g. Humulin No dose change Halve morning dose. Take eve dose as normal Halve morning dose. Take eve dose as normal M3)Pre- and post-op prescribing principles Have a high index of suspicion in patients who have not eaten for 3+ days Why?Pre- and post-op prescribing principles Have a high index of suspicion in patients who have not eaten for 3+ days These patients are at risk of REFEEDING SYNDROME when they start consuming calories Refeeding syndrome: ◦ Electrolyte disturbances: low phosphate, low potassium, low magnesium, high calcium levels ◦ Cardiac arrhythmias, neurological disturbances, coma, death ◦ Management: reduce calorie intake, measure and replace electrolytes daily (daily refeeding bloods), IV Pabrinex (B and C vitamins) – 1 pair OD for 5-7 days ◦ Start patients on IV Pabrinex or PO vitamins (B Co-strong + Thiamine + Forceval) if they are at risk of refeeding syndrome – do not wait for it to develop ◦ Always get dietetics involved early on if someone is at risk of refeeding syndromeSCENARIO 3 CONTINUED Mrs Browning underwent a midline laparotomy and adhesiolysis to relieve her SBO She returned to the ward with bilateral rectus sheath catheters in situ, and the Ryles tube had been removed. She is started on a light diet when back on the ward. Three days post-op the RSCs have been removed. Mrs Browning complains of a painful, distended abdomen on ward round. She says she can’t pass any wind and hasn’t opened her bowels since before she was admitted to hospital. She asks the Consultant if the surgery had been for nothing as she feels her symptoms are starting again. Is she back in small bowel obstruction?Post-op prescribing principles Read the operation notes for specific instructions from surgeon e.g. ‘Give prophylactic dose LMWH at 22:00 tonight’ or ‘Restart Apixaban 48 hour after surgery’ VTE prophylaxis: continue LMWH and TEDs – patients will often remove them! May also require LMWH on discharge Analgesia: start strong and gradually decrease ◦ Combine different classes: paracetamol, NSAID, opiates for acute pain ◦ Regular analgesia and PRN for breakthrough pain ◦ Avoid doubling up opiates especially if has PCA or rectus sheath catheters post-op Constipation: due to immobility and opiates – always prescribe laxatives if not NBM Ileus: common post-pelvic or -abdominal surgery; deceleration or arrest of intestinal motility. Prokinetic require Ryles if vomiting severe10mg TDS, as well as Glycerine suppositories 4g OD. May also Antiemetics: N&V from pain and opiates SCENARIO 3 conclusion Mrs Browning begins vomiting again and requires another Ryles tube insertion to decompress her GI tract. After lots of mobilisation with the physios, IV Metoclopramide and regular PR Glycerine suppositories she manages to start passing flatus, and the following day she opens her bowels. During this time she was on daily IV Pabrinex, which continued once her ileus resolved and she started eating again. She required IV Magnesium and IV Potassium replacement as these electrolytes were low on her daily refeeding bloods. Once her electrolytes stabilised and she was able to eat normally again she was switched onto oral tablets (B co-strong, Thiamine and Forceval) and oral analgesia (Paracetamol, Ibuprofen and Tramadol). In her discharge summary you list the following diagnoses: ◦ Small bowel obstruction secondary to adhesions ◦ Midline laparotomy and adhesiolysis ◦ Post-op ileus ◦ Refeeding syndromePRESCRIBIN G IN EMERGENCIE SSCENARIO 4 You are the Gynae SHO and you get a call from a GP saying they have a 17yr old female, Jade Matthews, who has very heavy periods. The GP is concerned with the amount of blood she has lost recently, passing large clots and changing pads every half an hour, and would like her to be reviewed. She reports feeling dizzy on standing and easily gets out of breath. You ask the GP for Jade’s observations and any bedside tests: ◦ HR 98bpm, BP 80/52 mmHg, RR 16, SpO2 97% RA, Temp 36.4C, alert ◦ Urinalysis: Blood 3+ ◦ Urinary pregnancy test: Neg ◦ ECG: sinus tachycardiaSCENARIO 4 CONTINUED On admission you do a brief clerking: HPC: Periods have always been heavy and last a long time, this time she has been bleeding for 10 days. Changing pads frequently, passing large clots. Started periods age 10. Have got progressively heavier as she’s got older. Initially she was too embarrassed to speak to her mum or GP about it. Not currently sexually active. No previous surgeries. PMH: Underactive thyroid, Coeliac disease DH: Levothyroxine 75mcg OD. NKDA. Prescribed Ferrous sulfate but does not take it due to constipationSCENARIO 4 CONTINUED On admission you do a brief clerking: HPC: Periods have always been heavy and last a long time, this time she has been bleeding for 10 days. Changing pads frequently, passing large clots. Started periods age 10. Have got progressively heavier as she’s got older. Initially she was too embarrassed to speak to her mum or GP about it. Not currently sexually active. No previous