tailieunhanh - Essential Guide to Acute Care - part 9

Lịch sử, cũng như kiểm tra, điểm hướng tới sự suy giảm khối lượng. Nôn mửa cũng có thể gây hạ kali máu. Cô đòi hỏi phải hồi sức dịch và giám sát chặt chẽ. Thông báo cho bác sĩ gây mê, những người có thể yêu cầu giám sát tinh vi hơn | 168 Chapter 9 The history as well as examination points towards volume depletion. Vomiting may have also caused hypokalaemia. She requires fluid resuscitation and close monitoring. Inform the anaesthetist who may request more sophisticated monitoring to guide fluid and other therapies before surgery. 2 Myocardial infarction is diagnosed by history ECG changes and a cardiac enzyme rise. Two out of three indicates a probable recent myocardial infarction. This and the type of surgery places the patient at high risk of perioperative cardiac complications but as the surgery is for malignancy it would be impractical to postpone this for 3 months. The patient has good functional capacity. A cardiology opinion should be sought and management may include stress testing and post-myocardial infarction treatment including a beta-blocker which may also reduce peri-operative risk . Inform the anaesthetist as the anaesthetic technique and post-operative care may be modified see Fig. . A discussion of the risks involved should take place between the doctors involved and the patient. 3 The questions are How significant is this patient s ischaemic heart disease What is his peri-operative cardiac risk Can that risk be reduced by any specific measures Safe implies negligible risk a term which should be avoided in this situation see Figs and . He is an intermediate risk patient having intermediate risk surgery. You need to ascertain his functional capacity which may be masked by his limited mobility. Cardiology referral stress testing peri-operative beta-blockers and modification of anaesthetic technique and post-operative care are the issues that need to be considered. 4 Management in this case starts with A airway and oxygen B breathing C circulation and D disability . She requires humidified oxygen therapy antibiotics for community acquired pneumonia and fluid challenges for volume depletion. As she is drowsy her pupil reactions capillary glucose and neurological .