surgeries. PMH: Underactive thyroid, Coeliac disease DH: Levothyroxine 75mcg OD. NKDA. Prescribed Ferrous sulfate but does not take it due to constipation Exam findings: pale skin, conjunctival pallor, dry mucus membranes. Abdo SNT, BS present throughout. Nil organomegaly. Speculum exam with consent & chaperone: Vulva normal, vagina normal – filled with dark blood. Large clot removed. Cervix normal, blood trickling from external cervical os. How are you going to manage her? Main principles: 1. Stop the bleeding 2. Replace what is lost How are you going to manage her? Main principles: 1. Stop the bleeding ◦ Tranexamic acid 1g IV/PO up to TDS ◦ Hormonal treatment: Provera or Norethisterone to stop bleeding in the short term How are you going to manage her? Main principles: 1. Stop the bleeding ◦ Tranexamic acid 1g IV/PO up to TDS ◦ Hormonal treatment: Provera or Norethisterone to stop bleeding in the short term 2. Replace what is lost ◦ Iron: oral (Ferrous sulfate or ferrous fumarate) or IV (Monofer or Ferinject) ◦ Blood – packed red cellsInvestigationsInvestigations Bloods: FBC, U&Es, Haematinics, CRP, G&S, TFTs, VBG US pelvis – no inpatient slots available today, booked for tomorrowInvestigations Bloods: FBC, U&Es, Haematinics, CRP, G&S, TFTs, VBG US pelvis – no inpatient slots available today, booked for tomorrow Haematinics: Ferritin, Folate and Vit B12 – everything that is needed to make RBCs • Ferritin: measure of iron stores; also acute phase protein – will be spuriously raised during infection/inflammation MCV: mean corpuscular volume (size of erythrocyte) • <80: microcytic, can indicate iron deficiency • >100: macrocytic, can indicate B12 deficiency TSH: thyroid stimulating hormone – used to monitor Thyroid functionInvestigations Bloods: FBC, U&Es, Haematinics, CRP, G&S, TFTs, VBG US pelvis – no inpatient slots available today, booked for tomorrow Bloods: Haematinics: Ferritin, Folate and Vit B12 – everything that is U&Es NAD needed to make RBCs CRP 17 (0-3) WCC 10.2 (4-10) • Ferritin: measure of iron stores; also acute phase protein MCV 63 (80-100)) – will be spuriously raised during infection/inflammation Ferritin 4 (13-150) MCV: mean corpuscular volume (size of erythrocyte) Folate 5.6 (3.1-18.3) Vit B12 210 (180-2000) • <80: microcytic, can indicate iron deficiency TSH 6.7 (0.35-4.5) • >100: macrocytic, can indicate B12 deficiency Blood group: O+, TSH: thyroid stimulating hormone – used to monitor Thyroid no antibodies present functionDiagnosis 1. Menorrhagia 2. Iron-deficiency anaemia 3. HypothyroidismIron replacement Oral iron: ◦ Ferrous sulfate 200mg or ferrous fumarate 210mg ◦ Max once daily dosing – better absorbed if given on alternate days ◦ Give on empty stomach with some Vit C to maximise absorption ◦ Avoid with Omeprazole, Gaviscon, tea (stops absorption), Levothyroxine (competes for absorption) IV iron: ◦ Monofer or Ferinject depending on Trust ◦ Dose by weight and extend of deficiency (prescription proforma usually present) ◦ Max 1000mg at a time – second dose a week later if needed ◦ Can permanently stain skin if cannula tissues ◦ Occasional reactions/anaphylaxis – avoid overnight ◦ No oral iron for 7-10 days after IV iron infusion Blood transfusion National shortage of blood – only allowed to prescribe 1 unit RBC per patient unless in extremis. Reassess patient after 1 unit RBC NICE guidance: “restrictive cell transfusion thresholds” ◦ Check local Trust guidance on transfusion threshold ◦ Don’t transfuse if Hb >70 (except in ACS) if not actively bleeding ◦ Need two Group & Save samples (pink tube) ◦ Phone the Blood Bank to request the blood for rapid dispensing ◦ Prescribe: 1 unit Packed RBC IV over 3hr ◦ Always let nursing staff know you have prescribed blood, and let them know when the blood is ready in the fridge for collection ◦ Recheck Hb 4-6hr after transfusion ◦ Require nursing obs pre-, during- and post-transfusionSCENARIO 4 conclusion Jade received 1L IV Hartmann’s over 2hr and was encouraged to eat and drink thereafter. the bleeding.d on Provera 10mg TDS and regular Tranexamic acid for 5 days which settles Jade receives a Monofer infusion and you organise for her to come back to the Planned Infusion Unit for a second infusion a week later. You contact the Endocrinology SpR during her admission regarding her raised TSH and she advises that you increase her Levothyroxine to 100mcg daily with follow-up TSH check with dose to alternate days, and that is must be taken at the opposite time of day to thefate Levothyroxine. Jade has her US pelvis which shows no abnormalities other than a mildly thickened endometrium of 12mm. You organise a Gynae Outpatient follow-up clinic appointment for 4 weeks after discharge, where it is decided that she should have a Mirena coil inserted for menorrhagia, and she stops the Provera. 1. Use helpful resources: download BNF on your app, scottish palliative care guidelines are excellent, use the renal handbook for prescribing in CKD/AKI SummaryQuestions